QJM Advance Access originally published online on March 10, 2005
QJM 2005 98(4):283-289; doi:10.1093/qjmed/hci044
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Impact of an acute medical admission unit on length of hospital stay, and emergency department ‘wait times’
From the 1Division of Internal Medicine St. James’ Hospital and 2Department of Therapeutics and Pharmacology, Trinity College Dublin, Trinity Centre at St. James’ Hospital, Dublin, Ireland
Received 13 August 2004 and in revised form 21 December 2004
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Background: While many UK hospitals have introduced an acute medical admissions unit (AMAU) to facilitate an efficient emergency admission process and reduce length of hospital stay (LOS), there is a lack of such data in the Republic of Ireland
Aim: To determine the impact of an AMAU on emergency department (ED) wait times for a hospital bed, consultant practice, and LOS.
Design: Retrospective analysis of data recorded in the hospital in-patient enquiry (HIPE) system.
Methods: We studied all emergency medical patients admitted to St James’ Hospital Dublin between 1 January 2002 and 31 December 2003. In 2002, patients were admitted directly to a variety of wards, many of which were not affiliated with a medical specialty, under the care of a named consultant physician. In 2003, two centrally located wards were re-configured to function as an AMAU, and all emergency patients were admitted to this unit.
Results: For all physician teams, median LOS shortened significantly from 2002 to 2003 (6 vs. 5 days, p<0.0001). Overall, patients seen by general physicians had a shorter LOS (5 days) than that of those seen by sub-specialists (6 days) (p<0.0001). The number of patients waiting in the ED for a hospital bed was reduced by 30% from 2002 to 2003 (p<0.001). Extrapolated cost savings for the hospital with the introduction of the AMAU were estimated at approximately 4039 bed-days and 
1 714 152.
Discussion: Introduction of the AMAU speeded access to acute medical service and reduced costs.
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Introduction |
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In the last decade, a relentless rise in emergency admissions has coincided with a reduction in hospital beds, resulting in severe problems in most acute hospitals, and each year managers and clinicians are expected to treat more with less.1–3 Evidence suggests that in many instances existing resources are used inefficiently, and that with re-organization it might be possible to improve patient care and reduce the pressure on beds within existing resources.4 Spare bed capacity is essential if an emergency admissions service is to operate efficiently and at a level of risk acceptable to patients. Given growing demands to manage costs and maximize efficiency in acute hospital services, information on patterns of resource utilization, including emergency department (ED) wait times for a hospital bed, consultant practice, and length of acute hospital stay (LOS), is valuable. While many UK hospitals have introduced an acute medical admissions unit (AMAU) to facilitate an efficient high-quality emergency admission process and reduce LOS,5–9 there is a lack of such data among patients admitted as emergencies to hospitals in the Republic of Ireland.
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Methods |
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Data relating to emergency medical patients admitted to St James’ Hospital (SJH) between 1 January 2002 and 31 December 2003 were recorded. SJH, although a tertiary referral centre for various specialties, has a daily sectorized acute general medical ‘take-in’, serving as a secondary care centre for emergency medical admissions for its local Dublin catchment area. We compared the year 2003 with the base year 2002.
In 2002, patients were admitted directly to a variety of wards, many of which were not affiliated with a medical specialty, under the care of a named consultant physician. Fourteen consultant physicians, (all dual-accredited in Internal Medicine and a major subspecialty), were responsible for the management of these patients, of whom ten were whole-time health service consultants and four held split service/academic appointments. The ‘on-call’ roster was a 1:9, with two slots each operated by teams from respiratory medicine and gastroenterology (GI), one slot each contributed by specialty teams from diabetes/endocrinology, clinical pharmacology, and rheumatology, and one slot each contributed by two teams of general internal medicine (GIM).
In 2003, two of the modern centrally located wards, with close proximity to the ED and diagnostic imaging department, were re-configured to function as an AMAU. Emergencies in acute medicine were initially assessed by the staff of the ED and referred by them to the ‘on-call’ team of the day. All such patients requiring hospitalization, apart from cases admitted directly to the coronary care or intensive care units, were admitted to the AMAU. The 59-bed capacity of the AMAU is such that with an average of 15 admissions each day, <70% of all admissions would be predicted to receive their entire hospital care within the unit (maximum permitted stay in AMAU, 5 days), and days in the AMAU were counted as hospital days. Those patients requiring a longer stay were transferred from the AMAU to the appropriate specialty or general medical beds. In 2003, the on-call roster remained a 1:9, with each physician on-call for 24 h, and a post-call ward round each morning in the AMAU; other fixed commitments were cancelled to accommodate this. Radiology, endoscopy, laboratory services, physiotherapy, occupational therapy, and social services prioritized appropriate requests from the AMAU. All patients identified as suitable for fast-track discharge had a provisional discharge date identified on the post-call ward round. Medical teams reviewed these patients early on the morning of discharge, so that discharge could be confirmed, and arrangements made to transfer the patient to the discharge lounge to free up beds for patients waiting in the ED. The discharge manager's role was to help identify patients suitable for early discharge, and work with the multidisciplinary team to ensure timeliness of discharge. A detailed operational plan for the Unit was devised following extensive discussions with all interested parties in the year prior to the inception.
A patient database was acquired by linking the patient administration system (PAS) to the Hospital In-Patient Enquiry Scheme (HIPE). HIPE is a national database of coded discharge summaries from acute public hospitals in Ireland. Ireland uses the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for both diagnosis and procedure coding since 1990, with updates every five years. Sixty hospitals participate in the system nationally; the computer-based discharge abstracting system is designed to collect demographic, clinical and administrative data on discharges and deaths from acute general hospitals. It is the only source of morbidity data available nationally for acute hospital services in Ireland. Linking the HIPE dataset with the patient administration system (PAS) permits application of routinely collected data for the purposes of research, planning and quality control. Data collected include: hospital number; patient's name; dates of admission and discharge; date of birth; sex; area of residence by county; diagnosis (principal and up to 9 additional secondary diagnoses); procedures (principal and up to 9 additional secondary procedures); and consultant responsible for care. The HIPE dataset of all coded diseases at time of discharge/death, together with procedures and investigations undertaken during the in-hospital stay was examined. Codes with <20 occurrences were not considered for analysis. Individual codes together with the combination of all related codes were evaluated.
Statistical methods
Descriptive analyses are presented in the form of medians, inter-quartile range (IQR) and proportions. Comparisons were made for LOS between groups using a non-parametric Wilcoxon rank sum test, as LOS data were significantly skewed. The Charlson co-morbidity method was used to compute a weighted index for each patient.10 A higher weighting score (based on 19 diagnostic categories) indicates more co-morbid disease. LOS was categorized into two groups using the median value, as 
6 or 7+ days. Logistic regression was used to predict LOS 7+ days by year of discharge (2002 vs. 2003) and consultant group. An interaction term was added. Adjusted odds ratio (OR) and 95%CIs are presented. Logistic regression analysis was used to identify how factors and resources differed between emergency admissions in 2003 vs. 2002; factors included gender, age, diagnosis, investigative procedures and year. In order to predict the cost-savings between generalists/specialists and between 2002/2003, a multiple regression model was used to predict average cost of bed days per patient, adjusting for case-mix between 2002/2003 by including age and gender in the model. As cost of bed days was skewed, a log transform was used to ensure the data were less skewed for the regression analysis. To predict the number of people waiting in ED, log-linear (Poisson) regression analysis was used with month and year of admission as predictors. Incidence rate ratios, the ratio of predicted number in each category in relation to reference category are presented. Statistical significance at p<0.05 is assumed throughout. All analyses were performed using the JMPin statistical package (Version 5.1, SAS Institute).
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Results |
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In the 24-month study period (1 January 2002 to 31 December 2003), we recorded 10 566 episodes among 7857 patients admitted acutely via the ED. There was an overall increase of 9.7% (5038 to 5528 episodes) in acute medical episodes presenting to St James’ Hospital requiring emergency admission from 2002 to 2003. Median age of admissions was 60.6 years (IQR 44.6–77.4); 10% were aged >84 years. Less than half of patients (48.7%) were male. Median length of stay (LOS) was 6 days (IQR 2–12); 820 episodes (7.8%) had a LOS >30 days. We compared demographic characteristics for patients admitted in 2002 and 2003; gender (p = 0.117), age (p = 0.88) and Charlson case-mix index (generalist p = 0.52; specialists p = 0.88) did not differ significantly between the years.
Effect of AMAU on hospital LOS (Table 1)
For all physician teams, the median LOS for 2002 was 6 days (IQR 3–13), being significantly longer than that for 2003 at 5 days (IQR 2–11) (p<0.0001). Overall, general physicians had a shorter LOS at 5 days (IQR 2–10) compared with sub-specialists at 6 days (IQR 2–13) (p<0.0001). For the AMAU period, the median difference was 2 days: general physicians 4 days (IQR 1–9), sub-specialists 6 days (IQR 2–12) (p<0.0001). These results remained significant after adjusting for the number of co-morbid diseases. Both generalists and specialists lowered LOS between the years; 2003 showed a 21% reduced likelihood of above median LOS (OR 0.79–95%CI 0.73–0.86). There was significant (p = 0.01) interaction between consultant team and year.
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Effect of AMAU on bed cost per patient and resource utilization (Table 2)
Cost per bed-day increased from
363.2 to 424.4 from 2002 to 2003 (+16.9%). Applying the 2003 cost per bed-day, the saving of 4039 bed-days would have yielded a cost benefit of 1 714 152, excluding those with LOS >30 days. The median cost per patient increased over the period from 1816 (IQR 726.4–3632) to 2122 (IQR 848.8–3820) (p<0.0001). Interestingly, the generalists had lower attributed costs than those of their specialist colleagues (p<0.0001). For 2002, the median generalists costs (IQR) were 1816 (726.4–3632) compared with specialist colleagues (2179, 1090–4721.6). The comparable figures (generalists vs. specialists, p<0.0001) for 2003 were 1697.6 (424.4–3819.7) and 2546.5 (848.8–5029.9), respectively. There was no significant interaction between year of discharge and generalist/specialist category, i.e. the difference between consultant groups was relatively consistent between 2002 and 2003 (p = 0.07 for test of interaction). The results remained significant after adjusting for the number of co-morbid diseases.
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Differences in admission profile between 2002 and 2003 (Table 3)
We analysed the admission profile and pattern of resource utilization for patients from each year; Table 3 shows the extent to which factors such as consultant team, discharge diagnosis and investigation procedures differed between admissions in 2003 vs. 2002. The distribution of admission between consultants altered with two teams more likely and one less likely to admit, compared with an arbitrarily chosen reference (consultant 9) between the two periods. Age, but not gender, increased in admissions between the years. Even in the short period of one year, some diagnoses/investigations (including syncope and chest pain) or procedures (ultrasound of heart, abdomen and vessels or intravenous antibiotic administration) were more common in emergency medical admissions. Others diagnoses including stroke, neoplasm, diabetes, hypertension and alcohol were significantly less common from 2002 to 2003. However the Charlson case-mix index did not differ between the years.
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Effect on Emergency Department ‘wait times’ (Table 4)
The number of those waiting in the ED for a hospital bed, was reduced by 30% in 2003 (OR 0.70, 95%CI 0.67–0.74). Months with >10 patients waiting on average for identification of a bed at 7 am, decreased from nine in 2002 to four in 2003 (p<0.05). The likelihood of waiting on a trolley was greatest in November and January, compared with all other months.
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Discussion |
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We describe a novel approach to the hospital care of acutely ill medical patients. Following the introduction of the AMAU in 2003, both the ED wait times for a hospital bed, and the in-patient LOS for acute general medical admissions were significantly shortened. Overall, general physicians (without a major specialty workload) had a shorter LOS compared with sub-specialists; this difference persisted over the two years of this observation. There was a 10% increase of acute medical episodes requiring emergency hospitalization between 2002 and 2003. The admission profile altered between the years, with increased frequencies of some diagnostic codes (chest pain and syncope) and procedures (ultrasound heart/abdomen, pulmonary scan, MR brain scan, and intravenous antibiotic). However, despite the increase in acute medical episodes, extrapolated bed day savings for the hospital in 2003 with the introduction of the AMAU have been estimated at approximately 10%.
We linked the hospital PAS and HIPE data set to define a clinically useful database relating to emergency admissions to the division of medicine for the years 2002 and 2003. Analysis of such data requires information that is comprehensive, accurate and timely. Given the costs associated with such data collection, there is considerable literature using this type of data, and supporting its use for research and monitoring purposes.11,12 However, the fact that the coding is done with a version of ICD-9-CM up to 5 years old means that advances in medical technology cannot always be captured in sufficient detail. Moreover, complex clinical documentation, inexperienced coding personnel, and illegible handwritten medical record entries all contribute to inaccurate classification. The Department of Health uses HIPE data and hospital financial information from the specialty costing system to measure and compare hospitals’ performance. The case-mix directly influences funding given to a hospital, with more efficient hospitals rewarded at the expense of the less efficient. Therefore, improvement in the quality of clinical coding is a desired goal, to make such comparisons more meaningful and to provide a firm basis for both clinical and management decisions. In our study, the HIPE database was very powerful in predicting differences in consultant practice, and LOS. We used a validated method in adjusting for the differences in physicians’ LOS, with the frequency of co-morbid diseases.10 Severity-adjusted LOS provides a more accurate measure of LOS then unadjusted LOS, and the presence of co-morbidity is significantly associated with longer LOS and hospital costs.13–15
Effective and appropriate bed usage is one of the essential elements in the efficient care and management of patients. Juggling the demands for beds against supply is problematic in the medical specialties, because the major component of the workload arises from emergency admissions (in Ireland, 84% of all medical in-patients are admitted as emergencies). AMAUs provide a focus of clinical care for medical staff, rather than having patients spread across several different wards, and facilitate an efficient high-quality emergency admissions process, with a view to a shorter LOS. The Royal College of Physicians (RCP) report in 2000 emphasized the need for more AMAUs with dedicated staff, for many physicians to be dual-trained, sessional time for consultants for emergency care, and seven-day access to investigations and support services.16
The variations we found between consultants’ practice in the AMAU may reflect a genuine special interest bias, or absence of definitive guidelines for the management of common acute medical conditions. For those instances in which guidelines do exist, a decision to investigate beyond these may be taken either in response to additional findings, increasing demand for care, fear of litigation, and the urge to make use of new technology.17–19 It would be of interest to examine the extent to which protocols and guidelines in the AMAU could reduce such variations. Moreover, there is growing evidence that, compared to specialists, general medical physicians can shorten LOS and decrease in-patient costs while maintaining the quality of patient care.20,21 Specialist practice represents a substantial workload and thus creates a conflict with the need to retain high-quality general medicine to manage the emergency workload. The balance, therefore, between specialist care and good general medical skills is critical in acute medicine.22,23 We believe that the wide diversity of diagnostic categories admitted on-take underlines the need for emergency patients to be seen by physicians who maintain a broad general medical base, and that the majority of physicians still need to be ‘general physicians with a special interest’.
The factors felt to be important in the success of the AMAU in our study were: (a) planning from the very early stages by a group including all clinicians involved in acute take and senior members of the management team; (b) a willingness by clinicians to accept that re-organization would involve a change in working practices; (c) a willingness by management to accept that some extra resources would be required (in particular, the appointment of a discharge planning co-ordinator, physiotherapist, occupational therapist, social worker, and clerical support in the AMAU); (d) the co-operation of colleagues in other specialties, such as radiology, endoscopy, and laboratory services, to provide fast-track services in their specialties; and (e) the appointment of ward managers committed to making the new system work.
In contrast to the design of our AMAU, there have been numerous initiatives in the UK designed to cope with the increase in emergency hospital admissions.24–26 In 1996 the RCP proposed that studies be conducted to evaluate the role of an acute care physician (ACP) in an AMAU.27 Such a physician would provide support to an AMAU, teach and train staff, develop protocols, undertake continuing audit, and provide an OPD service for follow-up of some patients discharged from the acute take. A study from Bournemouth showed that having senior leadership with an ACP in the AMAU avoided unnecessary admissions, and promoted strong team spirit, with junior doctors valuing having a consultant physician presence on the AMAU at all times.5 However, among the concerns for the ACP grade are the lack of career structure, the risk of burn-out from relentless acute work, the dislocation of acute medicine from subsequent in-patient care, and the deskilling of other physicians.
The alternative model of ‘physician of the week’ has been used effectively in some hospitals to provide this senior cover.7,28 In terms of organizational change, the decision by consultants to place themselves on call for one week at a time and cancel their other commitments during this week is a radical step, acknowledging that there is pressure within hospitals not to cancel specialist clinics or procedures because of the impact on waiting times. A study from Scotland found that following re-organization of acute medical care with the establishment of a ‘physician of the week’ approach in a 38-bed AMAU, more patients were discharged early within 24–48 h; those who remained were transferred to the appropriate specialist ward, and the boarding of patients in non-medical wards was eliminated through improved bed management.7 The consultant involvement in the hour-by-hour work of the AMAU was felt to be crucial to its success. Moreover, the concern that the cancellation of consultants’ out-patient clinics every 6 weeks to liberate time for ‘physician of the week’ in the AMAU would lengthen out-patient waiting times was unfounded.7 However, a full week as ‘physician of the week’ on-call is onerous, and routine commitments often simply have to be picked up again the following week.
Following this, the RCP recommended that consultant physicians should carry out a post-take ward round at least once every 24 h, and that other fixed commitments must be cancelled to accommodate this.29 Moreover, if discharge decisions are made at the consultant's ward round, then the frequency of these ward rounds can influence LOS.30 A study found that following re-organization of emergency medical admissions through an AMAU, with each physician on-call for 24 h, a post-call ward round carried out each morning, and early triage to medical specialties, there was a reduction in average LOS, and patient and staff satisfaction surveys indicated preference for the new system over the old.8 The main reasons for the increased efficiency were considered to be the appointment of a discharge planning co-ordinator, a fast-track service for laboratory investigations, and close liaisons with other medical colleagues.8
Our experience suggests that re-organization of a system for acute general medical admissions in the Republic of Ireland, with the introduction of an AMAU, and subsequent reduction in LOS, can produce major efficiency savings. In our AMAU, good practice continues to evolve with additional weekend discharge ward rounds, and the introduction of formal care pathways with evidence based acute medicine guidelines. Moreover, the wide diversity of diagnostic categories admitted underlines the need for emergency patients to be seen by physicians who maintain a broad general medical base.
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Footnotes |
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Address correspondence to Dr B. Silke, Department of Pharmacology & Therapeutics, Trinity Centre for Health Sciences, St. James’ Hospital, James’ Street, Dublin 8, Ireland. e-mail: silkeb{at}tcd.ie
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