Clinical outcomes in medical outliers admitted to hospital with heart failure

Outlier analysis for accelerating clinical discovery: An augmented intelligence framework and a systematic review

Clinical discoveries largely depend on dedicated clinicians and scientists to identify and pursue unique and unusual clinical encounters with patients and communicate these through case reports and case series. This process has remained essentially unchanged throughout the history of modern medicine. However, these traditional methods are inefficient, especially considering the modern-day availability of health-related data and the sophistication of computer processing. Outlier analysis has been used in various fields to uncover unique observations, including fraud detection in finance and quality control in manufacturing. We propose that clinical discovery can be formulated as an outlier problem within an augmented intelligence framework to be implemented on any health-related data. Such an augmented intelligence approach would accelerate the identification and pursuit of clinical discoveries, advancing our medical knowledge and uncovering new therapies and management approaches. We define clinical discoveries as contextual outliers measured through an information-based approach and with a novelty-based root cause. Our augmented intelligence framework has five steps: define a patient population with a desired clinical outcome, build a predictive model, identify outliers through appropriate measures, investigate outliers through domain content experts, and generate scientific hypotheses. Recognizing that the field of obstetrics can particularly benefit from this approach, as it is traditionally neglected in commercial research, we conducted a systematic review to explore how outlier analysis is implemented in obstetric research. We identified two obstetrics-related studies that assessed outliers at an aggregate level for purposes outside of clinical discovery. Our findings indicate that using outlier analysis in clinical research in obstetrics and clinical research, in general, requires further development.

Outlier or handover: outcomes for General Medicine inpatients

Objective Patients admitted from the emergency department may be co-located on the treating team's 'home ward'. If no bed is available, patients may be sent to another ward, where they may remain under the admitting team as an 'outlier'. Conversely, care may be handed over to the team on whose home ward they are located. We conducted a retrospective analysis to understand the impact of outlier status and handovers of care on outcomes for General Medicine inpatients. Methods General Medicine admissions at the Royal Adelaide Hospital between September 2020 and November 2021 were analysed. We examined the rate of hospital-acquired complications, inpatient mortality rate, mortality within 48 h of admission, Relative Stay Index, time of discharge from hospital and rate of adverse events within 28 days of discharge. Results A total of 3109 admissions were analysed. Handovers within 24 h of admission were associated with a longer length of stay. There was a trend towards higher rates of adverse events within 28 days of discharge with handovers of care. Outlier status did not affect any outcome measures. Conclusions Handovers within the first 24 h of admission are associated with longer than expected length of stay.

The impact of atypical intrahospital transfers on patient outcomes: a mixed methods study

The architectural design of hospitals worldwide is centred around individual departments, which require the movement of patients between wards. However, patients do not always take the simplest route from admission to discharge, but can experience convoluted movement patterns, particularly when bed availability is low. Few studies have explored the impact of these rarer, atypical trajectories. Using a mixed-method explanatory sequential study design, we firstly used three continuous years of electronic health record data prior to the Covid-19 pandemic, from 55,152 patients admitted to a London hospital network to define the ward specialities by patient type using the Herfindahl-Hirschman index. We explored the impact of 'regular transfers' between pairs of wards with shared specialities, 'atypical transfers' between pairs of wards with no shared specialities and 'site transfers' between pairs of wards in different hospital site locations, on length of stay, 30-day readmission and mortality. Secondly, to understand the possible reasons behind atypical transfers we conducted three focus groups and three in-depth interviews with site nurse practitioners and bed managers within the same hospital network. We found that at least one atypical transfer was experienced by 12.9% of patients. Each atypical transfer is associated with a larger increase in length of stay, 2.84 days (95% CI 2.56-3.12), compared to regular transfers, 1.92 days (95% CI 1.82-2.03). No association was found between odds of mortality, or 30-day readmission and atypical transfers after adjusting for confounders. Atypical transfers appear to be driven by complex patient conditions, a lack of hospital capacity, the need to reach specific services and facilities, and more exceptionally, rare events such as major incidents. Our work provides an important first step in identifying unusual patient movement and its impacts on key patient outcomes using a system-wide, data-driven approach. The broader impact of moving patients between hospital wards, and possible downstream effects should be considered in hospital policy and service planning.

High ward occupancy, bedspacing, and 60 day mortality for patients with myocardial infarction, stroke, and heart failure

Aims

To study the consequences of crowded wards among patients with cardiovascular disease.

Methods and results

This is a cohort study among 201 801 patients with 258 807 admissions who were acutely admitted for myocardial infarction (N = 107 895), stroke (N = 87 336), or heart failure (N = 63 576) to any Norwegian hospital between 2008 and 2016. The ward admitting most patients with the given clinical condition was considered a patient's home ward. We compared patients with the same condition admitted when home ward occupancy was different, at the same hospital and during comparable time periods. Occupancy was standardized such that a one‐unit difference corresponded to the interquartile range in occupancy in the given month. One interquartile increase in home ward occupancy was associated with 7% higher odds of admission to an alternate ward [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.09 to 1.11], and length of stay was shorter (−0.10 days, 95% CI −0.18 to −0.09). Patients with heart failure had 15% higher odds of admission to alternate wards (OR 1.15, 95% CI 1.08 to 1.23) and increased mortality [hazard ratio (HR) 1.08, 95% CI 1.03 to 1.15]. We found no apparent effect on mortality for patients with myocardial infarction (HR 0.99, 95% CI 0.94 to 1.05) or stroke (HR 1.00, 95% CI 0.96 to 1.05).

Conclusions

Patients with heart failure had higher risk of admission to alternate wards when home ward occupancy was high. These patients may be negatively affected by full wards.

Older medical outliers on surgical wards: impact on 6-month outcomes

BACKGROUND

Medical patients are on occasion admitted transiently to surgical wards when more appropriate wards are at capacity, potentially leading to suboptimal care. The aim of this study was to compare 6-month outcomes in older adults diagnosed with medical conditions in the ED then admitted inappropriately to surgical wards (defined as outliers), with outcomes in comparable patients admitted to medical wards (controls).

METHODS

In a matched cohort study, 100 consecutive medical outliers from the ED aged 75 years and over were matched according to age, sex and diagnosis to 200 controls. Collected data included number of diagnoses reported in acute care, level of patient illness severity, length of stay, mortality and destination of patients discharged from acute care units (home, rehabilitation facility, nursing home or palliative care facility). An assessment was made of patient vital status and living environment (home, nursing home or hospital) at 6 months post-ED admission.

RESULTS

Mean age was 85.6 years. The most common ED diagnoses were gait disorders/falls (18%), neurological disorders (17%) and exhaustion (16%). Outliers displayed lower illness severity levels (0.001) and shorter lengths of stay from ED admission to acute care discharge (p=0.040). Subsequent to acute care, outliers were less commonly discharged home (45% vs 59%) and more commonly discharged to rehabilitation facilities (42% vs 28%). At 6 months post-ED admission, multivariable regression analysis showed that outlier status (OR=0.44 (0.25-0.83); p=0.011) and numbers of diagnoses reported in acute care (OR=0.87 (0.76-0.98); p=0.028) were independently associated with lower probability of living at home.

CONCLUSION

Outlying of older patients to surgical wards negatively affects their prospects of living at home at 6 months after hospital admission. Older patients hospitalised via the ED are entitled to appropriate medical care.

Not-for-profit observational study to evaluate the quality and safety of care in <em>outliers</em> hospitalized with medical diseases - Study Protocol of Safety Issues and SurvIval For Medical Outliers (SISIFO study)

The progressive cutting of hospital beds in some health systems, together with the increased needs related to the aging population, has led to the phenomenon of patients hospitalized outside the appropriate ward (outliers). This is particularly relevant in the context of Internal Medicine. Despite its relevance in daily clinical practice, available evidence for the potential impact of this phenomenon is limited. The aim of this study is to evaluate the effects of this situation on patients’ outcomes and possibly identify organizational and managerial aspects related to the presence of outliers. The multicenter, observational, prospective Study Protocol of Safety Issues and SurvIval For Medical Outliers (SISIFO) was promoted by the Italian Federation of Associations of Hospital Doctors on Internal Medicine (FADOI). The primary study endpoint is the evaluation of in-hospital mortality in outliers versus controls. A sample size of 2400 patients has been estimated by assuming a mortality rate of 12% and 8% in outliers and controls, respectively. By virtue of the multicentric dimension, the expected number of patients, and the controlled design, the FADOI-SISIFO study might provide interesting and useful findings to better manage the phenomenon of outliers.

Length of hospital stay among oldest-old patients in acute geriatric ward

PURPOSE

To examine risk factors for prolonged hospital length of stay (LOS) in the oldest-old inpatients aged ≥ 90.

METHODS

This retrospective cross-sectional study was performed in acute Geriatrics Department at Kaplan Medical Center. The target population was the oldest-old inpatients aged ≥ 90 hospitalized with acute illness. In total 1536 admissions of 987 patients admitted between January 2007 and December 2010 from the emergency room were included in the study. We retrieved from the electronic hospital records the following data: demographics, admission diagnosis, comorbidities, laboratory tests, drugs, functional and cognitive status, Charlson Comorbidity Index (CCI) score and age-adjusted CCI score.

RESULTS

The risk factors for a prolonged LOS were tube-feeding, consumption of ≥ 5 drugs, non-independent functional status, diagnosis of urinary tract infection (UTI), pneumonia and malignancy on admission, and comorbidities of congestive heart failure (CHF) and hypoalbuminemia. Multiple linear regression analysis found that UTI, hypoalbuminemia, elevated troponin, pneumonia, number of drugs, malignancy, CHF and number of comorbidities explain a higher risk for a longer LOS.

CONCLUSION

Hospital LOS in the oldest-old patients in acute geriatric ward was associated with admission diagnosis and comorbidities. Awareness of the risk factors for a longer LOS might contribute to reducing hospitalization stay and its related negative consequences. Accurate prediction of prolonged LOS in this age group of patients may be more challenging and require variables that were not included in our study. Future research is warranted.

Effect of hospital interventions to improve patient flow on emergency department clinical quality indicators

INTRODUCTION

The Royal College of Emergency Medicine highlights poor flow through hospitals as a major challenge to improving emergency department flow. We describe the effect of several hospital-wide flow interventions on Yeovil District Hospital's emergency department flow.

METHODS

During 2016, a design science research study addressed several areas disproportionally contributing to exit block within Yeovil District Hospital. In this follow-up study, we used a retrospective, before/after design, to describe the effect of these interventions on the ED. We used the Royal College of Emergency Medicine's clinical quality indicators (4-hour standard, time to decision-maker, 7-day unplanned reattendance, left without being seen, ambulatory patient care and patient experience). Pearson correlation coefficient (r) was used to compare variables. Wilcoxon signed-rank test was used to compare performance before and after the intervention.

RESULTS

Yeovil District Hospital emergency department was attended by 160 373 patients between August 2015 and October 2018. Mean monthly attendance was 4112 (±342) patients, mean age was 43 (±28) years with equal male/female split (49/51%). The 4-hour standard made a recovery from 92% to 97% (p=0.01) that did not correlate with a recovery in national data (r=0.09); this despite rising attendances both at Yeovil and nationally (r=0.75). All clinical quality indicators improved significantly (except unplanned reattendance and patient feedback which improved but not significantly).

DISCUSSION

The positive effect on emergency department clinical quality indicators reveals the beneficial impact of improving in-patient flow. Qualitative research is needed to better understand facilitators and barriers to flow improvement work. .

A qualitative exploration of escalation of care in the acute ward setting

BACKGROUND

"Failure to Rescue" includes failing to prevent avoidable patient deterioration and death. Despite its use, delays in care escalation still affect patient outcomes.

AIMS AND OBJECTIVE

The aim of this qualitative service evaluation was to map the barriers and facilitators to the escalation of care in the acute ward setting and identify those that are modifiable.

DESIGN

A total of 55 hours of qualitative observations were completed to capture care escalation events. These were conducted at two hospital sites in one National Health Service trust.

METHODS

Observations were iterative, with research team meetings being used to discuss the data and future methods. Field notes were analysed thematically by two researchers, extracting data on barriers and facilitators to escalation of care.

RESULTS

Clinical nursing staff challenged the sensitivity and specificity of Early Warning Scores, describing tool failings in certain clinical scenarios. Staff did not escalate based on the alerting Early Warning Scores alone but used other clinical factors, such as bleeding, which are not necessarily captured in the scoring systems. Staff frequently did not re-escalate low-level scores. Patient and non-patient factors identified as posing barriers to escalation were complex care needs, patient outlier status, and involvement of multiple care teams. Factors negatively affecting the chain of communication during escalation were team tension, staffing levels, and inadequate handover.

CONCLUSION

This service evaluation identified barriers and facilitators to the escalation of care in the acute ward setting. Unlike other studies, we found that re-escalation or tracking of deterioration was problematic. Patients identified as being at a higher risk of escalation failure included complex patients, outliers, and patients with multiple care teams.

RELEVANCE TO CLINICAL PRACTICE

This service evaluation demonstrates continuing health care communication barriers. Patient groups (complex patients and outliers) risk process failures during escalation. This can be applied in clinical practice by staff anticipating problems in these patients, documenting clear escalation pathways.

What Quality and Safety of Care for Patients Admitted to Clinically Inappropriate Wards: a Systematic Review

BACKGROUND

In countries with public health system, hospital bed reductions and increasing social and medical frailty have led to the phenomenon of "outliers" or "outlying hospital in-patients." They are often medical patients who, because of unavailability of beds in their clinically appropriate ward, are admitted wherever unoccupied beds are. The present work is aimed to systematically review literature about quality and safety of care for patients admitted to clinically inappropriate wards.

METHODS

We performed a systematic review of studies investigating outliers, published in peer-reviewed journals with no time restrictions. Search and screening were conducted by two independent researchers (MLR and ER). Studies were considered potentially eligible for this systematic review if aimed to assess the quality and/or the safety of care for patients admitted to clinically inappropriate units. Our search was supplemented by a hand search of references of included studies. Given the heterogeneity of studies, results were analyzed thematically. We used PRISMA guidelines to report our findings.

RESULTS

We collected 17 eligible papers and grouped them into six thematic categories. Despite their methodological limits, the included studies show increased trends in mortality and readmissions among outliers. Quality of care and patient safety are compromised as patients and health professionals declare and risk analysis displays. Reported solutions are often multicomponent, stress early discharge but have not been investigated in the control group.

CONCLUSIONS

Published literature cannot definitely conclude on the quality and safety of care for patients admitted to clinically inappropriate wards. As they may represent a serious threat for quality and safety, and moreover often neglected and under valued, well-designed and powered prospective studies are urgently needed.

Analysis of frequency, type of complications and economic costs of outlying patients in general and digestive surgery

INTRODUCTION

The shortage of available beds and the increase in Emergency Department pressure can cause some patients to be admitted in wards with available beds assigned to other services (outlying patients). The aim of this study is to assess the frequency, types of complications and costs of outlying patients.

METHODS

Using a retrospective cohort model, we analysed the 2015 general and digestive surgery records (source: Minimum Basic Data Set and economic database). After selecting all outlying patients, we compared the complications, length of stay, costs and consequences of complications against a randomized sample of non-outlying patients with the same DRG and date of episode for every outlying patient, obtaining one non-outlying patient for each selected outlying patient. Thirteen outlying patients with no non-outlying patient pair were excluded from the study.

RESULTS

From a total of 2,915 patients, 363 (12.45%) were outlying patients. A total of 350 outlying patients were analysed versus 350 non-outlying patients. There were no significant differences in complications (9.4 vs. 8.3%), length of stay (4.33 vs. 4.65 days) or costs (€3,034.12 vs. €3,223.27). Outlying patients men presented a significantly higher risk of complications compared to women (RR=2.10). Outlying patients presented complications after 2.5 or more days.

CONCLUSIONS

When outlying admissions become necessary, the selection of patients with less complex pathologies does not increase complications or their consequences (ICU admissions, readmissions, reoperations or mortality), hospital stays or costs. Only in cases of prolonged outlying stays of more than 2.5 days, or in males, may more complications appear. Therefore, male outliers should be avoided in general, and patients should be transferred to the proper ward if a length of stay beyond 2.5 days is foreseen.

[Outlier patient admissions and their relationship with the emergence of clinical complications and prolonged hospital stays]

OBJECTIVE

To analyze the relationship between the type of hospital admission (outlier and non-outlier admissions) and the appearance of clinical complications and the average stay.

METHODS

From a retrospective epidemiological study of a cohort of patients admitted to the Hospital Complejo Asistencial Universitario de Salamanca (Salamanca, Spain) over a six-month period, outlier and non-outlier patients were identified. This project had access to the admissions department database, the hospital's CMBD (in Spanish, Conjunto Mínimo Básico de Datos) for hospitalisation, the AP-DRG (All Patient-Diagnosis Related Groups) and ALCOR (a clinical-statistics analytics tool). It then proceeded to break down the results by DRG, looking at the five most common DRGs in that period.

RESULTS

8.4% of the total 11,842 admissions were medical outliers. In the overall study, the average stay was longer for outlier patients (8. 11 days) than for other patients (7.15 days). The mortality rate was, likewise, higher for outlier patients, although there was a reduced incidence of complications (7.6% for outlier patients as opposed to 8.4% for others). The analysis by DRG corroborated these results in three of the five cases investigated, showing longer average stays but fewer clinical complications in the case of outlier patients.

CONCLUSIONS

On admission to hospital, a significant proportion of patients were allocated beds on inappropriate wards (outlier patients). It was more common to find medical patients placed on surgical wards than vice versa. The average stay of outlier patients was longer than that of patients admitted to the correct ward. The study found no significant difference between the two groupś in terms of clinical complication rates.

Investigating Immediate and Intermediate Patient Outcomes Following Transfer From the Acute Medicine Unit at the Western General Hospital, Edinburgh: A Prospective Cohort Study

BACKGROUND

An ageing population is placing increasing pressure on acute medical units (AMUs), necessitating frequent, and often inappropriate transfer of patients. We identified a gap in the literature, with similar studies relating to either cardiac or intensive care settings, with another, reporting frequency of movement and adverse outcomes in the elderly. The aim of this study was to ascertain whether patients admitted to the AMU and who are moved "out of hours" (22:00-06:59) experience adverse outcomes opposed to patients moved "within hours."

METHODS

Data was extracted from TrakCare-a unified, web-based healthcare information system- which facilitates real-time bed management processes. This prospective cohort study was carried out at the Western General Hospital (WGH), Edinburgh. The final cohort (n = 219) was split into two groups (out of hours vs. within hours) for statistical analysis. Specific sub-group analysis was used to supplement findings, with eight sub-groups, each defined by a 3-hr time frame around the 24-hr clock.

RESULTS

The final cohort after application of exclusion criteria was n = 219 (female: n = 114, median age = 76; male: n = 105, median age = 75). There was a significant difference in length of stay (LoS) between boarded and non-boarded patients who were: (1) moved out of hours (2) moved within hours (p = 0.003). Remainder of patient outcome results (readmission at 7 and 30 days respectively; mortality during admission, and at 7 and 30 days) were not statistically significant.

CONCLUSION

We revealed a significant difference in LoS between patients moved within and out with hours; the "out of hours" patient group-was significantly less than that of the "within" hours group.

Are medical outliers associated with worse patient outcomes? A retrospective study within a regional NHS hospital using routine data

OBJECTIVE

To explore the quality and safety of patients' healthcare provision by identifying whether being a medical outlier is associated with worse patient outcomes. A medical outlier is a hospital inpatient who is classified as a medical patient for an episode within a spell of care and has at least one non-medical ward placement within that spell.

DATA SOURCES

Secondary data from the Patient Administration System of a district general hospital were provided for the financial years 2013/2014-2015/2016. The data included 71 038 medical patient spells for the 3-year period.

STUDY DESIGN

This research was based on a retrospective, cross-sectional observational study design. Multivariate logistic regression and zero-truncated negative binomial regression were used to explore patient outcomes (in-hospital mortality, 30-day mortality, readmissions and length of stay (LOS)) while adjusting for several confounding factors.

PRINCIPAL FINDINGS

Univariate analysis indicated that an outlying medical in-hospital patient has higher odds for readmission, double the odds of staying longer in the hospital but no significant difference in the odds of in-hospital and 30-day mortality. Multivariable analysis indicates that being a medical outlier does not affect mortality outcomes or readmission, but it does prolong LOS in the hospital.

CONCLUSIONS

After adjusting for other factors, medical outliers are associated with an increased LOS while mortality or readmissions are not worse than patients treated in appropriate specialty wards. This is in line with existing but limited literature that such patients experience worse patient outcomes. Hospitals may need to revisit their policies regarding outlying patients as increased LOS is associated with an increased likelihood of harm events, worse quality of care and increased healthcare costs.

A review of inpatient ward location and the relationship to Medical Emergency Team calls

OBJECTIVE

To identify the relationship between in-hospital location and patient outcomes as measured by Medical Emergency Team calls.

STUDY DESIGN

A narrative systematic review of the literature.

DATA SOURCES

A systematic search of the literature was conducted in October 2014 using the electronic databases: Embase, Cochrane, Medline, CINAHL, Science Direct and Google Scholar for the most recent literature from 1997 to 2014.

INCLUSION CRITERIA

Non-randomised study designs such as case control or cohort studies were eligible. Articles were selected independently by two researchers using a predetermined selection criterion.

DATA SYNTHESIS

The screening process removed manuscripts that did not meet the inclusion criteria resulting in an empty review with one manuscript meeting most of the criteria for inclusion. The protocol was revised to a narrative synthesis including a broader scope of studies. The search strategy was expanded and modified to include manuscripts of any study design that comprise both inlier and outlier patients. Two manuscripts were selected for the narrative synthesis.

CONCLUSION

Two recently published studies investigated the incidence of MET calls for outlier patients, and whilst MET calls were increased in outlier hospital patients, definitive conclusions associated with patient outcomes cannot be made at this time due to paucity of studies.

Looking after patients, not looking for patients

How transfers from ward to ward can affect continuity of care.

Relationship between in-hospital location and outcomes of care in patients of a large general medical service

BACKGROUND

The discrepancy between the number of admissions and the allocation of hospital beds means that many patients admitted under the care of a general medical service can be placed in other departments' wards. These patients are called 'outliers', and their outcomes are unknown.

AIMS

To examine the relation between the proportion of time each patient spent in their 'home ward' during an index admission and the outcomes of that hospital stay.

METHODS

Data from Flinders Medical Centre's patient journey database were extracted and analysed. The analysis was carried out on the patient journeys of patients admitted under the general medicine units.

RESULTS

Outlier patients' length of stay was significantly shorter than that of the inlier patients (110.7 h cf 141.9 h; P < 0.001).They had a reduced risk of readmission within 28 days of discharge from hospital. Outlier patients' discharge summaries were less likely to be completed within a week (64.3% cf 78.0%; P < 0.001). Being an outlier patient increased the risk-adjusted risk of in-hospital mortality by over 40%. Fifty per cent of deaths in the outlier group occurred within 48 h of admission. Outlier patients had spent longer in the emergency department waiting for a bed (6.3 h cf 5.3 h; P < 0.001) but duration of emergency department stay was not an independent predictor of mortality risk.

CONCLUSION

Outlier patients had significantly shorter length of stay in hospital but significantly greater in-patient death rates. Surviving outlier patients had lower rates of readmission but lower rates of discharge summary completion.

Lost in hospital: a qualitative interview study that explores the perceptions of NHS inpatients who spent time on clinically inappropriate hospital wards

BACKGROUND

Prior research suggests that the placement of patients on clinically inappropriate hospital wards may increase the risk of experiencing patient safety issues.

OBJECTIVE

To explore patients' perspectives of the quality and safety of the care received during their inpatient stay on a clinically inappropriate hospital ward.

DESIGN

Qualitative study using semi-structured interviews.

PARTICIPANTS AND SETTING

Nineteen patients who had spent time on at least one clinically inappropriate ward during their hospital stay at a large NHS teaching hospital in England.

RESULTS

Patients would prefer to be treated on the correct specialty ward, but it is generally accepted that this may not be possible. When patients are placed on inappropriate wards, they may lack a sense of belonging. Participants commented on potential failings in communication, medical staff availability, nurses' knowledge and the resources available, each of which may contribute to unsafe care.

CONCLUSIONS

Patients generally acknowledge the need for placement on inappropriate wards due to demand for inpatient beds, but may report dissatisfaction in terms of preference and belonging. Importantly, patients recount issues resulting from this placement that may compromise their safety. Hospital managers should be encouraged to appreciate this insight and potential threat to safe practice and where possible avoid inappropriate ward transfers and admissions. Where such admissions are unavoidable, staff should take action to address the gaps in safety of care that have been identified.

Hospital out-lying through lack of beds and its impact on care and patient outcome

Background

When medical wards become saturated, the common practice is to resort to outlying patients in another ward until a bed becomes free.

Objectives

Compare the quality of care provided for inpatients who are outlying (O) in inappropriate wards because of lack of vacant beds in appropriate specialty wards to the care given to non outlying (NO) patients.

Methods

We propose a matched-pair cluster study. The exposed group consisted of inpatients that were outliers in inappropriate wards because of lack of available beds. Non-exposed subjects (the control group) were those patients who were hospitalized in the ward that corresponded to the reason for their admission. Each patient of the exposed group was matched to a specific control subject. The principal objective was to prospectively measure differences in the length of hospital stays, the secondary objectives were to assess mortality, rate of re-admission at 28 days, and rate of transfer into intensive care.

Results

238 were included in the NO group, 245 in the O group. More patients in the O group (86% vs 76%) were transferred into a ward with prescription completed. O patients remained in hospital for 8 days [4-15] vs 7 days [4-13] for NO patients (p = 0.04). 124 (52%) of the NO patients received heparin-based thromboembolic prevention during their stay in hospital vs 104 (42%) of the O patient group (p = 0.03). 66 (27%) O patients were re-admitted to hospital within 28 days vs 40 (17%) NO patients (p = 0.008).

Conclusion

O patients had a worse prognosis than NO patients.