Objectives The aim of this study is to determine if there is a relationship between medical bed occupancy, performance against the 4 hour standard and hospital mortality rates.
Background The problem of crowding in EDs is recognised by professional bodies around the world as a patient safety issue and, in 2014, this was the principle campaign of the UK Royal College of Emergency Medicine. Past research has focused on the outcome of ED patients, but less is known about the effect of access block, capacity and performance for the wider group of patients in a hospital.
In June 2013, as a result of increasing workload pressures, Derby Hospitals NHS Foundation Trust introduced a 90% medicine bed occupancy target. A number of interventions were undertaken across the patient journey to facilitate this. These included daily Consultant ward rounds on medical wards, CCG-commissioning of additional community beds and planned utilisation of traditional surgical bed base for medical patients. This permitted a natural experiment to see the effect of this reduction in bed occupancy on 4HTP and mortality.
Methods This before-and-after study was undertaken in a large UK District General Hospital over a 32 month period. A range of interventions were undertaken to reduce medical bed occupancy within the Trust. 4HTP and hospital mortality (HSMR, SHMI and Crude Mortality) were compared before, and after, intervention. Daily data on medical bed occupancy and 4HTP was collected from hospital records. Segmented regression analysis of interrupted time-series method was used to estimate the changes in levels and trends in average medical bed occupancy, monthly 95% 4HTP and monthly mortality measures (HSMR, SHMI and crude mortality) that followed the intervention.
Results Mean medical bed occupancy decreased significantly from 93.7% to 90.2% (p=0.02). The trend change in 4HTP, when comparing pre- and post-intervention, revealed a significant improvement in performance (p=0.019). The intervention resulted in a mean reduction in all markers of mortality (range 4.5%–4.8%). SHMI (p=0.02) and Crude Mortality (p=0.018) showed significant trend changes after intervention.
Conclusion Whole system transformation can create lower average medical bed occupancy, reduce mortality and improve performance against the four hour target⇓.
- emergency departments
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