QJM Advance Access originally published online on April 15, 2008
QJM 2008 101(7):529-533; doi:10.1093/qjmed/hcn042
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Improving continuity of care in an acute medical unit: initial outcomes
From the 1Department of Medicine, Chelsea and Westminster Hospital and 2Imperial College London, Chelsea and Westminster Hospital
Address correspondence to Professor D. Bell (Medicine), 4th floor, Main Building, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW3 2EH.
Received 6 November 2007 and in revised form 28 February 2008
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Background: The importance of acute medical units and their associated medical cover is stressed in current practice but there is a paucity of existing research to establish their impact on acute patient care.
Aim: To assess the impact of a new medical admission process and associated medical cover on patient length of stay (LOS), direct discharge rates (DDR) (for admissions <24 and 48 h), daily discharge and readmission rates (RR).
Design: We performed a retrospective analysis of 3163 medical patients admitted before and after a ward was reconfigured to function as an acute medical unit (AMU), with a new on-call rota: ‘consultant of the day’ changing to ‘consultant of the weekend’, with aligned junior medical cover.
Methods: All medical admissions were analysed over three 2-month periods: two periods prior to the new AMU process (October to November, 2005 and June to July, 2006), and one period after the changes (October to Nov, 2006) which were made in August 2006.
Results: Average LOS was reduced from 8.6 and 9.3 for the two previous periods (June to July, 2006 and October to November, 2005) to 7.8 days for October to November, 2006, (P = 0.028). DDR for patients with a LOS under 24 and 48 h increased from 21.3% and 31.2% to 28.5% and 39.5%, respectively for both 24 h (P < 0.005) and 48 h LOS (P = 0.038). No significant difference in RR were observed (within 7 days) over the same periods. For admissions <48 h, the percentage of patients discharged increased for the Consultant-led teams (P < 0.006) before and after the new process. A statistically insignificant trend in relation to DDR was observed towards increased discharges over the weekend.
Discussion: The change in AMU process has resulted in improved DDR and patient length of stay, with no adverse effects on RR.
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Introduction |
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The past decade has seen a significant reorganisation of doctors’ training and health care delivery within the NHS, which has inevitably posed challenges to the delivery of acute care to patients. These changes were in part brought about the Calman reforms in 1993,1 followed by the New Deal and the European Working Time Directive in 2004 which reduced junior doctors’ hours.2 More recently Modernising Medical Careers, while increasing the breadth of clinical exposure in the early years, has placed further constraints on acute care delivery.3 All of these initiatives have collectively resulted in a reduction in junior doctors’ hours, and therefore their availability for direct care, and necessitated a movement towards shift-based systems. Historically, the same team of doctors would have been responsible for a particular patient throughout their hospital stay. With the advent of shift systems this has became more difficult, and new systems must be devised to minimise unnecessary transfers of care between consultant teams. Furthermore, the introduction of the 4 h access target for emergency care in 2002—a timeframe which also includes patient assessment by the medical team, and placement on a designated ward—has also exerted a strain on the medical admissions process and called for more efficient systems to be established.4
Recommendations by the Royal College of Physicians in 2004 stress the importance of medical admissions units and the need for defined medical cover for acute medicine.5 Outcomes from changes in acute care delivery are not well published although the need for change is rarely questioned. Several retrospective analyses, including those in Iowa and Ontario, have previously suggested that patients have higher mortality rates if admitted over the weekend period, particularly those with more serious medical problems.6,7 However, a more recent but smaller study in Edinburgh found no significant discrepancy in length of patient stay, mortality or readmission rates (RR) over the weekend period, and suggested this may have been due to the introduction of a medical admissions unit.8 A further retrospective analysis of 7857 patients over a 24-month period demonstrated benefits in relation to reduction in length of patient stay from a mean of 6 to 5 days following the introduction of an assessment unit.9 Reorganization of health care delivery within acute hospitals has also been assessed in a Canadian study in 2005, which revealed improvements in specific clinical outcomes through hospital restructuring.10
However, data remains limited particularly in relation to acute care. We therefore planned to assess the impact of changes at Chelsea and Westminster hospital from August 2006, before and after the establishment of a new medical admissions process.
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Methods |
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In August 2006 in Chelsea and Westminster Hospital, a 24-bed medical ward was re-configured to function as an acute medical unit (AMU), including a six bed ‘level one’ bay to cater for higher dependency patients. We also instituted a new medical rota, with staggered 24 h cover provided by three newly appointed medical admissions SHO as well as the pre-existing night SHO. The consultant rota was also converted from a ‘consultant of the day system’ (running 7 days a week), to a ‘consultant of the weekend’ system. The latter includes the same consultant on call from Friday morning to Monday morning, with the intervening weekdays covered by different daily consultants. The weekend cover was aligned accordingly with junior doctors so that over a weekend period the same consultant, registrar and two SHO (or FY2 equivalent) were on call together.
We performed a retrospective analysis of emergency medical admissions to Chelsea and Westminster Hospital over three 2-month periods; a period after the introduction of the new AMU process (October to November, 2006; patient number 1058) and two periods for comparison: (October to November, 2005; patient number 1112) and the 2 months immediately prior to the changes (June to July, 2006; patient number 993). Statistical analysis was performed using ANOVA and paired t-tests.
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Results |
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Comparison of the average LOS for medical inpatients between the three periods of studydemonstrates a significant reduction in average LOS after the new AMU process was introduced (Figure 1). Average LOS was 7.8 days for the period October to November, 2006, compared to 8.6 and 9.3 for the two previous periods (June to July 2006 and October to November, 2005, respectively) (P = 0.028).
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DDR for patients with a LOS under 24 and 48 h duration were compared between the three periods of study. There was a statistically significant improvement in DDR when the study period (October to November, 2006, 28.5% and 39.5%) was compared with the two control periods for both 24 and 48 h DDR (June to July, 2006; 21.6% and 33.9% and October to November, 2005; 21.3% and 31.2%), P < 0.005 and P = 0.038, respectively (Figure 2).
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There was no significant difference in RR (within 7 days) over the three periods (Figure 3).
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We analysed data for DDR between different consultant-led teams between the periods of June to July, 2006 and October to November, 2006 (Figure 4). For admissions under 48 h, the percentage of patients discharged increased in 11 of the 12 consultant-led teams (P < 0.006). Data for discharge rates by day of the week are shown in Figure 5. There was a trend towards a smoother daily discharge rate in October to November, 2006 compared to the previous periods with more Sunday discharges, but this was not statistically significant.
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Discussion |
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This study aimed to look at the early impact on patient-related indicators following the introduction of a new acute medical admission process. Little has been published in this area but our data agrees with recent publications and supports the potential benefits of acute medical units and coordinated medical cover in delivering acute medical care.5,9
In particular, we found an increase in the DDR for emergency medical patients (with LOS of less than 24 and 48 h), following the introduction of the new AMU process. There was also a reduction in hospital LOS over the same period. These improvements were not associated with an increase in RR within 7 days. These changes were also reflected within the consultant teams with a significant improvement in DDR. Only one of the 12 teams showed a reduction in DDR, which may be related to case mix or sample size. Discharge rates by individual consultant teams also became more uniform, which may suggest the new admissions process predominated over any previous discrepancies in team discharge patterns.
The profile of discharges over the individual weekdays appeared to show less variability but this was not statistically significant and may reflect the sample size when analysed by day, with Friday consistently having the highest percentage of discharges in all three periods. Although not statistically significant, percentage discharge rates at weekends in the study period were slightly increased as compared with both control periods. The overall result was a smoother pattern of discharges over 7 days. This is likely to have been related to the new rota changes and associated continuity of care.
In this particular study we have not monitored mortality or morbidity rates. Mortality rates are low in general and therefore a much larger study would be needed to assess the impact of these simple changes on this key outcome measure. We believe that our data supports the beneficial effects of designing an acute medical process to more closely match patient's needs. In our case this included changes to the medical rota, with a shift from the old ‘consultant of the day’ system to ‘consultant of the weekend’. Complementing this was an alignment of junior medical staff over the weekend period in order to maximise continuity of care. Thereby, tasks in patient care can be executed efficiently, negating the delay in necessary investigations and treatment until the ‘working week’. These changes are part of ongoing plans to provide even longer periods of consultant cover for the medical take, moving towards a ‘consultant of several days’ to further improve continuity of care for medical inpatients as well as potentially providing more cost-effective care. This is recommended in the recent Royal College of Physicians report ‘Acute Medical Care: The right person in the right setting—first time’, which highlights the need for on-going evaluation of changes.11
It is clear, therefore, that future large scale studies will be required to fully establish the impact of changes in the acute medical process and better define those practices which deliver improved patient outcomes. Furthermore, the impact of changes to acute healthcare delivery and rota management on the overall duties of individual hospital consultants need to be adequately explored, thereby ensuring a balance is found between resource allocation for acute medical care and other aspects of NHS care.
Conflict of interest: None declared.
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References |
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1. Calman KC. Hospital doctors: training for the future. In: The Report of the Working Group on Specialist Medical Training. (1993) London; Department of Health.
2. Department of Health. A compendium of solutions to implementing the working time directive for doctors in training. (2004) London. [www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4082635.pdf].
3. Department of Health. Modernising medical careers: the next steps. (2004) London. [http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4079530].
4. Department of Health. Reforming emergency care, streaming in Accident and Emergency Departments. (2001–2002) London. [http://www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=25511&Rendition=Web].
5. Black C. Acute medicine: making it work for patients. Hosp Med (2004) 65:493–6.[Web of Science][Medline]
6. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. New Engl J Med (2001) 345:663–8.
7. Cram P, Hillis SL, Barnett M, Rosenthal GE. Effects of weekend admission and hospital teaching status on in-hospital mortality. Am J Med (2004) 117:151–7.[CrossRef][Web of Science][Medline]
8. Schmulewitz L, Proudfoot A, Bell D. The impact of weekends on outcome for emergency patients. Clin Med (2005) 5:621–5.[Web of Science][Medline]
9. Moloney ED, Smith D, Bennett K, O’Riordan D, Silke B. Impact of an acute medical admission unit on length of hospital stay, and emergency department ‘wait times’. QJM (2005) 98:283–9.
10. Curtis B, Gregory D, Parfrey P, Kent G, Jelinski S, Kraft S, O'Reilly D, Barrett B. Quality of medical care during and shortly after acute care restructuring in Newfoundland and Labrador. J Health Serv and Res Policy (2005) 10(Suppl. 2):38–47.[CrossRef]
11. Royal College of Physicians, London Acute medical care. The right person, in the right setting – first time. In: Report of the Acute Medicine Task Force. (2007) London RCPL.
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