Unplanned transfers highlight need for better systems

Better systems are needed for recognising and responding to deteriorating patients in subacute care settings, according to an Australian study that shows one-third of unplanned transfers from subacute to acute care occur within 24 hours of patients being admitted to subacute care.
			Patients in subacute care require regular physiological assessment and early escalation of care if there are physiological abnormalities

Transfers within 24 hours

The researchers analysed data on 431 patients within four Victorian health services who were transferred from subacute to acute care by ambulance due to clinical deterioration or an acute adverse events, such as a fall. The median age of patients was 81 years.

They found the median length of stay in subacute care was 43 hours, with 29% of patients transferred to acute care within 24 hours, and 83.5% transferred within 72 hours of subacute care admission.

Patients transferred within 24 hours of subacute care admission were older, had more comorbidities and a longer acute care length of stay following readmission than those transferred later.

Findings in Australian Health Review showed that patients who experienced unplanned transfer had high hospital admission and in-hospital mortality rates.

Physiological assessment in the 24 hours preceding transfer was infrequent and incomplete in most patients, the study showed. Just one in 10 patients had all six elements of physiological observations that are recommended by the Australian Council on Quality and Safety of Health Care documented, despite deterioration significant enough to warrant ambulance transfer to an acute care facility.

“Patients in subacute care require regular physiological assessment and early escalation of care if there are physiological abnormalities,” the authors wrote. “Risk of clinical deterioration should be a factor in the decision to admit patients to subacute care after an acute illness or injury.”

Study supports transfers to optimise bed capacity

Transferring acutely unwell general medical patients from one hospital to another to optimise regional bed capacity does not adversely affect patient outcomes, an Australian study shows.

Researchers analysed “lateral” patient transfers between two tertiary-referral urban hospitals within a single area healthcare network, which were arranged to optimise bed capacity. The patients presented to one of the hospitals, which had an ED. Some patients were then transferred to the other hospital which had no ED, but greater bed capacity to accommodate acutely unwell admissions.

“None of our patients was transferred for their individual benefit, but to coordinate better the flow of patients with the bed availability in our region,” the authors wrote.

The study, in Australian Health Review, showed that transferred patients were likely to be older and suffer from less comorbidity than those kept at the initial hospital where they had presented.

Appropriate patients for transfer could be selected within 24 hours of arrival at an index hospital, they found.

Patients who were transferred spent a shorter time in hospital, were less likely to readmitted within seven days and had lower mortality than patients who were not transferred.

“This study may have wider implications for hospital managers at a time when tertiary referral centres are suffering bed block and community hospitals are threatened with closure,” the study authors wrote.

“Lateral transfer would reduce congestion and decrease elective surgery waiting time.”

Patient groups that benefit from the "four-hour rule"

The push to improve compliance with National Emergency Access Targets (NEAT) ‒ or the “four-hour rule” ‒ has led to reduced mortality among some groups of patients presenting to emergency, including older patients with complex medical conditions, new research shows.

Patients presenting to ED after hours or on weekends, or those with time-sensitive acute cardiorespiratory conditions also benefited from hospitals’ improved compliance with the NEAT targets ‒ under which hospitals aim to either discharge, admit or transfer ED patients within four hours of presentation.

The researchers analysed data from a major tertiary hospital that reported a near halving in mortality in association with a doubling in NEAT compliance over a two-year period from 2012‒2014.

Findings in Australian Health Review show that the inpatient mortality rate for emergency admissions decreased from 1.9% in 2011 to 1.2% in 2013, although there was no change in the percentage of deaths in the ED.

The mortality rate of older patients admitted to medical wards decreased significantly from 3.5% to 1.7%. over that time. In 2011, there was a higher mortality rate seen among patients presenting to ED triage between midnight and 12 noon and among patients presenting on weekends versus weekdays. However, those differences had disappeared by 2013.

“The present study provides the first preliminary evidence that low-cost targeted clinical redesign of the ED-inpatient interface leading to enhanced NEAT compliance is associated with improved mortality for particular subgroups of emergency patients admitted to inpatient wards,” the authors wrote.

SMR “misleading” as a measure of hospital quality

New research has raised questions about the use of the Standardised Mortality Ratio (SMR) as an indicator of hospital performance, after finding that the measure is a “misleading” measure of quality and is not associated with a hospital’s avoidable death rate.

For two decades, the overall SMR for all deaths in a hospital had been advocated as an indicator of the quality of the hospital, despite little evidence to support its use in that way, the UK researchers said.

They reviewed case records of 100 randomly selected hospital deaths from each of 34 English acute hospital trusts to determine the proportion of avoidable deaths and to determine the association with the trust’s hospital-wide SMR.

Findings in the BMJ showed that the proportion of avoidable deaths was 3.6%, but there was no statistically significant association between this measure and the hospital-wide SMRs.

The authors said the low rate of avoidable deaths, combined with the absence of any association with the SMR, suggested neither measure was a helpful or informative indicator of the quality of a hospital trust.

“Both hospital-wide SMRs and avoidable death proportions based on the judgment of only one or two reviewers have methodological shortcomings making them unsuitable indicators to compare the quality of hospitals,” the authors wrote.

They warned that it was “potentially misleading to the public, clinicians, managers and commissioners to praise or condemn” a health service or hospital on the basis of either the SMR, or the avoidable death proportions.

They added that neither of the two measures should be used as a screening test or “smoke alarm” to identify poorly performing hospital trusts until its validity for that purpose had been rigorously evaluated and demonstrated.

Inpatient deaths an efficient indicator of adverse events

Reviewing records of inpatient deaths is a more efficient way of identifying preventable adverse events than reviewing the records of those discharged alive, a new study finds. The researchers, from the Netherlands, said retrospective review of patient records was a commonly used method for estimating adverse event rates, but reviewing the records of discharged patients was time-consuming and costly.
			The authors said sampling inpatient deaths was an efficient method of reviewing adverse events, as fewer records needed to be studied to identify where safety improvements were possible

An efficient choice

They studied a sample of nearly 12,000 admissions, half of which were inpatient deaths and half for patients who had been discharged alive, to look at whether records of inpatient deaths were a valid indicator of preventable adverse events. 

Trained external nurses and physicians reviewed the nursing, medical and inpatient records to determine adverse events, which were defined as unintended injury resulting in prolongation of hospital stay, temporary or permanent disability or death that was caused by healthcare management rather than the patient’s disease.

They found patients who died in hospital were on average older, had a longer length of stay and were more often urgently admitted.

Twice as many adverse events and preventable adverse events were found among inpatient deaths, compared with in patients discharged alive

No specific type of preventable adverse event that was found in the patients discharged alive was absent in deceased patients, according to findings in BMJ Open.

The authors said sampling inpatient deaths was an efficient method of reviewing adverse events, as fewer records needed to be studied to identify where safety improvements were possible.

“To acquire information on as many improvement possibilities as possible, this would seem to be an efficient choice,” they wrote, although they added it was important to be aware that studying inpatient deaths may result in some problems remaining underexposed or overexposed.

Administrative database of little value to identify adverse events

A hospital’s clinical administrative database is of very limited value in detecting post-operative adverse events, a Spanish study has found, after showing it fails to identify almost half of such incidents.

Using a sample of 1602 patients undergoing surgery in a Spanish hospital, the researchers compared information originating from clinical and administrative database (CADB) with the data extracted from the patients’ complete clinical record, which is seen as the “gold standard”.

The study found that the rate of adverse events within 30 days of surgery was 12.5% when using the CADB, compared with 24% when using the patients’ clinical records.

The clinical administrative database failed to identify 48% of the adverse events, for two main reasons: the high rate of adverse events occurring after discharge from the hospital, and that most adverse events were identified in different patients, depending on the records used.

Of 19 types of adverse events studies, only two had moderate validity using the CADB: cardiac arrest requiring cardiopulmonary resuscitation and accidental puncture or laceration, according to findings in the International Journal for Quality in Health Care.

“Despite its limitation, we did not have a better source of information than a complete medical record,” the authors wrote.

They said despite the fact that the use of the clinical administrative database was appealing, it was of “very limited value” and could not collect information on the many adverse events that happened after discharge.

One in 10 cancer patients experience errors in care

About 10% of cancer patients report that there were errors in in the diagnosis of their illness and one in four say they experienced errors during their hospital treatment, a Danish study shows. The survey of 4346 adults with cancer found that 10% of the respondents said they experienced error at their GP during their diagnosis, 11% at the specialist practitioner and 15% at the hospital.
			The findings suggested that practices related to informed consent, diagnostic reasoning as well as handling of test results, referrals and the medical chart, should be further improved

Surgical errors most common

During hospital treatment, 25% reported experiencing errors, with 61% of those saying the error had consequences such as an increased length of hospital stay, physical and psychological consequences.

The most frequent type of errors identified in the study were unexpected surgical errors and complications (27%), delay due to doctors’ assessment errors (24%) and test results being unavailable when expected after being mislaid or delayed (21%), according to findings in the Patient Experience Journal.

The authors said it was likely the prevalence of errors was high compared to international health professional estimates because patients and healthcare professionals had different perspectives on errors.

The findings suggested that practices related to informed consent, diagnostic reasoning as well as handling of test results, referrals and the medical chart, should be further improved, they said.

They added that greater attention to patient-provider communication was needed, with a particular focus on information about surgical complications.

“The fact that patients identify errors that are not necessarily recognised by the health care system sets the stage for the involvement of patients as an extra safety barrier,” they wrote.

The evolving role of cancer registries

The role of cancer registries has evolved since they were first established in Australia more than four decades ago, a new paper suggests, with data linkage enabling registers to play an increasing part in contributing to health systems management.

The perspective piece in Australian Health Review states that cancer incidence monitoring began in NSW in 1972, with other jurisdictions soon following.

Traditionally, the role of cancer registers included monitoring incidence mortality and survival by cancer type, in order to demonstrate the changing burden of cancers and how they affected different subgroups of the population.

Registers had also been useful to show decreases in cancer incidence following interventions and had been used for workforce and other infrastructure planning, the paper stated.

However, more recently, the role of registers had expanded to include using survival data to assess health service performance, and clinical quality surveillance and improvement.

“Increasingly, population-based registry data in Australia are linked with administrative data on service delivery to assess system performance,” the authors said.

The addition of tumour stage and other prognostic indicators was important for those analyses, they said. Structured reporting of pathology, surgery and radiology data was increasing the opportunities for registers to automatically collect data on stage, grade, biomarkers and other prognostic indicators, they added.

“Registry data linkage with administrate data enable assessments of patterns of care and other performance indicators for health-system monitoring,” they wrote.

The paper was published as the federal government moved ahead with plans to introduce a new National Cancer Screening Register. As announced in this year’s budget, the new register will cover both the national bowel and cervical screening programs and will provide a template for any future national population screening tests.

This month, the federal Department of Health issued a request for a tender for a new ICT (information communication technology) system to build the register, Pulse +It magazine reported.