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Patient Safety in the Acute Healthcare Chain: Is it Safer@home?
van Galen, L.S.
2017
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van Galen, L. S. (2017). Patient Safety in the Acute Healthcare Chain: Is it Safer@home?.
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PATIENT SAFETY IN
THE ACUTE HEALTHCARE CHAIN
PA
TIENT SAFETY IN THE A
CUTE
HEAL
THC
ARE CHAIN
I s i t s a f e r @ h o m e ?
Is it safer@home?
Louise S. van Galen
Louise
S. van
PATIENT SAFETY IN
THE ACUTE HEALTHCARE CHAIN
PA
TIENT SAFETY IN THE A
CUTE
HEAL
THC
ARE CHAIN
I s i t s a f e r @ h o m e ?
Is it safer@home?
Louise S. van Galen
Louise
S. van
VRIJE UNIVERSITEIT
Patient Safety in the Acute Healthcare Chain:
Is it Safer@home?
ACADEMISCH PROEFSCHRIFT
ter verkrijging van de graad Doctor aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus
prof.dr. V. Subramaniam, in het openbaar te verdedigen ten overstaan van de promotiecommissie
van de Faculteit der Geneeskunde op dinsdag 27 juni 2017 om 15.45 uur
in de aula van de universiteit, De Boelelaan 1105
door
promotor: prof.dr. M.H.H. Kramer
Leescommissie: dr. J. Car
prof.dr. M.E. Holland prof.dr. H.A.H. Kaasjager prof.dr. J. Klein
TABLE OF CONTENTS
Chapter 1 Introduction and general outline of the thesis 9
The starting point of the hospital care chain: novel ways of organizing care
Chapter 2 Acute medical units: The way to go? A literature review 27Eur J Intern Med 2017;39:24-31
Chapter 3 Measurement of generic patient reported outcome 47 measures (PROMs) in an acute admission unit: A feasibility study
Acute Med 2016;15(1):13-9
Prevention of serious adverse events on the clinical wards
Chapter 4 Delayed recognition of deterioration of patients in general wards is 61 mostly caused by human related monitoring failures:
A root cause analysis of unplanned ICU admissions
PLoS One 2016;11(8):e0161393
Chapter 5 A protocolised once a day modified early warning score (MEWS) 79 measurement is an appropriate screening tool for major adverse
events in a general hospital population
PLoS One 2016;11(8):e0160811
The use of quality indicators to assess patient safety
Chapter 6 Exploring the preventable causes of unplanned readmissions using 93 root cause analysis: Coordination of care is the weakest link
Eur J Intern Med 2016;30:18-24
Chapter 7 Hospital readmissions: A reliable quality indicator? 111
Ned Tijdschr Geneeskd 2016;160:A9885
Chapter 8 Physician consensus on preventability and predictability of 117 readmissions based on standard case scenarios
Neth J Med 2016;74(10):434-42
Chapter 9 Patients’ and providers’ perceptions of the preventability of 131 hospital readmission: A prospective, observational study in
4 European countries
BMJ Qual Saf. 2017; In press
Chapter 10 Hospital Standardized Mortality Ratio: 153 A reliable indicator of quality of care?
Chapter 11 Summary of main results, general discussion and future perspectives 165
Chapter 12 Dutch summary 181
Appendix List of publications 193
List of scientific presentations 194
Author affiliations 195
Word of thanks 198
CHAPTER 1
INTRODUCTION AND GENERAL OUTLINE OF THE THESIS
‘Primus non nocere (in the first place, do not harm)’
11
INTRODUCTION
The (acute) healthcare chains in Europe are increasingly under pressure due to the rise in demand for care caused by the change in demographics (aging populations) and policy changes in the healthcare system. This growing demand for healthcare is also reflected by the expenditure in healthcare in the Netherlands. Currently, 90 billion euros are spend yearly on healthcare,
this is 40% more than in 2005.1 While emergency presentations have decreased, emergency
department (ED) admissions have risen greatly in the last decades, and the adjusted mean length of hospital stay in the Netherlands has also increased by 8.5%.2,3 The ageing patient
often has more comorbidities and uses more medicine when compared to a younger patient. In addition, due to overloaded general practitioners, budget cuts for nursing homes and the introduction of obligatory deductible excess these patients tend to stay at home longer without receiving the care they need. Because of this, they eventually present themselves to the hospital with more complicated problems which are often not straightforward and therefore require more diagnostics and therapy.4,5 This leads to congestion in the whole care
chain with resultant negative implications for the patients. As a result, the 1,1 million people employed in the healthcare field in the Netherlands face a daily burden trying to make patient flow as effective as possible.6 Healthcare workers in hospitals are constantly struggling to
find the balance between increasing number of ED admissions and a relative shortage of beds. Furthermore, general practitioners (GPs) and primary care facilities such as home nurses are also overloaded trying to organize appropriate care at home using the limited resources available. This accumulation in medical teams’ workload in and outside the hospital results in problems in communication and coordination within the acute healthcare chain. Inadequate care coordination and poor teamwork take place both across sites of care as between providers7
and can result in poor handovers and inadequate teamwork.8,9 These issues are relevant to
focus on since they may lead to (serious) adverse events and complications, endangering patient safety in hospitals.8,10 It is known, that in every ten patients, one is still harmed while
receiving hospital care.11
THE HEALTHCARE SYSTEM IN THE NETHERLANDS
The Dutch healthcare system often receives positive appraisal. Its overall ranking on healthcare quality, access and efficiency compared to other countries is high.12,13 The philosophy of
the system is based on some universal principles: ‘access to care for all, solidarity through medical insurance (which is compulsory and available to all) and high-quality health services.’6
It is divided into three compartments: long-term care for chronic conditions, supplementary care (i.e. dental care and physiotherapy) and basic and essential medical care (general practitioner (GP), visits to hospital admissions and specialist appointments or procedures). This last compartment consists of ‘planned’ care and ‘unplanned acute’ care.
Managed competition in healthcare market
the government but operate independently. The Netherlands has 9 insurance companies, of which the four largest share 90% of the total.14 In the last decade, the increased amount for
obligatory deductible excess has led to a restriction to care.14,15 This ‘own risk’ is the amount
paid for covered health services before the insurance plan starts to pay. As a result, this increase has unleashed a cascade effect on the insured, since the amount of supplementary insurance has steadily decreased in the last 10 years.14 This financial burden for patients results
in less visits to a physician when needed, as well as not undergoing recommended diagnostics or treatment. This causes a patient population that is more severely ill than needed if these patients had timely consulted a doctor, since reasonably ‘simple’ problems could potentially evolve in complicated syndromes.16
Patient flow through the healthcare chain (see infographic inside front cover)
Most of the times the patient flows start with the GP, the GP is seen as the gate-keeper of the Dutch healthcare system. The Dutch GP-system consists of about 5000 GP offices and is originally a well-designed system. Patients requiring hospital care mostly need a GP-referral before they are seen by specialists. An exception is the patients who live in nursing homes and are cared for by a nursing home physician or geriatric specialist on location. On average, a patient contacts his GP 4.4 times a year, children from 5-17 years visit their GP 2.3 times, patients above 85 visit 13.2 times.17 When a patient falls ill he usually visits the GP first, if
the GP assesses the patient as needing acute care he will refer the patient to the ED, mostly after contacting emergency/acute physicians in the hospital for referral. If the problem is not acute, the patient might be send home with a therapy initiated by the GP, or when the patient needs non-acute specialized care he is referred to a specialist outpatient clinic.
If a patient becomes acutely ill without having time or the physical capability to visit the GP, an ambulance may be called upon. This could for example be the case in an out-of-hospital cardiac arrest on the streets or a severely septic patient who is in immediate need of life support at home. Patients in the ED are mostly seen by emergency doctors or residents of the specialty they were referred for. From the ED, patients can be sent home for problems which do not require admission. Sometimes it is judged that better care can be provided in another hospital, or in case of a social problem transfer to a nursing home might be most suitable. If a patient does need in-hospital diagnostics and/or treatment he/she will be admitted. This can be either to an acute medical unit (AMU) or directly on to a (specialist) clinical ward. On these wards the patient is cared for by medical specialists, nurses, and other supportive healthcare providers such as occupational therapists and geriatric nurses. If patients are severely ill, they might also directly be admitted to an intensive care unit (ICU) or a unit likewise. During admission, patients may revive rapidly and can be discharged soon, either from the AMU or from another clinical ward. However, if patients deteriorate during their admission on a regular ward, an unplanned ICU admission or even death might be inevitable.
13 of his patient and the course of events during hospital admission. Not all patients can be discharged to their pre-existent (home) situation. Sometimes a transfer to another hospital, a nursing home or a rehabilitation centre might be required temporarily, or in some cases transfer to a nursing home permanently. Also, extra care such as professional ADL-support might sometimes be needed when sending the patient back to their previous home situation. Unfortunately, some discharged patients are readmitted unexpectedly to hospital, with readmission rates varying from 10-30% internationally.18 Reasons for these readmissions can
for example be recurrence of or unresolved earlier complaints, or lack of social support in the (new) home situation.
The text below describes an example of a patient moving through hospital and the difficulties faced within the chain, which was used to illustrate the problem in a recent Dutch article.19
An 80-year old woman fell at home during the evening and was not able to get up by herself. The next morning a homecare nurse found her on the floor. In the past years, this patient hardly visited her general practitioner. She had suffered from some cognitive deterioration, but with the support of her family (two sons), current home situation was still acceptable. At the time of her fall, her sons were on vacation.
The home-care nurse called the GP immediately. He visited the patient and after seeing her he wanted to refer her to the hospital for further diagnostics and treatment. The ambulance services were busily engaged and after waiting for hours an ambulance picked her up at 5.15 pm. The GP had already left then and could not provide a face-to-face handover. After patient arrived at the overcrowded ED she was seen firstly by a medical student (an intern), followed by an emergency physician, and lastly by an internal medicine resident. The patient was diagnosed with delirium and had a low sodium, probably caused by a so called ‘tea and toast’-diet. Patient was unable to recall the exact medication she currently used. Initially, there were no hospital beds available to admit patient to hospital. Finally, at 11.30 pm a bed became available and patient was admitted. After a few days in hospital, patient recovered quickly and wished to go back home. She reported to the ward nurses that things at home were going well before the admission, and she did not need any additional help. This was a relief for the (transfer) nurses, since the originally intended nursing home did not have a place at that moment for her anyway. She was discharged to her initial home situation. It was however agreed that extra professional home care would be needed and provided twice a week. In addition, the GP’s practice nurse was advised to visit her occasionally.
A few days later, patient was readmitted to hospital, again in a confused state with low sodium. This time it was decided, in agreement with the GP among others, to move patient to a nursing home. Patients was discharged and she was advised not to continue with her diuretics because of the recurring hyponatremia. A week after discharge patient presented once again to the ED. Patient was found in bed, unresponsive. The letter from the ward doctor with advice on fluid restriction and discontinuation of diuretics was sent to the GP in time, but had not reached the nursing home doctor.
CHANGING DEMOGRAPHY
The proportion of patients of 65 year and older is rising, in 2017 18% of the Dutch population is over 65 years. In 2050, it is estimated this percentage will rise to 26%.8,20 The healthcare system
is forced to adapt to this development since preventable adverse events occur significantly more often in older patients.21 In addition, older patients tend to have multiple comorbidities
and polypharmacy and often have atypical clinical presentations leading to more diagnostics
The high workload caused by this increased patient flow and a decrease of human resources due to budget cuts leads to the expense of time for patients. This is important especially in this older population where communication plays an important role in the treatment. Patient’s expectations and wishes should be spoken of thoroughly in order to prevent overtreatment
and unnecessary diagnostics.16 Lack of proper communication can have an effect on patient
safety sometimes even resulting in an unwanted ICU-admission or CPR in the elderly.23,24
Another problem faced by the Dutch healthcare system in the care for elderly is the recent governmental budget cuts on chronic care. In 2012 the Netherlands spend three times more on chronic care than Germany, and two times more than France, and the peak of the aging population was yet to be reached.25 These cuts resulted in a decrease in numbers of nursing
homes available. To date, this gap in needed care has not been adequately taken over by homecare nurses since the organization of home care by the local authorities to compensate has fallen behind. Because of this, professional help is getting more scarce and the home-caregivers are put under pressure to provide the necessary care and are forced to take responsibility for the care of the patient. Ideally, general practitioners should provide care for these patients. However, it is often difficult for a GP, who takes care of 2000 patient on average, to manage this complex care at home for probably more than one patient. Since there is no professional support for these patients, many patients remain at home until the situation is unsustainable and are ultimately admitted to the ED, often quite severely ill. Older patients are admitted more often than their younger equals and when admitted they often stay longer in hospital than required. This results in stagnation of patient flow within the chain.19
PATIENT SAFETY
As previously stated, the increasing burden on the acute healthcare chain can potentially lead to serious adverse events within the chain.26 Iatrogenic harm was already described by Hippocrates
2400 years ago (‘iatros’=doctor, ‘genesis’=origin), but in the last decades the importance of patient safety has been increasingly emphasized.8 Adverse events bring unintended, potentially
preventable care-related harm, and can compromise patient safety. Patient safety is defined as: ‘preventing errors and adverse effects to patients associated with health care’.11 These serious
advents such as in-hospital mortality, unplanned readmissions, and ICU admissions are also often the result of a lack in adequate communication and coordination between professionals, poor handover and inefficient teamwork.8,9,27,28 It is reported that patients can be handed
over 15 times in a 5-day hospitalization, and individual doctors participate in more than 3000 handovers per month.29 In addition, medical teams that are overloaded tend to perform poor
on patient safety outcomes.30
Since the first report ‘To err is human’ of the Institute of Medicine in 1999 which revealed that 7-13% of all health-related harm contributes to the death of a patient, many countries have started similar investigations.8,31 In 2004 the WHO started the Patient Safety Program,
15 care.11 This rate has stagnated and has not changed for more than 50 years.32 Statistics have
exposed that solely reducing the rate of adverse events in the European Union would prevent more than 750.000 harm-inflicting errors per year leading to over 3.2 million fewer days of hospitalization, 260.000 fewer incidents of permanent disability and 95000 fewer deaths per year, and thus providing a relief of the current pressure on the healthcare system.11 It must
be remarked that most failures do not arise from lack of knowledge or inadequate skills of the physicians, but rather from problems in the systems of care in place at time.33
Patient safety in the Netherlands
In the Netherlands, patient safety has also been an important subject of attention. EMGO-NIVEL has investigated triggers for care-related harm since 2004. Due to multiple interventions and
improvement strategies such as implementing quality indicators34 (unplanned readmissions,
unintended long length of stay, HSMR), checklists35 (SBAR), and new monitoring instruments36
(early warning scores) the incidence of potentially preventable death was reduced from 5.5% in 2008 to 2.6% in 2012.37
However, not all these new implementations are found beneficial within the healthcare chain. An unintended result of these implementations is the resistance it causes among healthcare workers on the frontline, who find most measures time-consuming, exhaustive, too administrative, and unconnected to their actual work on the floor.32 They claim the government
is battling the complexity of hospital organizations with even more complex quality and safety tools. As a result attention has shifted from care for the patient to care for the system.38
The Dutch Hospital Association has revealed that the number of health indicators is currently
up to more than 3400.8,38 In other European countries some of these indicators, such as
unplanned 30-day readmissions, are already used as a quality tool to rate and reimburse hospitals, and financial penalties may also be attached.18,39 The intensive bureaucracy also has
resulted in nurses spending 60-70% of their time performing administrative actions, of which they consider more than half as useless.38,40
Current situation in patient safety
In order to avoid harm to patients current caveats in improving patient safety must be addressed:
→ Specialization and sub specialization within hospitals result in multiple healthcare providers taking care of an individual patient, who only feel responsible for certain aspects of the patient, rather than the patient as a whole. Due to this,
patients sometimes see from 50-200 healthcare workers during their treatment.8
Since these groups of professionals are more divided than ever, but still deal with the same patient, more handovers are needed to get all required information to other healthcare workers. More handovers weakens appropriate communication
and coordination.9 Handovers between shifts and disciplines should therefore be
→ Fragmentation in healthcare processes (the GP’s office, the ED, the AMU, the ward, the ICU, transfer locations, nursing home etc.) results in inefficient and discontinuity in patient flow since the transfer between these fragments is not appropriately synchronized. Interdisciplinary interventions to streamline the patient flow between all these partners, may reduce the incidence of adverse events.28,41
→ Hospitals are often trying to assess patient safety issues independently, and are learning too little from each other’s work. Hospital partnerships could for example play a critical role for technical-knowledge exchange between healthcare workers. Also, co-development of solutions might result in rapidly evolving efficient global health systems.42
→ The rise of electronic help devices and E-health to perform more care outside the hospitals warrants adequate and smooth implementation, without impairing patient safety.
→ Since most impulses improving patient safety have been external impulses, initiated by supra-professional and regulatory bodies for example by the government or the inspection of healthcare, they have caused an insufficient bureaucratic system, which removes/takes away the attention from the real problems in the primary process on the workfloor.8,28 These politicians, regulators, policy makers among
others, are too far from the clinical frontline, basing their efforts and solutions on what they imagine everyday clinical work to be. However, these insights are all based on second or third-hand accounts of how work on the frontline is actually done, relying on data often analysed with delays.32 Efficient patient flow providing
a safer environment should be investigated from a practical and healthcare worker point of view in order to find connection with the safety issues which are faced in the field on a daily basis. Research on healthcare systems should focus on systems ‘that are real rather than ideal’.8,32
→ A culture change providing more patient participation, attitude changes in professionals and more value-based leadership is needed to shift the attention on patient safety from extrinsic to intrinsic motivation. Intrinsic motivation entails activities undertaken because of internal motivation and provide immediate effect after the action itself whereas extrinsic motivation makes people undertake actions to get a reward or to dodge a penalty from an external party, without actually being interested its immediate potential effect. High levels of ward’s shared values, beliefs and behaviours plus an individual’s perception of culture are associated with organization-wide reductions in adverse events.43
→ The focus in patient safety is mainly on the things that go wrong, instead of the things that do go right. This fixation on errors is reactive and encourages a ‘find
and fix’ approach, without changing the mindset and culture on the workfloor.32
17 → The current quality indicators used often do not measure real ‘quality’ or ‘safety’.
Of the 3400 quality indicators in the Netherlands, hardly any are developed that actually measure outcomes of quality of care. The added value of all these benchmarks and registration which should be performed to report them does not measure up to the burden they cause in daily clinical life.38,44
→ Most importantly, even though we are aiming to improve patient care, we often forget to include them in this development.
Patient involvement
In an age where patients are increasingly active as partners and demanders of care and in which patient feedback is a compulsory part it seems surprising that patients’ (and their carers’) views are not more routinely requested. In order to retrieve insights in how to do this properly we must frequently converse with patients, especially those who have suffered through unintended harm.8 The World Health Organization has also emphasized this by stating
that patient and community engagement and empowerment are the key. Their experiences and perspectives are valuable resources for identifying needs, measuring progress and evaluating outcomes.11
GENERAL OUTLINE OF THE THESIS
The aim of this thesis is to provide insight and potential improvement strategies in safety issues within the chain using novel ways to investigate these matters.
The fragments of the chain focused on in this thesis:
The starting point of the hospital care chain: novel ways of organizing care
Originally, patients enter the hospital through the ED, and if needed are admitted to the regular clinical wards in the hospital. Over the past few decades shifts in this model have occurred. Acute medical units (AMUs) have been introduced as a novel way to potentially improve the efficiency of patient flow within the healthcare chain. AMUs are defined as hospital wards specifically staffed and equipped to receive medical inpatients presenting with acute medical illness from the ED, outpatient clinics and/or the community for expedited multidisciplinary and medical specialist assessment, care and treatment for up to a designated period (typically between 24 and 72 h) prior to discharge or transfer to other wards.45 In the Netherlands,
Over the past years their implementation has rapidly evolved, especially in the UK and Australia. Since 2000, AMUs (or similar units) have also started up in the Netherlands. However, since no national Dutch guidelines or implementation standards have been created, it is still hard to conclude whether patient safety benefits from this (re)organization. In addition, no national registration of centres with such a unit are easily available, making it hard for hospitals to find and learn from each other and exchange experiences and pitfalls faced during implementation.
In chapter 2 of this thesis a systematic literature overview is provided describing the effects of an acute medical unit on patient outcomes. In addition, it gives an overview of the current situation in the Netherlands and makes recommendations that could be used to formulate national AMU guidelines.
Even though research on the effectiveness of these units has been performed extensively, the perspectives of patients on acute medical units have been underreported. The wards are often busy and operate 24 hours a day, generating a constant buzz and a potential turmoil for patients. It might be worthwhile talking to the patients in order to gather information about their experienced quality of care and the feeling of safety in such a ward. Patients are predominantly the initiator of their own healthcare pathway and their motives and experiences should therefore be investigated in order to construct more streamlined care. In addition, since the AMU caters to a heterogeneous patient population with a variety of pathology, it might be interesting to test whether the planned patient-experience orientated research is feasible in such a diverse group.
In chapter 3, we present the results of a feasibility study using Patient Reported Outcome Measures (PROMs) to measure the perceived quality of care and feeling of safety in an AMU.
Prevention of serious adverse events on the clinical wards
Serious adverse events and adverse outcomes on clinical wards such as cardiac arrest, death and unplanned ICU admissions endanger patient safety if they are the result of healthcare processes. They are often preceded by signs of clinical deterioration, such as changes in vital parameters as pulse rate, respiratory rate and level of consciousness.49,50
Unplanned ICU admissions from the ward
An unplanned ICU admission of an inpatient to the Intensive Care Unit from a general ward is considered as a SAE, and is associated with poor long term survival, especially in older patients.51 Therefore, it is important to investigate the root causes of these admissions, in order
to improve detection of these deteriorating patients and to potentially avoid unplanned ICU admissions to enhance patient safety. A useful tool to analyse root causes of adverse events is
the PRISMA-tool (Prevention and Recovery Information System for Monitoring and Analysis).52
19 accepted by the World Alliance of Safety of the World Health Organization and has shown to provide effective starting point for improvement in quality and safety of care.52-54
In chapter 4 we used a record review study to analyse the healthcare worker-, organizational-, technical-, disease- and patient-related causes that contribute to late detection and treatment of deteriorating patients in the general words using PRISMA-analysis.
Timely recognition of deterioration
To increase patient safety on nursing wards by timely detecting and treating the deteriorating patients to prevent adverse events, rapid response systems (RRs) have been introduced. These RRSs consist of an afferent limb residing a track and trigger system (TTS) such as the Modified Early Warning Score (MEWS), and an efferent limb residing a rapid intervention team (RIT) consisting of trained ICU personnel who will deliver treatment at the bedside when required.55
The effectiveness of these systems depends on timely recognition of these patients, and requires proper implementation of both limbs. The TTS such as the MEWS, mostly used by nurses to systematically monitor the patients in the wards, should be adequately implemented in order to prevent potential adverse events.
In addition to the PRISMA-analysis, chapter 4 also assessed the adherence and effectiveness of an already implemented track and trigger system (TTs) to investigate if patient deteriorations were identified timely.
In chapter 5 we determined protocol adherence of a recently reimplemented rapid response system in a prospective real-life setting, with a main focus on the effectuation of the afferent limb, assessed by the use of MEWS on the wards. We also investigated the ability of this once a day protocolised MEWS measurement to predict patient outcomes associated with poor patient safety: in-hospital mortality, hospital length of stay, cardiac arrests, ICU-admissions and unplanned 30-day readmissions.
The use of quality indicators to assess patient safety
Readmissions
Since 2015 the percentage of unplanned readmissions within 30 days after discharge of a clinical admission in the same hospital was added as an official quality indicator to already existing indicators, unintended long length of stay and in-hospital mortality.34
Currently, these indicators are regarded as a ‘major adverse events’ and are supposed to reflect the quality of healthcare in Dutch hospitals. Policy makers in the USA and the UK are already using the percentage of readmissions as a marker of quality and hospital safety; in these countries a ‘high’ readmission rate can result in financial penalties.18,39 Empirical Dutch
readmissions, and does not integrate ‘preventability’. The problem is that preventability is not easily incorporated in this quality indicator, but should be the focus of improvement.
Readmissions are not easy to investigate, since they are often multi-causal, and their causes do not solely lie in inadequate hospital care. It is however important to address this issue since the increasing burden on healthcare might pressure doctors to discharge patients too soon, potentially causing more unplanned readmissions since the actual problems may not have been resolved during initial admission.30 In addition, it is known that in an older population,
which will make up an increasing amount of our patient-mix in the next years, mortality increases if these patients are readmitted frequently.56 When studying a readmission the whole
process and decision-making in the chain should be looked upon, instead of concentrating solely on the patient and his comorbidities.
Chapter 6 aimed to identify organizational-, technical-, healthcare worker- and patient-related causes that contributed to readmission using previously described PRISMA-analysis. In addition, we assessed how many of the investigated readmissions were deemed preventable. The commentary presented in chapter 7 argues why readmissions cannot be regarded as a reliable way of assessing quality of healthcare within a hospital in its current form.
Uniform factors related to preventable readmissions have not yet been identified.57,58 In
addition, consensus definition of the preventability of a readmission has not been established. The current gold standard predominantly used is the opinions of physicians determining if a readmission is preventable. Subsequently, factors that could predict preventable readmissions are extracted from these findings.58-60
In chapter 8 we performed an international study to assess if there is any consensus between physicians regarding the predictability and preventability of medical readmissions
As previously stated, in comparison to extensive US data, no large-scale European studies have been performed about the predictability and preventability of readmissions. Furthermore, patient and healthcare worker opinions, the stakeholders that are really confronted with this problem on the frontline, are not frequently addressed to elucidate their vision.
21
Hospital Standardized Mortality Ratio (HSMR)
In order to be transparent about the quality of care, Dutch hospitals are compulsory to
publish their HSMR since 2014.61 It is one of the numerous healthcare indicators used in
the Netherlands, but together with unplanned readmissions and unexpected long length of stay, these three elementary quality indicators ought to rate and represent the quality of care within Dutch hospitals. The HSMR represents the ratio between the observed and expected deaths. The expected deaths are calculated with the use of a statistical model that corrects for certain factors such as age, socio-economic status and comorbidity.62 It is
questionable if the indicator in its current form really portrays the quality of a hospital, since it is hard to extract a complete dataset which also incorporates the clinical illness in these deceased patients.
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CHAPTER 2
ACUTE MEDICAL UNITS: THE WAY TO GO?
A LITERATURE REVIEW
Louise S. van Galen & Eline M. Lammers | Linda J. Schoonmade | Nadia Alam | Mark H. Kramer | Prabath W. Nanayakkara
Eur J Intern Med 2017;39:24-31
‘Focus on systems that are real rather than ideal’
ABSTRACT
Background
The acute healthcare chains in the Netherlands are increasingly under pressure because of rising emergency department (ED) admissions, relative bed shortages and government policy changes. In order to improve acute patient flow and quality of care through hospitals, an acute medical unit (AMU) might be a solution, as demonstrated in the UK. However, limited information is available concerning AMUs in the Netherlands.
Therefore the aims of this study were to:
1. Systematically provide an overview of current international literature regarding the effectiveness of AMUs
2. Give an overview of the current situation in the Netherlands
3. Make recommendations that could be used for future Dutch AMU guidelines
Methods
A systematic literature search was performed searching 3 electronic databases: PubMed, Cochrane and EMBASE. All 106 hospitals in the Netherlands were contacted, inquiring about the status of an ED, the AMU or future plans to start one.
Results
The literature search resulted in 31 studies that met inclusion criteria. In general, these studies reported significant benefits on number of admissions, hospital length of stay (LOS), mortality, other wards and readmissions. Among the Dutch hospitals with an Ed, 33 out of 93 Dutch hospitals implemented an AMU or similar ward, these are however organized heterogeneously. Following current trends, more AMUs are expected to be realized in the future.
Conclusion
In order to improve the current strain on the Dutch acute healthcare system, an AMU could potentially provide benefits. However, a uniform guideline is warranted to optimize and compare quality of care throughout the Netherlands.
Keywords
Acute medical unit, Healthcare quality, Implementation guidelines
Highlights
1. An Acute Medical Unit (AMU) could improve patient flow and hospital quality of care.
29
INTRODUCTION
Acute healthcare chains in the Netherlands have been increasingly under pressure in the last decade. Due to the aging population and the policy changes in the Dutch healthcare system the hospitals have seen a steady rise in emergency admissions. In addition, these patients present themselves with a higher severity of illness because this population is increasingly older and often have multiple comorbidities and polypharmacy.1 This strain on the emergency
departments (ED) increases ED length of stay (LOS) which in turn is related to a higher morbidity and mortality.2,3 Older patients tend to have atypical clinical presentations leading
to more diagnostics and 75% spend too long in the ED.4 A recent report has stated that,
for the first time in years, the adjusted mean hospital length of stay in the Netherlands has increased by 8,5 %.5 In addition to increasing admissions, a relative shortage of hospital beds
in combination with a high percentage of beds not being used efficiently have also contributed to this increase.5 Therefore, the introduction of novel ways to improve the efficiency of
the whole acute care chain is needed.
Acute medical units (AMU), which have widely been implemented in the United Kingdom (UK) and Australia, might offer a solution to the current burden on acute healthcare chains in the Netherlands. AMUs or units with similar names [i.e. medical assessment units (MAU), emergency assessment units (EAU)] are defined as hospital wards specifically staffed and equipped to receive medical inpatients presenting with acute medical illness from the ED, outpatient clinics and/or the community for expedited multidisciplinary and medical specialist assessment, care and treatment for up to a designated period (typically between 24 and 72 hours) prior to discharge or transfer to other wards.6 Frequently admitted medical conditions
are for example: sepsis, acute coronary syndrome, pneumonia, and COPD.7 An implementation
of an AMU by reorganizing already available hospital beds could potentially lead to a better and a more efficient use of available beds. Other possible advantages of implementing an AMU is to improve the quality of care by stimulating multidisciplinary (team)work, simplifying logistics, and accelerating diagnostics and therapy. In addition, an AMU potentially reduces complications and unintended errors.8
Since 2000, an increasing number of hospitals have started implementing AMUs in the Netherlands. However, there are no national guidelines setting uniform standards for creating such a ward and therefore these AMUs have been established heterogeneously. Also, no value-based indicators have been developed to evaluate the quality of healthcare in these AMUs.
Previous work has already shown the effectiveness of an AMU on patient outcomes and certain quality indicators.6,9,10 Since, in the coming years more AMUs are expected to start up
Therefore, our primary aim is to [1] Provide a systematic overview of current knowledge in international literature about the effectiveness of AMUs, [2] give an overview of the current situation in the Netherlands, and [3] make recommendations that could be used to formulate national AMU guidelines.
METHODS
Search strategy
In order to find the correct key terms used to identify units similar to ‘acute medical units’, we scanned previously written literature overviews and documentations on the matter. To identify all relevant publications search terms included controlled terms from MeSH in PubMed, EMtree in EMBASE.com plus free text terms for The Cochrane Library. Terms expressing ‘acute medical units’ and their synonyms identified were used. The full search strategies and synonyms used for all databases can be found in the Supplementary Information (Appendix A: search strategy). Afterwards, a systematic search was performed in the bibliographic databases PubMed, EMBASE.com and The Cochrane Library (via Wiley) from inception to 08-08-2016 in collaboration with a medical librarian (LS). The search was performed without date, language or publication status restriction. The references of the identified articles were searched for relevant publications.
Selection process
A total of 1909 records were excluded from the analysis primarily, because these articles did not address the effect of implementation of an AMU as their main subject (for example, articles about HIV testing or the use of antibiotics in the AMU obtained during the search were excluded). Both reviewers (LG, EL) independently screened all remaining articles identified with the search on title and abstract. If considered necessary, the whole article was checked for eligibility. After individual screening, included articles were compared and differences in opinions between the reviewers were resolved through consensus. Inclusion criteria were (i) the study should report the outcome measures on an AMU (ii) the AMUs or similar wards described should have a minimum LOS of 24 h and should conform to the definition given in the introduction [designated hospital wards specifically staffed and equipped to receive
medical inpatient presenting with acute medical illness from the ED, outpatient clinics and/ or the community for expedited multidisciplinary and medical specialist assessment, care and treatment for up to a designated period (typically between 24-72 h) prior to discharge or transfer to other wards] (iii) the AMU must admit medical patients because the AMUs were
originally designed for medical patients, and most available literature was on medical patients (iv) the study should include patients from 14 years and above (v) the unit in the study must be functional 7 days a week, 24 hours a day. Exclusion criteria were (i) no full text available (in English) (ii) certain publication types: editorials, letters, legal cases, annual hospital reports, etc. (iii) AMUs which solely admitted surgical patients, (iv) psychiatric AMUs.
Literature assessment
31 trials were found. An item ‘clinical relevance’ was added to individually assess the relevance of the paper in answering the primary objective (varying in four categories from ‘poor’ to ‘highly’ relevant). A standardized data worksheet was used for data extraction with the following variables: study design, ward description, study population, time period, aim, methods, primary endpoint, secondary endpoint, clinical relevance and overall study quality (NICE). This worksheet was filled out after reaching consensus by both reviewers during their meetings.
Search results
In total the literature search generated 3386 references, excluding duplicates. Flowchart 1 (Fig. 1) illustrates our search and selection process. After selection 100 articles remained and 2 extra articles were added after reference checks. After assessment by both reviewers, a total of 31 studies were suitable for inclusion. Appendix B shows an overview of all included articles in a table with the variables selected for data extraction.
Situation in the Netherlands
To evaluate the current situation in the Netherlands, all 106 Dutch hospital locations were telephoned and inquired 1) whether they had an ED 2) if yes, whether they had an AMU 3) if yes, since when and 4) how their AMU was organized. If hospitals did not have an AMU, they were asked if they had a similar construction such as a short stay unit, an observation unit or an acute ambulatory unit, all being located on or near the ED. Subsequently, they were asked if they had plans to implement an AMU in the future. The staff members involved with the management were inquired about the organization of the AMU if available. The results were processed anonymously. To assure no hospitals were missed a registered list of all hospitals was used. For this analysis we only included hospitals that delivered (unplanned) acute care, and thus had an ED. Fused hospitals were counted and assessed separately if they both had a separate ED.
RESULTS
Study design
The studies included in this review were published in different countries; twelve originate from the UK7,12-22, seven from Australia23-29, seven from Ireland30-36, one from Australia and
New-Zealand37, one from Canada38, one from Denmark39, one from Hong Kong40 and one from
the Netherlands41. The data of all studies were collected between 1993 and August 2016. 27
of the 30 studies had a quantitative design, three had a qualitative design.16,18,26
The most common types of quantitative study designs were comparisons of the situation before and after establishment of the AMU (thirteen in total) and comparison of the AMU to other medical wards/clinical teaching units (four in total). Furthermore, three studies used questionnaires to assess the outcomes in a cross-sectional design.19,21,35 Brand et al. (2010)
and Suthers et al. (2012) made two comparisons: pre-AMU vs. AMU and AMU vs. ward.23,27
Elder et al. (2015) compared standard care to physician at triage and the combination of
Figure 1 | Flowchart search and selection procedure of studies
the acute medical assessment unit to international benchmarking data.35 Sullivan et al. (2013)
compared different AMUs to emergency admissions in other specialties and to scheduled admissions.21 The qualitative studies all used either focus groups, semi-structured interviews
or questionnaires. Two had a cross-sectional design and one compared the situation before
and after implementation of the AMU.18
All three articles published by Boyle et al. described the situation before and after reorganization of the ED and the AMU into one emergency assessment unit.12-14. Seven articles described
the same 59-bedded acute medical assessment unit in an Irish hospital.30-36 Pradhan et al.
(2015) and McNeill et al. (2011) were multicentre analyses that includes different AMUs,
55 in the UK and 32 in Australia and New-Zealand.19,37 Sullivan et al. (2013) performed
a national study of different AMUs within the UK (the exact amount of AMUs is unknown).21
33 performed.32 Multivariate logistic regression and multiple linear regression were used in two
different studies.21,27 One longitudinal cohort study performed by Van Galen et al. (2016) used
a Bonferroni correction to compare between different time periods.41
Study population
All AMUs included in this review organized care for ‘medical’ patients. Medical patients are patients admitted for the following specialties: cardiology, gastroenterology, internal medicine, nephrology, neurology, oncology, pulmonary medicine, geriatrics, and rheumatology. In addition, the emergency assessment unit described in the three articles by Boyle et al. also consist of a surgical and a paediatric unit.12-14 Furthermore, Hadden et al. (1996) described
an AMU dedicated to both medical and surgical patients.17 For these four articles we only
report on medical patients (Appendix 2). Van Galen et al. described an acute admission unit with medical and surgical patients, but no results for the separate group of medical patients were reported and therefore could not be displayed separately.41 Figure 2 shows the Dutch
AMU model, compared to the traditional model of emergency admissions and the patient flow model mostly used on the AMU in the United Kingdom.
Becket et al. and Vork et al. described patients in the AMU who were referred from their general physician (GP) or the ED.7,39 The acute admission unit described by van Galen et
al. (2016) received patients mainly from the ED but also from the outpatients clinic.41 In
all other included studies, patients were referred from the ED only or the process was not described clearly.
Ward description
The AMUs included in this paper have heterogeneous designs. The units differ in name, location (next to ED or not), number of beds, number of nurses and physicians and the maximum LOS on the unit before discharge home or to another medical ward. When reported, the number and type of physicians on rotation differed significantly. In addition, the frequency of supervision and number of ward rounds varied.
Assessed NICE quality and clinical relevance
Cohort studies were assessed for selection, attrition, performance and detection bias according to the NICE-criteria.11 Boyle et al. (2012), Coary et al. (2014), McNeill et al. (2011),
Moloney et al. (2005), Slatyer et al. (2008), Suthers et al. (2012) and Rooney et al. (2008) were rated the highest quality cohort studies included in this review.13,26,30,34,36,37 Hadden et
al. (1996) and Yong et al. (2011) were rated the lowest quality cohort studies included.17,29
Qualitative studies were scored for the quality of their study methodology, data collection and analysis. The qualitative study with the best rating was Hanlon et al. (1997) and the study with the lowest rating was McErlain Burns et al. (1997).16,18 Basey et al. (2016), Hadden et al.
(1997) and Yong et al. (2011) were assessed as poorly relevant in contribution to answering the primary objective of this paper,17,22,29 while Coary et al. (2014), Conway et al. (2014),
McNeill et al. (2011), Moloney et al. (2005) , Rooney et al. (2008) and Suthers et al. (2012) were assessed as highly relevant.27,30,31,34,36,37
Patient outcomes
*(only significant outcomes are reported, other outcomes can be found in table 2/appendix B)Number of emergency admissions
Two articles from the Irish acute medical assessment unit describe an increase of 9,7% (5038 vs. 5528 admissions) and 4.4%(5476 vs. 5715 admissions) in the number of acute medical
admissions after establishment of an AMU.32,34 Man Lo et al. (2014) in Hong Kong found
a 14.4% decrease in the average emergency admissions rate after reorganization into an
emergency medicine ward (absolute figures unknown).40
In the UK, Boyle et al. (2008) found a 16.3% decrease in the number of acute medical admissions after reorganization of a separate AMU and ED into one emergency assessment unit, from
3667 admissions during a 3-month period before reorganization to 3068 afterwards.14 No
other reorganization structure as such was described elsewhere. Length of stay (LOS)
St. Noble t al. (2008), Downing et al. (2008) and Williams et al. (2000) found a decrease in mean hospital LOS after reorganization into an AMU from 9.3 to 7.8 days, from 5.5 to 4.6 days and from 3.8 to 2.6 days respectively.15,20,28 Moloney et al. (2005, 2006 and 2007),
35 Hanlon et al. (1997) reported no significant difference in median hospital LOS.18 Man Lo et
al. (2014) reported a significant decrease in hospital LOS (excluding the time spent in the ED) after establishment of an AMU: from 5.1 days to 4.1 days.40 In addition, a study reporting on
a medical assessment and coordination Unit in Australia showed that patients that solely stay in this unit have the shortest LOS (1.9 days), followed by patients that only stay in the medical ward (4.9 days). Patients that stay in the Medical Assessment and Coordination Unit first and in the medical ward afterwards have the longest LOS (9.2 days). St. Noble et al. (2008) reported an increased trend of patients discharged in less than 24 h and 48 h after implementation
of an AMU.20 In contrast, Yong et al. (2011) showed a decrease in the number of patients
discharged within 72 h.29
Mortality
The acute medical assessment unit used in the analysis from Ireland showed a significant decrease in 30-day mortality and annual mortality after establishment this unit from 8.8% to 5.6% and from 12.6% to 7%, respectively.36 Coary et al. (2014) also calculated the multivariate
estimate odds ratio (OR) of in-hospital 30-day mortality on this Irish acute medical assessment
unit and found an OR of 0.67 (95% CI; 0.71-0.82).30 In addition, Conway et al. (2014)
calculated the relative risk ratio (RRR) of mortality by episode and by patient in this cohort and saw a decrease of both.31 An Australian study performed by Brand et al. (2010) obtained
a significantly lower in-hospital mortality rate in their medical assessment and planning Unit (3.2%) compared to the rate in the medical ward (7.6%), however there was no significant difference between overall in-hospital mortality before and after implementation.23 Boyle et
al. (2011) saw a lower actual all-cause mortality rate than the expected all-cause mortality, whereas Yong et al. (2011) measured no significant difference, the all-cause mortality persisted at 2%.12,29 Boyle et al. (2012) also calculated the hospital standardized mortality ratio (HSMR)
and had the lowest ratio of the included UK hospitals in 3 out of 4 years.13 Suthers et al. (2012)
reported no significant change in mortality either (measurement of mortality undefined).27
Effect on other wards
Beneficial effects on other wards have been described by Downing et al. (2008) who reported a significant decrease in the number of medical patients in non-medical beds after reorganization (38 vs. 11 patients).15 Man Lo et al. in Hong Kong found an average monthly decrease of 187
patients (15%) admitted to other medical wards than the AMU.40 Hadden et al. (1997) showed
a lower percentage of patients that needed transfer to an outpatient clinic from the short stay ward in comparison to the medical ward.18 Another beneficial effect, solely described by Yong
et al. (2011), is the decrease of patients that needed transfer to the intensive care unit (ICU) (3% before vs. 2% after reorganization).29. Besides positive effects, Abenhaim et al. (2000)
reported a percentage of 20% of patients who required transfer from the medical short stay unit to ‘ordinary wards’ because of the severity of their disease.38 Also, in an Australian study
Emergency Department LOS / outpatient waiting times
Two studies reported a significant decrease in median ED LOS after establishment of an AMU, 3.1 h to 2.9 h and 8.7 h to 8.0 h respectively.24,27 Ong et al. (2012) found a significantly shorter
ED LOS for medical assessment unit patients than for medical ward patients (4.9 h vs. 6.5 h).25 Hanlon et al. (1997) saw no significant change in outpatient waiting times.18 Elder et al.
(2014) showed a significantly increased compliance to the 4-h target in the ED from 53.3%
before the medical assessment unit to 73% after implementation.24 However, McNeill et al.
(2011) reported that in more than 50% of the included units patients had to wait more than 4 hours on a daily basis because of limited AMU capacity.37 Basey et al. (2016) argued that
68% of patients were treated within the 4-h target.22 In addition, Moloney et. al (2005 and
2006) showed a decrease in the number of patients waiting in the ED after establishment of the acute medical assessment unit, 9 patients before implementation, vs. 8 afterwards.32,34
Readmission rate
Five studies describe the effect of an AMU on the readmission rate. Two studies recorded no change in 28-day readmission rate after reorganization into an AMU.15,33 Brand et al. (2010)
reported a decrease in the number of readmissions within 28 days in the medical hospital population after establishment of the medical assessment and planning unit (MAPU) (6 % readmitted vs. 5.4% readmitted), yet there was no significant difference between the MAPU
and the non-MAPU group.23Abenhaim et al. (2000) obtained a lower 30-day readmission rate
in the AMU than in the ward (9.6% vs. 13.9%), however this was not statistically significant.38
The only study performed in Denmark included in this literature review, states a significant decrease in 30-day readmission rate from 19.8% before implementation of the Medical Admission Unit to 14.6% afterwards.39
Staff and patient perspectives
The qualitative studies in this review mostly reported on the staff and patient experiences. One study from the UK presented positive reactions to the AMU from both GPs and patients. Furthermore, they also reported 64% of patients who were in the hospital before and after the establishment of the AMU indicated improvement.16 Another study from the UK,
performed by Hanlon et al. (1997) also presented positive feedback from patients and staff. However, medical staff were significantly more concerned about blocked beds in other clinical wards than before implementation and nurses expressed that they felt significantly more stressed in the AMU.18 A cross-sectional study performed in Ireland showed that the staff rated
their working environment in the AMU higher than the international benchmarking data.35
Van Galen et al. (2016) on a Dutch AMU found that patients felt safe in the AMU.41 Slatyer
et al. (2013) yet reported that patients and family members often leave the hospital with limited understanding of their health problems.26 Sullivan et al. (2013) showed that the AMU
