Lowering levels of bed occupancy is associated with decreased inhospital mortality and improved performance on the 4-hour target in a UK District General Hospital

Building a public-private partnership to confront the emergency department boarding crisis

The nation's critically crowded emergency departments have aptly been called "the sentinel canaries in the health care system," given their nexus point between inpatient, ambulatory, perioperative, and long-term care systems. Emergency department boarding-holding or physically keeping a patient in an emergency department after the clinical decision to admit the individual to the hospital-is a critical symptom of overload and breakdown of the more extensive health care delivery system. Despite more than 25 years of incontrovertible scientific evidence that the practice is associated with significant harm, little progress has been made in confronting its structural and economic drivers at a national scale. This article, authored by federal health care leaders, opens the Health Affairs Scholar Featured Series by highlighting the importance of a public-private partnership approach and lays the foundation for a series that will further present a holistic evaluation of the topic, encouraging a multi-faceted approach toward resolving this critical health system issue.

A need for systems thinking and the appliance of (complexity) science in healthcare

Hospitals represent complex adaptive systems where interactions and relationships of different components both affect and shape the way they work simultaneously. Pressures on hospitals determine how they behave and many of the problems seen in the NHS and indeed other health services can be viewed through the lens of complexity science and systems thinking. 'Flow' of patients through the hospital can be seen as an indicator of how well the hospital 'system' is working. The better flow is, the more patients can be treated and the less time is spent waiting in the various queues that accrue around the hospital, In this article, we explore the impact of these disciplines on patient flow and examine how short-term and overly simple solutions can exacerbate problems in the health service, despite the best intentions of those working in it. Many of today's problems can be described in terms of 'system archetypes' and 'game theory'. Understanding this may lead to improvement in how services are redesigned to solve these problems.

A New Approach for Understanding International Hospital Bed Numbers and Application to Local Area Bed Demand and Capacity Planning

Three models/methods are given to understand the extreme international variation in available and occupied hospital bed numbers. These models/methods all rely on readily available data. In the first, occupied beds (rather than available beds) are used to measure the expressed demand for hospital beds. The expressed occupied bed demand for three countries was in the order Australia > England > USA. Next, the age-standardized mortality rate (ASMR) has dual functions. Less developed countries/regions have low access to healthcare, which results in high ASMR, or a negative slope between ASMR versus available/occupied beds. In the more developed countries, high ASMR can also be used to measure the 'need' for healthcare (including occupied beds), a positive slope among various social (wealth/lifestyle) groups, which will include Indigenous peoples. In England, a 100-unit increase in ASMR (European Standard population) leads to a 15.3-30.7 (feasible range) unit increase in occupied beds per 1000 deaths. Higher ASMR shows why the Australian states of the Northern Territory and Tasmania have an intrinsic higher bed demand. The USA has a high relative ASMR (for a developed/wealthy country) because healthcare is not universal in the widest sense. Lastly, a method for benchmarking the whole hospital's average bed occupancy which enables them to run at optimum efficiency and safety. English hospitals operate at highly disruptive and unsafe levels of bed occupancy, manifesting as high 'turn-away'. Turn-away implies bed unavailability for the next arriving patient. In the case of occupied beds, the slope of the relationship between occupied beds per 1000 deaths and deaths per 1000 population shows a power law function. Scatter around the trend line arising from year-to-year fluctuations in occupied beds per 1000 deaths, ASMR, deaths per 1000 population, changes in the number of persons hidden in the elective, outpatient and diagnostic waiting lists, and local area variation in births affecting maternity, neonatal, and pediatric bed demand. Additional variation will arise from differences in the level of local funding for social care, especially elderly care. The problems associated with crafting effective bed planning are illustrated using the English NHS as an example.

A multivariable analysis to predict variations in hospital mortality using systems-based factors of healthcare delivery to inform improvements to healthcare design within the English NHS

Over the last decade, the strain on the English National Health Service (NHS) has increased. This has been especially felt by acute hospital trusts where the volume of admissions has steadily increased. Patient outcomes, including inpatient mortality, vary between trusts. The extent to which these differences are explained by systems-based factors, and whether they are avoidable, is unclear. Few studies have investigated these relationships. A systems-based methodology recognises the complexity of influences on healthcare outcomes. Rather than clinical interventions alone, the resources supporting a patient's treatment journey have near-equal importance. This paper first identifies suitable metrics of resource and demand within healthcare delivery from routinely collected, publicly available, hospital-level data. Then it proceeds to use univariate and multivariable linear regression to associate such systems-based factors with standardised mortality. Three sequential cross-sectional analyses were performed, spanning the last decade. The results of the univariate regression analyses show clear relationships between five out of the six selected predictor variables and standardised mortality. When these five predicators are included within a multivariable regression analysis, they reliably explain approximately 36% of the variation in standardised mortality between hospital trusts. Three factors are consistently statistically significant: the number of doctors per hospital bed, bed occupancy, and the percentage of patients who are placed in a bed within four hours after a decision to admit them. Of these, the number of doctors per bed had the strongest effect. Linear regression assumption testing and a robustness analysis indicate the observations have internal validity. However, our empirical strategy cannot determine causality and our findings should not be interpreted as established causal relationships. This study provides hypothesis-generating evidence of significant relationships between systems-based factors of healthcare delivery and standardised mortality. These have relevance to clinicians and policymakers alike. While identifying causal relationships between the predictors is left to the future, it establishes an important paradigm for further research.

Introducing a structured daily multidisciplinary board round to safely enhance surgical ward patient flow in the bed shortage era: a quality improvement research report

Hospital bed shortage is a worldwide concern. Their unavailability has caused elective surgery cancellations at our hospital peaking in spring 2016 at over 50%. This is often due to difficult patient step-down from intensive care (ICU) and high-dependency units (HDU). In our general/digestive surgery service admitting approximately 1000 patients yearly, ward rounds were run on a consultant firm basis.We report quality improvement (ISRCTN13976096) after we introduced a structured daily multidisciplinary board round framework (SAFER Surgery R2G) adapted from the 'SAFER patient flow bundle' and the 'Red to Green days' approaches to enhance flow. We compare 2016-2017, when our framework was applied for 12 months.We used a Plan-Do-Study-Act (PDSA) methodology. Our intervention consisted in (1) systematically communicating the key care plan after the afternoon ward rounds to the nurse in charge; (2) 30' 10:00 hours Monday-to-Friday multidisciplinary board rounds, attended daily by the senior team and weekly by hospital and site managers, revising the key care plan to aim at safe, early discharges, assessing the appropriateness of each inpatient day and tackling any cause of delay. We measured patient flow by average length of stay (LOS), ICU/HDU step-downs and operation cancellations count, monitoring safety through early 30-day readmissions. Compliance was assessed by board round attendance and staff satisfaction rate surveys.After 12 months of intervention (PDSA-1-2, N=1032), compared with baseline (PDSA-0, N=954) average LOS significantly decreased from 7.2 (8.9) to 6.3 (7.4) days (p=0.003); ICU/HDU bed step-down flow increased by 9.3% from 345 to 375 (p=0.197), surgery cancellations dropped from 38 to 15 (p=0.100). 30-day readmissions increased from 0.9% (N=9) to 1.3% (N=14)(p=0.390). Average cross-specialty attendance was 80%. Satisfaction rates were >75%, regarding enhanced teamwork and faster decisions.The SAFER Surgery R2G framework has increased patient flow in the context of an enhanced multidisciplinary approach, requiring senior staff commitment to remain sustainable.

The association between bed occupancy rates and hospital quality in the English National Health Service

We study whether hospitals that exhibit systematically higher bed occupancy rates are associated with lower quality in England over 2010/11-2017/18. We develop an economic conceptual framework to guide our empirical analysis and run regressions to inform possible policy interventions. First, we run a pooled OLS regression to test if high bed occupancy is associated with, and therefore acts as a signal of, lower quality, which could trigger additional regulation. Second, we test whether this association is explained by exogenous demand-supply factors such as potential demand, and unavoidable costs. Third, we include determinants of bed occupancy (beds, length of stay, and volume) that might be associated with quality directly, rather than indirectly through bed occupancy. Last, we use a within-between random-effects specification to decompose these associations into those due to variations in characteristics between hospitals and variations within hospitals. We find that bed occupancy rates are positively associated with overall and surgical mortality, negatively associated with patient-reported health gains, but not associated with other indicators. These results are robust to controlling for demand-supply shifters, beds, and volume. The associations reduce by 12%-25% after controlling for length of stay in most cases and are explained by variations in bed occupancy between hospitals.

Stressed systems: Stroke unit bed occupancy and impact on reperfusion therapy in acute ischemic stroke

Objectives

We observed a decrease in the number of patients who were offered reperfusion therapy. We aimed to investigate if whether hospital system pressure measured as the percentage of stroke bed occupancy influenced decisions on treatment and disposition.

Design

Data from a regional quality of stroke care database were obtained and linked to the organizational data monitoring of the hourly inpatient stroke bed occupancy rate. Logistic regression was used to analyze the relationship.

Results

A total of 15,025 admissions were included from 1 January 2019 to 24 August 2022. Of these, 5,659 (38%) had an acute ischemic stroke. The rates of reperfusion therapy treatment were the highest in 2019 (36.2%) and 2020 (34.1%) and declined afterward (30.0% in 2021). In the logistic regression analysis, an occupancy rate of ≥85% in the hour of the first admission was associated with reduced odds of admission at the stroke unit within 3 h from the symptom onset [adjusted odds ratio: 0.80, 95% confidence interval: (0.71-0.90), p < 0.001] and a reduced odds of receiving reperfusion therapy (adjusted odds ratio: 0.83 (0.73-0.95), p = 0.007).

Conclusion

An increased bed occupancy level in the hour of the first hospital admission for stroke patients was strongly associated with decreased odds of receiving reperfusion therapy.

The effect of time-varying capacity utilization on 14-day in-hospital mortality: a retrospective longitudinal study in Swiss general hospitals

BACKGROUND

High bed-occupancy (capacity utilization) rates are commonly thought to increase in-hospital mortality; however, little evidence supports a causal relationship between the two. This observational study aimed to assess three time-varying covariates-capacity utilization, patient turnover and clinical complexity level- and to estimate causal effect of time-varying high capacity utilization on 14 day in-hospital mortality.

METHODS

This retrospective population-based analysis was based on routine administrative data (n = 1,152,506 inpatient cases) of 102 Swiss general hospitals. Considering the longitudinal nature of the problem from available literature and expert knowledge, we represented the underlying data generating mechanism as a directed acyclic graph. To adjust for patient turnover and patient clinical complexity levels as time-varying confounders, we fitted a marginal structure model (MSM) that used inverse probability of treatment weights (IPTWs) for high and low capacity utilization. We also adjusted for patient age and sex, weekdays-vs-weekend, comorbidity weight, and hospital type.

RESULTS

For each participating hospital, our analyses evaluated the ≥85th percentile as a threshold for high capacity utilization for the higher risk of mortality. The mean bed-occupancy threshold was 83.1% (SD 8.6) across hospitals and ranged from 42.1 to 95.9% between hospitals. For each additional day of exposure to high capacity utilization, our MSM incorporating IPTWs showed a 2% increase in the odds of 14-day in-hospital mortality (OR 1.02, 95% CI: 1.01 to 1.03).

CONCLUSIONS

Exposure to high capacity utilization increases the mortality risk of inpatients. Accurate monitoring of capacity utilization and flexible human resource planning are key strategies for hospitals to lower the exposure to high capacity utilization.

The health cost of reducing hospital bed capacity

In the past two decades, most high-income countries have reduced their hospital bed capacity. This could be a sign of increased efficiency but could also reflect a degradation in quality of care. In this paper, we use repeated cross-sections on mortality and staffed hospital beds per capita in all 21 Swedish regions to estimate the potential death toll from reduced bed capacity. Between 2001 and 2019, mortality and beds decreased across all regions, but regions making smaller bed reductions experienced on average greater decreases in mortality, equivalent to one less death per three beds retained. This estimate is stable to a wide range of specifications and to adjustment for potential confounders, which supports a causal interpretation. Our results imply that by providing one more bed, Swedish health care could produce about three quality-adjusted life years (QALYs) at a cost of SEK 400,000 (∼US$40,000) per QALY. These findings could be informative about the marginal productivity of health care and support the credibility of empirical work attempting to estimate the opportunity cost of funding new healthcare interventions subject to a constrained budget.

Observational study of the clinical performance of a public-private partnership national referral hospital network in Lesotho: Do improvements last over time?

Public-private partnerships (PPP) may increase healthcare quality but lack longitudinal evidence for success. The Queen ‘Mamohato Memorial Hospital (QMMH) in Lesotho is one of Africa’s first healthcare PPPs. We compare data from 2012 and 2018 on capacity, utilization, quality, and outcomes to understand if early documented successes have been sustained using the same measures over time. In this observational study using administrative and clinical data, we assessed beds, admissions, average length of stay (ALOS), outpatient visits, and patient outcomes. We measured triage time and crash cart stock through direct observation in 2013 and 2020. Operational hospital beds increased from 390 to 410. Admissions decreased (-5.3%) while outpatient visits increased (3.8%). ALOS increased from 5.1 to 6.5 days. Occupancy increased from 82% to 99%; half of the wards had occupancy rates ≥90%, and Neonatal ward occupancy was 209%. The proportion of crash cart stock present (82.9% to 73.8%) and timely triage (84.0% to 27.6%) decreased. While overall mortality decreased (8.0% to 6.5%) and neonatal mortality overall decreased (18.0% to 16.3%), mortality among very low birth weight neonates increased (30.2% to 36.8%). Declines in overall hospital mortality are promising. Yet, continued high occupancy could compromise infection control and impede response to infections, such as COVID-19. High occupancy in the Neonatal ward suggests that the population need for neonatal care outpaces QMMH capacity; improvements should be addressed at the hospital and systemic levels. The increase in ALOS is acceptable for a hospital meant to take the most critical cases. The decline in crash cart stock completeness and timely triage may affect access to emergency treatment. While the partnership itself ended earlier than anticipated, our evaluation suggests that generally the hospital under the PPP was operational, providing high-level, critically needed services, and continued to improve patient outcomes. Quality at QMMH remained substantially higher than at the former Queen Elizabeth II hospital.

The presentations/physician ratio predicts door-to-physician time but not global length of stay in the emergency department: an Italian multicenter study during the SARS-CoV-2 pandemic

To investigate the effects of the dramatic reduction in presentations to Italian Emergency Departments (EDs) on the main indicators of ED performance during the SARS-CoV-2 pandemic. From February to June 2020 we retrospectively measured the number of daily presentations normalized for the number of emergency physicians on duty (presentations/physician ratio), door-to-physician and door-to-final disposition (length-of-stay) times of seven EDs in the central area of Tuscany. Using the multivariate regression analysis we investigated the relationship between the aforesaid variables and patient-level (triage codes, age, admissions) or hospital-level factors (number of physician on duty, working surface area, academic vs. community hospital). We analyzed data from 105,271 patients. Over ten consecutive 14-day periods, the number of presentations dropped from 18,239 to 6132 (- 67%) and the proportion of patients visited in less than 60 min rose from 56 to 86%. The proportion of patients with a length-of-stay under 4 h decreased from 59 to 52%. The presentations/physician ratio was inversely related to the proportion of patients with a door-to-physician time under 60 min (slope - 2.91, 95% CI - 4.23 to - 1.59, R² = 0.39). The proportion of patients with high-priority codes but not the presentations/physician ratio, was inversely related to the proportion of patients with a length-of-stay under 4 h (slope - 0.40, 95% CI - 0.24 to - 0.27, R² = 0.36). The variability of door-to-physician time and global length-of-stay are predicted by different factors. For appropriate benchmarking among EDs, the use of performance indicators should consider specific, hospital-level and patient-level factors.

The impact of inpatient bed capacity on length of stay

OBJECTIVE

Large reductions in inpatient length of stay and inpatient bed supply have occurred across health systems in recent years. However, the direction of causation between length of stay and bed supply is often overlooked. This study examines the impact of changes to inpatient bed supply, as a result of recession-induced healthcare expenditure changes, on emergency inpatient length of stay in Ireland between 2010 and 2015.

STUDY DESIGN

We analyse all public hospital emergency inpatient discharges in Ireland from 2010 to 2015 using the administrative Hospital In-Patient Enquiry dataset. We use changes to inpatient bed supply across hospitals over time to examine the impact of bed supply on length of stay. Linear, negative binomial, and hospital-month-level fixed effects models are estimated.

RESULTS

U-shaped trends are observed for both average length of stay and inpatient bed supply between 2010 and 2015. A consistently large positive relationship is found between bed supply and length of stay across all regression analyses. Between 2010 and 2012 while length of stay fell by 6.4%, our analyses estimate that approximately 42% (2.7% points) of this reduction was associated with declines in bed supply.

CONCLUSION

Changes in emergency inpatient length of stay in Ireland between 2010 and 2015 were closely related to changes in bed supply during those years. The use of length of stay as an efficiency measure should be understood in the contextual basis of other health system changes. Lower length of stay may be indicative of the lack of resources or available bed supply as opposed to reduced demand for care or the shifting of care to other settings.

How do policy levers shape the quality of a national health system?

Poor quality of care may have a detrimental effect on access and take-up and can become a serious barrier to the universality of health services. This consideration is of particular interest in view of the fact that health systems in many countries must address a growing public-sector deficit and respond to increasing pressures due to COVID-19 and aging population, among other factors. In line with a rapidly emerging literature, we focus on patient satisfaction as a proxy for quality of health care. Drawing on rich longitudinal and cross-sectional data for Spain and multilevel estimation techniques, we show that in addition to individual level differences, policy levers (such as public health spending and the patient-doctor ratio, in particular) exert a considerable influence on the quality of a health care system. Our results suggest that policymakers seeking to enhance the quality of care should be cautious when compromising the level of health resources, and in particular, health personnel, as a response to economic downturns in a sector that traditionally had insufficient human resources in many countries, which have become even more evident in the light of the current health crisis. Additionally, we provide evidence that the increasing reliance on the private health sector may be indicative of inefficiencies in the public system and/or the existence of features of private insurance which are deemed important by patients.

Review article: Has the implementation of time-based targets for emergency department length of stay influenced the quality of care for patients? A systematic review of quantitative literature

Time-based targets (TBTs) for ED stays were introduced to improve quality of care but criticised as having harmful unintended consequences. The aim of the review was to determine whether implementation of TBTs influenced quality of care. Structured searches in medical databases were undertaken (2000-2019). Studies describing a state, regional or national TBTs that reported processes or outcomes of care related to the target were included. Harvest plots were used to summarise the evidence. Thirty-three studies (n = 34 million) were included. In some settings, reductions in mortality were seen in ED, in hospital and at 30 days, while in other settings mortality was unchanged. Mortality reductions were seen in the face of increasing age and acuity of presentations, when short-stay admissions were excluded, and when pre-target temporal trends were accounted for. ED crowding, time to assessment and admission times reduced. Fewer patients left prior to completing their care and fewer patients re-presented to EDs. Short-stay admissions and re-admissions to wards within 30 days increased. There was conflicting evidence regarding hospital occupancy and ward medical emergency calls, while times to treatment for individual conditions did not change. The evidence for associations was mostly low certainty and confidence in the findings is accordingly low. Quality of care generally improved after targets were introduced and when compliance with targets was high. This depended on how targets were implemented at individual sites or within jurisdictions, with important implications for policy makers, health managers and clinicians.

Waiting times in emergency departments: exploring the factors associated with longer patient waits for emergency care in England using routinely collected daily data

Background

Long lengths of stay (also called waiting times) in emergency departments (EDs) are associated with higher patient mortality and worse outcomes.

Objective

To add to the literature using high-frequency data from a large number of hospitals to analyse factors associated with long waiting times, including exploring non-linearities for 'tipping points'.

Methods

Multivariate ordinary least squares regressions with fixed effects were used to analyse factors associated with the proportion of patients in EDs in England waiting more than 4 hours to be seen, treated and admitted or discharged. Daily situation reports (Sitrep), hospital episode statistics and electronic staffing records data over 90 days between December 2016 and February 2017 were used for all 138 English NHS healthcare providers with a major ED.

Results

Higher inpatient bed occupancy was correlated with longer ED waiting times, with a non-linear association. In a full hospital, with 100% bed occupancy, the proportion of patients who remained in the ED for more than 4 hours was 9 percentage points higher (95% CI 7.5% to 11.1%) than with an 85% occupancy level. For each percentage point change in the following factors, the proportion of ED stays over 4 hours also increased: more inpatients with hospital length of stay over 21 days (0.07%, 95% CI 0.008% to 0.13%); higher emergency admissions (0.08%, 95% CI 0.06% to 0.10%); and lower discharges relative to admissions on the same day (0.04%, 95% CI 0.02% to 0.06%), the following day (0.05%, 95% CI 0.03% to 0.06%) and at 2 days (0.05%, 95% CI 0.04% to 0.07%).

Conclusions

These results suggest that tackling patient flow and capacity in the wider hospital, particularly very high bed occupancy levels and patient discharge, is important to reduce ED waiting times and improve patient outcomes.

The Association Between Hospital Occupancy and Mortality Among Medicare Patients

BACKGROUND

Hospital crowding is a major challenge facing US health care systems, but few studies have evaluated the association between inpatient occupancy and patient mortality. The objective of this study was to determine how increasing hospital occupancy is associated with the likelihood of inpatient and 30-day out-of-hospital mortality using a novel measure of inpatient occupancy.

METHODS

The researchers conducted a retrospective, observational study using secondary data from the California Office of Statewide Health Planning and Development, including nonfederal, acute care facilities from 1998 to 2012. Using measures of relative hospital occupancy, the researchers ran logistic regressions to assess the relationship between increasing hospital occupancy and inpatient mortality and 30-day out-of-hospital mortality among Medicare patients age 65 years and older with myocardial infarction, heart failure, or pneumonia.

RESULTS

Higher admission day occupancy (odds ratio [OR] = 0.96, 95% confidence interval [CI]: 0.94-0.99) and higher discharge day occupancy (OR = 0.62, 95% CI: 0.60-0.64) were associated with decreased inpatient mortality. Thirty-day out-of-hospital mortality increased with higher discharge day occupancy (OR=1.28, 95% CI: 1.24-1.32) but was unrelated to admission day occupancy.

CONCLUSION

This study found a counterintuitive relationship between admission and discharge day occupancy and inpatient mortality. Higher discharge day occupancy appears to displace deaths into the outpatient setting. Understanding why higher inpatient occupancy is associated with lower overall mortality merits investigation to inform best practices for inpatient care in busy hospitals.

Association Between Hospital Bed Occupancy and Outcomes in Emergency Care: A Cohort Study in Stockholm Region, Sweden, 2012 to 2016

STUDY OBJECTIVE

We evaluate the importance of hospital bed occupancy for 30-day mortality, inhospital mortality, readmission for inpatient care within 30 days, and revisits to the emergency department (ED) within 7 days among all adult patients visiting the ED.

METHODS

This was an observational cohort study including all adult patients visiting 6 EDs in Stockholm Region, Sweden. ED visits from 2012 to 2016 were categorized into groups by hospital bed occupancy in 5% intervals between 85% and 105%. A proportional hazards model was used to estimate adjusted hazard ratios with 95% confidence intervals (CIs). The model was stratified by hospital and adjusted for age, sex, comorbidities, hospital stays in the year preceding the index visit, marital status, length of education, and weekday/weekend timing of visit.

RESULTS

A total of 816,832 patients with 2,084,554 visits were included. Mean hospital bed occupancy was 93.3% (SD 3.3%). In total, 28,112 patients died within 30 days, and 17,966 patients died inhospital. Hospital bed occupancy was not associated with 30-day mortality (hazard ratio for highest category of occupancy ≥105% was 1.10; 95% CI 0.96 to 1.27) or inhospital mortality. Patients discharged from the ED at occupancy levels greater than 89% had a 2% to 4% higher risk of revisits to the ED within 7 days. A 10% increase in hospital bed occupancy was associated with a 16-minute increase (95% CI 16 to 17 minutes) in ED length of stay and 1.9-percentage-point decrease (95% CI 1.7 to 2.0 percentage points) in admission rate.

CONCLUSION

We did not find an association between increasing hospital bed occupancy and mortality in our sample of 6 EDs in Stockholm Region, Sweden, despite increased length of stay in the ED and a decline in admissions for inpatient care.

Emergency department and hospital crowding: causes, consequences, and cures

Overcrowding with associated delays in patient care is a problem faced by emergency departments (EDs) worldwide. ED overcrowding can be the result of poor ED department design and prolonged throughput due to staffing, ancillary service performance, and flow processes. As such, the problem may be addressed by process improvements within the ED. A broad body of literature demonstrates that ED overcrowding can be a function of hospital capacity rather than an ED specific issue. Lack of institutional capacity leads to boarding in the ED with resultant ED crowding. This is a problem not solvable by the ED and must be addressed as an institution-wide problem. This paper discusses the causes of ED overcrowding, provides a brief overview of the drastic consequences, and discusses possible cures that have been successfully implemented.

Converting acute inpatient take to outpatient take with fast-track assessment in internal medicine wards - a before-after study

Background

With an extensive rise in the number of acute patients and increases in both admissions and readmissions, hospitals are at times overcrowded and under immense pressure and this may challenge patient safety. This study evaluated an innovative strategy converting acute internal medicine inpatient take to an outpatient take. Here, acute patients, following referral, underwent fast-track assessment to the needed level of medical care as outpatients, directly in internal medicine wards.

Method

The two internal medicine wards at Diagnostic Centre, Silkeborg, Denmark, changed their take of acute patients 1st of March 2017. The intervention consisted of acute medical patients being received in medical examination chairs, going through accelerated evaluation as outpatients with assessment within one hour for either admission or another form of treatment. A before-and-after study design was used to evaluate changes in activity. All referred patients for 10 months following implementation of the intervention were compared with patients referred in corresponding months the previous year.

Results

A total of 5339 contacts (3632 patients) who underwent acute medical assessment (2633 contacts before and 2706 after) were included. Median hospital length-of-stay decreased from 32.6 h to 22.3 h, and the proportion of referred acute patients admitted decreased with 36.3% points from 94.5 to 58.2%. The median length-of-admission time for the admitted patients increased as expected after the intervention. The risk of being admitted, being readmitted as well as having a hospital length-of-time longer than 24 h, 72 h or 7 days, respectively, were significantly lower during the after-period in comparison to the before-period. Adverse effects, unplanned re-contacts, total contacts to general practice and mortality did not change after the intervention.

Conclusion

Assessing referred acute patients in medical examination chairs as outpatients directly in internal medicine wards and promoting an accelerated trajectory, reduced inpatient admissions and total length-of-stay considerably. This strategy seems effective in everyday acute medical patients and has the potential to ease the increasing pressure on the acute take for wards receiving acute medical patients.

Case-control study to investigate variables associated with incidents and adverse events in the emergency department

OBJECTIVE

To detect and analyse incidents (Is) and adverse events (AEs) in the ED. We hypothesised that I/AE are associated with patient load.

METHODS

We undertook a case-control study in a tertiary level hospital ED (from 1 April 2012 to 31 March 2013). Three percent of patients were randomly selected and screened for I/AEs. I/AEs were adjudicated by consensus of four FACEMs. Controls were matched to cases 2:1. Logistic regression was used to analyse the data.

RESULTS

We sampled 2167 patients. After exclusions, 217 I/AEs were detected and analysed. The I and AE rates were 6.0 and 4.1%, respectively. The serious AE rate was 0.8% and 30 day mortality was 0.1%. Diagnostic error occurred in 3.7% of all patients and adverse drug reactions in 2.5%. Seventy-seven percent of the I/AEs were judged preventable. ED occupancy of <35 patients was the reference group. Compared with this group, if 36-40 or 41-45 patients were in the ED, I/AEs were more likely to occur (odds ratio [OR] 2.37 [95% confidence interval (CI) 1.40-4.01, P < 0.0] and 1.8 [95% CI 1.03-3.15, P = 0.04], respectively) but not when there were >46 patients (OR 1.7, 95% CI 1.0-3.1). Higher hospital occupancy (90-99%) was a protective factor for sustaining an I/AE (OR 0.57, 95% CI 0.35-0.92, P = 0.02).

CONCLUSION

I/AEs are common in the ED and a large proportion is preventable. Strategies for prevention are required. The relationship with patient load needs further clarification, since our data suggests increased I/AE rates with higher occupancy but not highest occupancy.