Original article
Implementation of an acute surgical admission ward C. F. H. Eijsvoogel1 , R. W. Peters1 , A. J. Budding1 , D. T. Ubbink1,2 , H. Vermeulen2 and N. W. L. Schep1 Departments of 1 Surgery and 2 Quality Assurance and Process Innovation, Academic Medical Centre, Amsterdam, The Netherlands Correspondence to: Dr N. W. L. Schep, Department of Surgery, Academic Medical Centre, Meibergdreef 9, PO Box 1105 AZ, Amsterdam, The Netherlands (e-mail: [email protected])
Background: The aim of the study was to assess the impact of an acute surgical admission ward on
admission and discharge processes. Methods: This prospective cohort study was conducted in a university tertiary referral centre. All acute
surgical patients were clustered in the acute surgical unit (ASU) in February and March 2012, and discharged or transferred to specialized departments within 48 h. The primary outcome was length of hospital stay (LOS). Secondary outcomes were impact on emergency department waiting times, discharge home within 48 h, incorrect ward admissions, readmissions and mortality. Outcomes of the study group were compared with those of a historical reference group admitted during the same interval the year before. Results: Some 249 patients were admitted to the ASU during the study interval. The reference group consisted of 211 patients. The total LOS decreased significantly from a median of 4⋅0 to 2⋅0 days (P = 0⋅004). The percentage of patients who were discharged within 48 h increased from 30⋅3 to 43⋅4 per cent (P = 0⋅004). The rate of incorrect ward admission decreased from 9⋅5 to 0 per cent. Emergency department waiting time, readmission rate and 30-day mortality did not change. Conclusion: Introduction of an acute surgical unit-shortened length of hospital stay without comprising readmission and mortality rates. Paper accepted 6 June 2014 Published online 13 August 2014 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9605
Introduction
Establishing an acute admission ward may improve both the efficiency of the acute admission and discharge process, and the quality of care delivered1 – 5 . The purpose of an acute admission ward is to cluster all acute patients, and to discharge or transfer them to specialized departments within 24–72 h2 . Upon admission, diagnostic testing and initial treatment is performed either in the emergency department (ED) or on the acute admission ward2,5 . In some hospitals, patients from all specialties are admitted to an acute admission ward, whereas in others a dedicated acute admission ward is set up for specialties such as surgical or internal medicine1,2 . There is evidence that an acute admission ward decreases ED waiting times1 – 4,6,7 . Moreover, pooling and subsequent transfer of all acute patients allows anticipation of the required number of beds, which could prevent incorrect ward admissions1 . Previous studies2,8 have shown that acute admission wards can increase the percentage of patients discharged within 48 h from 31 per cent up to 40 per cent. Additionally, some studies1 – 5,7 – 9 have reported © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
a reduction in length of hospital stay (LOS), with no increase in the 30-day readmission rate. Implementation of an acute admission ward can also increase the quality of care delivered and reduce mortality2,7,10 . However, it is unclear whether these potential benefits are also true for surgical patients. An acute surgical unit (ASU) was recently established in the authors’ hospital. The primary aim of the present study was to assess the impact of an ASU on LOS. Secondary outcomes were the impact on ED waiting times, discharge home within 48 h, incorrect ward admissions, readmissions, mortality and patient satisfaction. Methods
This study was conducted and described according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement11 .
Study design This cohort study investigated patients admitted to an ASU during a 2-month interval (February and March 2012), BJS 2014; 101: 1434–1438
Implementation of an acute surgical admission ward
Table 1
1435
Patient characteristics Admitted to ASU (n = 249)
Age (years)* Sex ratio (M : F) Specialty Gastrointestinal surgery Trauma surgery Orthopaedics Urology Vascular surgery Oral and maxillofacial surgery Internal medicine Plastic surgery Cardiology Neurology Patients who underwent surgery Entry portal Emergency department Outpatient clinic Day treatment centre Interventional radiology Other Diagnosis Fractures/ligament injuries Urinary tract pathology Wound/soft tissue infection Peritonitis Abdominal symptoms NOS Appendicitis Observation after trauma Ileus Peripheral vascular syndromes Cholecystitis Perianal abscess Abdominal aneurysm Other Type of referral Self-referral Recent discharge General practitioner Tertiary referral Nursing home
Reference group (n = 211)
P†
57 (39–69) 147 : 102
53 (38–67) 129 : 82
0⋅266‡ 0⋅647
73 (29⋅3) 69 (27⋅7) 36 (14⋅5) 34 (13⋅7) 9 (3⋅6) 9 (3⋅6) 13 (5⋅2) 3 (1⋅2) 2 (0⋅8) 1 (0⋅4) 90 (36⋅1)
86 (40⋅8) 42 (19⋅9) 22 (10⋅4) 30 (14⋅2) 13 (6⋅2) 6 (2⋅8) 6 (2⋅8) 4 (1⋅9) 0 (0) 2 (0⋅9) 92 (43⋅6)
0⋅010 0⋅051 0⋅194 0⋅862 0⋅202 0⋅643 0⋅202 0⋅546 0⋅192 0⋅124 0⋅103
213 (85⋅5) 23 (9⋅2) 6 (2⋅4) 3 (1⋅2) 4 (1⋅6)
206 (97⋅6) 5 (2⋅4) 0 (0) 0 (0) 0 (0)
< 0⋅001 0⋅002 0⋅023 0⋅110 0⋅064
64 (25⋅7) 32 (12⋅9) 31 (12⋅4) 19 (7⋅6) 14 (5⋅6) 8 (3⋅2) 33 (13⋅3) 9 (3⋅6) 2 (0⋅8) 10 (4⋅0) 3 (1⋅2) 4 (1⋅6) 20 (8⋅0)
53 (25⋅1) 29 (13⋅7) 27 (12⋅8) 25 (11⋅8) 14 (6⋅6) 14 (6⋅6) 13 (6⋅2) 10 (4⋅7) 6 (2⋅8) 4 (1⋅9) 4 (1⋅9) 3 (1⋅4) 9 (4⋅3)
0⋅886 0⋅779 0⋅911 0⋅125 0⋅651 0⋅087 0⋅011 0⋅546 0⋅095 0⋅190 0⋅546 0⋅872 0⋅154
141 (56⋅6) 101 (40⋅6) 4 (1⋅6) 3 (1⋅2) 0 (0)
125 (59⋅2) 77 (36⋅5) 4 (1⋅9) 3 (1⋅4) 2 (0⋅9)
0⋅571 0⋅372 0⋅808 0⋅838 0⋅124
Values in parentheses are percentages unless indicated otherwise; *values are median (i.q.r.). ASU, acute surgical unit; NOS, not otherwise specified. †χ2 test, except ‡Mann–Whitney U test.
shortly after its opening on 1 February 2012. This group was compared with a historical reference group of similar patients admitted during the same period the year before (February and March 2011).
urology. Before the implementation of the ASU in 2012, all acute patients were admitted directly to one of the specialized surgical wards under the care of the attending surgeon. The ASU is a 12-bed facility where all acute surgical patients are clustered following admission.
Setting The setting was a university medical centre in the Netherlands. Annually, about 32 000 patients are seen in the ED, of whom 5000 are acute surgical patients. Approximately 2000 patients are admitted to a surgical ward. The surgical department includes seven subspecialties: trauma, gastrointestinal, vascular, plastic and reconstructive, oral and maxillofacial, orthopaedic surgery and © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
Participants All patients admitted to the ASU were included in the study. Acute patients who had recently been discharged from a specialty ward (in the previous 6 weeks) were not admitted to the ASU but transferred directly to the same specialty ward. The historical reference group included all acute surgical patients admitted during the same www.bjs.co.uk
BJS 2014; 101: 1434–1438
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C. F. H. Eijsvoogel, R. W. Peters, A. J. Budding, D. T. Ubbink, H. Vermeulen and N. W. L. Schep
Outcome of acute surgical patients admitted to the acute surgical unit and specialized surgical wards (reference group)
Table 2
Total length of hospital stay (days)* ED waiting time (h)* Discharged home within 48 h Incorrect ward admission† 30-day readmission 30-day mortality
Admitted to ASU (n = 249)
Reference group (n = 211)
P‡
2⋅0 (1⋅0–6⋅0)
4⋅0 (2⋅0–8⋅0)
0⋅004§
3⋅2 (2⋅2–4⋅6) 108 (43⋅4)
3⋅6 (2⋅2–4⋅9) 64 (30⋅3)
0⋅414§ 0⋅004
0 (0) 39 (15⋅7) 7 (2⋅8)
20 (9⋅5) 38 (18⋅0) 11 (5⋅2)
Continuous data are shown as median (i.q.r.), and were analysed by means of Mann–Whitney U test. Differences in proportions were tested using the χ2 test. P < 0⋅050 was considered statistically significant. Data were analysed using SPSS® version 18.0 (IBM, Armonk, New York, USA).
< 0⋅001 0⋅514 0⋅189
Values in parentheses are percentages unless indicated otherwise; *values are median (i.q.r.). †Surgical patients admitted to surgical wards other than their own specialty. ASU, acute surgical unit; ED, emergency department. ‡χ2 test, except §Mann–Whitney U test.
2-month period of the previous year, before the ASU was opened. Patients were admitted from either the ED or the outpatient clinic. Patients admitted from the outpatient clinic were not included in the time analysis as exact time data were not available. All diagnostic procedures, including laboratory testing and radiological examinations, were done in the ED before admission to the ASU. All patients were immediately assigned to a specialist within a surgical specialty. This specialist remained responsible for the care of the patient during the entire stay in the ASU and on the specialized ward. All patients had to be discharged from the hospital or transferred to one of the surgical (specialty) wards within 48 h of admission to the ASU.
Variables and data sources Patient demographics were extracted from the digital hospital information system and digital patient records. Patients were classified according to their diagnosis. Peritonitis was defined as perforation of a hollow viscus or an intra-abdominal abscess following recent surgery. The diagnostic group ‘other’ included non-surgical diagnoses (for example pneumonia, arrhythmia, problems with feeding tubes or drains, and non-specific complaints). Data were collected on LOS (time between admission and discharge from hospital), ED waiting time (time spent in the ED before admission to the ASU), percentage of patients discharged within 48 h, and incorrect ward admissions (admission to a ward of another specialty owing to lack of beds on the surgical ward). The number of patients readmitted to hospital within 30 days was used to calculate the readmission rate. Mortality was recorded as the number of patients who died within 1 month after discharge. © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
Statistical analysis
Results
Between February and March 2012, 249 patients were admitted to the ASU. The reference group consisted of 211 patients. Patient characteristics are shown in Table 1. There were significantly fewer gastrointestinal admissions and slightly more trauma admissions in 2012. The most frequently occurring diagnoses in both groups were fractures and ligament injuries, urinary tract pathology, wound and/or soft tissue infections, peritonitis and abdominal symptoms not otherwise specified, and observation following trauma. The median LOS in the ASU was 21⋅0 (14⋅3–33⋅8) h. Some 220 patients (88⋅4 per cent) were either discharged or transferred to a specialized department within 48 h. The patient satisfaction survey was filled out by 99 (39⋅8 per cent) of the 249 patients; respondents gave an overall median satisfaction score of 8. Primary and secondary outcomes are shown in Table 2. Median LOS decreased significantly from 4⋅0 days before implementation of the ASU to 2⋅0 days in 2012 (P = 0⋅004). The percentage of patients discharged home within 48 h increased significantly by 13 per cent. There was no difference in ED waiting time between the groups (3⋅6 versus 3⋅2 h; P = 0⋅414). The rate of incorrect ward admissions dropped from 9⋅5 to 0 per cent. Readmission rates and 30-day mortality did not change from 2011 to 2012. Discussion
The aim of this study was to assess the impact of an ASU on the admission and discharge of surgical patients. Implementation of the ASU was associated with a decreased LOS and an increase in the percentage of patients discharged within 48 h. Incorrect ward admissions were avoided following implementation of the ASU, without comprising readmission and mortality rates or patient satisfaction. Previous studies also reported a reduction in LOS ranging from 0⋅2 to 2⋅5 days2,9 , and an increase in the percentage of patients discharged home within 48 h2,8 . Implementation of the ASU did not lead to a decrease in ED waiting times. Multiple factors, such as waiting for a www.bjs.co.uk
BJS 2014; 101: 1434–1438
Implementation of an acute surgical admission ward
physician or diagnostic tests, influence the patient’s duration of stay in the ED. According to the protocol in the authors’ hospital, all diagnostic tests are performed in the ED before admission to the ASU. This could explain why implementation of the ASU had a limited effect on the ED waiting time. The decision not to transfer diagnostics from the ED to the ASU was budget-driven. Other hospitals have allowed diagnosis on the ASU, located the acute admission ward close to the ED, or given priority to diagnostic tests for patients on the acute admission ward. Within this setting, a decrease in ED waiting times has been reported3,6,7 . Transferring part of diagnostic testing from the ED to the ASU will have an impact on logistics. Priority should be given to laboratory or radiological diagnosis of patients in the ASU to facilitate discharge within 48 h. Few studies have presented data on incorrect ward admissions. Some studies1,3,6,7 reported an increase in quality of care when the number of wrong admissions was reduced. Following implementation of the ASU in the present study, there were no incorrect ward admissions among surgical patients. However, more non-surgical patients (such as internal medicine, cardiology and neurology) were admitted; the diagnosis category ‘other’ in Table 1 consisted predominantly of such non-surgical patients. This finding may be explained by an increase in available beds while other departments were struggling with lack of beds. Similar to findings in other studies2,3,7 , the present study found no increase in the 30-day readmission rate. In the present study, patients rated their stay in the ASU as more than satisfactory. Chandra and colleagues12 compared patient satisfaction before and after implementation of an acute admission ward, and found an increase in patient satisfaction. The patients in the historical reference group in this study did not fill out a questionnaire, which made a comparison impossible. On the basis of a review of various types of acute admission ward, a number of key differences between the ASU and other acute admission wards can be pointed out. Unlike most acute admission wards, the ASU does not have doctors trained to deal exclusively with acute admissions. ED physicians at the authors’ hospital are not allowed to admit patients themselves; a surgeon or senior resident decides whether an acute surgical patient in the ED should be admitted to the ASU. Furthermore, the ASU does not have improved access to diagnostic facilities or a location near the ED. These differences may have mitigated the positive effects found in this study. Further improvement in efficiency may be expected from implementation of fixed twice-daily discharge evaluations. © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
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This study has some limitations. The prospectively collected data were compared with data from a historical control group, which introduces known and unknown sources of bias. There were differences in diagnosis between the two groups, which may have influenced the results. The percentage of patients in the gastrointestinal surgery specialty also differed significantly. However, there was no difference between the groups in the proportion of patients diagnosed with peritonitis, abdominal symptoms not otherwise specified, appendicitis, ileus or cholecystitis. Therefore, the shorter LOS was probably not explained by the lower proportion of gastrointestinal admissions in the ASU cohort. The number of patients admitted for clinical observation following trauma was significantly greater after implementation of the ASU. This may have influenced the LOS because most of these patients were discharged within 48 h. The study was conducted immediately after implementation of the new ASU and its effects may become more pronounced over time. A substantial number of patients admitted to the AUS exceeded the 48-h limit. Regulations stated that patients who were soon to be discharged could extend their stay by a few more hours, to avoid unnecessary patient transfers. Disclosure
The authors declare no conflict of interest. References 1 Cooke MW, Higgins J, Kidd P. Use of emergency observation and assessment wards: a systematic literature review. Emerg Med J 2003; 20: 138–142. 2 Scott I, Vaughan L, Bell D. Effectiveness of acute medical units in hospitals: a systematic review. Int J Qual Health Care 2009; 21: 397–407. 3 Moloney ED, Smith D, Bennett K, O’Riordan D, Silke B. Impact of an acute medical admission unit on length of hospital stay, and emergency department ‘wait times’. Q J Med 2005; 98: 283–289. 4 Daly S, Campbell DA, Cameron PA. Short-stay units and observation medicine: a systematic review. MJA 2003; 178: 559–563. 5 Vork JC, Brabrand M, Folkestad L, Thomsen KK, Knudsen T, Christiansen C. A medical admission unit reduces duration of hospital stay and number of readmissions. Dan Med Bull 2011; 58: A4288. 6 Scott IA, Wills RA, Coory M, Watson MJ, Butler F, Waters M et al. Impact of hospital-wide process redesign on clinical outcomes: a comparative study of internally versus externally led intervention. BMJ Qual Saf 2011; 20: 539–548. 7 Li JY, Yong TY, Bennett DM, O’Brien LT, Roberts S, Hakendorf P et al. Outcomes of establishing an acute
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assessment unit in the general medical service of a tertiary teaching hospital. Med J Aust 2010; 192: 384–387. 8 St Noble VJ, Davies G, Bell D. Improving continuity of care in an acute medical unit: initial outcomes. Q J Med 2008; 101: 529–533. 9 Leykum LK, Huerta V, Mortensen E. Implementation of a hospitalist-run observation unit and impact on length of stay: a brief report. J Hosp Med 2010; 5: E2–E5. 10 Rooney T, Moloney ED, Bennett K, O’Riordan D, Silke B. Impact of an acute medical admission unit on hospital
mortality: a 5-year prospective study. Q J Med 2008; 101: 457–465. 11 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61: 344–349. 12 Chandra A, Sieck S, Hocker M, Gerardo CJ, Villani J, Harrison D et al. An observation unit may help improve an institution’s Press Ganey satisfaction score. Crit Pathw Cardiol 2011; 10: 104–106.
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BJS 2014; 101: 1434–1438
Implementation of an acute surgical admission ward C. F. H. Eijsvoogel1 , R. W. Peters1 , A. J. Budding1 , D. T. Ubbink1,2 , H. Vermeulen2 and N. W. L. Schep1 Departments of 1 Surgery and 2 Quality Assurance and Process Innovation, Academic Medical Centre, Amsterdam, The Netherlands Correspondence to: Dr N. W. L. Schep, Department of Surgery, Academic Medical Centre, Meibergdreef 9, PO Box 1105 AZ, Amsterdam, The Netherlands (e-mail: [email protected])
Background: The aim of the study was to assess the impact of an acute surgical admission ward on
admission and discharge processes. Methods: This prospective cohort study was conducted in a university tertiary referral centre. All acute
surgical patients were clustered in the acute surgical unit (ASU) in February and March 2012, and discharged or transferred to specialized departments within 48 h. The primary outcome was length of hospital stay (LOS). Secondary outcomes were impact on emergency department waiting times, discharge home within 48 h, incorrect ward admissions, readmissions and mortality. Outcomes of the study group were compared with those of a historical reference group admitted during the same interval the year before. Results: Some 249 patients were admitted to the ASU during the study interval. The reference group consisted of 211 patients. The total LOS decreased significantly from a median of 4⋅0 to 2⋅0 days (P = 0⋅004). The percentage of patients who were discharged within 48 h increased from 30⋅3 to 43⋅4 per cent (P = 0⋅004). The rate of incorrect ward admission decreased from 9⋅5 to 0 per cent. Emergency department waiting time, readmission rate and 30-day mortality did not change. Conclusion: Introduction of an acute surgical unit-shortened length of hospital stay without comprising readmission and mortality rates. Paper accepted 6 June 2014 Published online 13 August 2014 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9605
Introduction
Establishing an acute admission ward may improve both the efficiency of the acute admission and discharge process, and the quality of care delivered1 – 5 . The purpose of an acute admission ward is to cluster all acute patients, and to discharge or transfer them to specialized departments within 24–72 h2 . Upon admission, diagnostic testing and initial treatment is performed either in the emergency department (ED) or on the acute admission ward2,5 . In some hospitals, patients from all specialties are admitted to an acute admission ward, whereas in others a dedicated acute admission ward is set up for specialties such as surgical or internal medicine1,2 . There is evidence that an acute admission ward decreases ED waiting times1 – 4,6,7 . Moreover, pooling and subsequent transfer of all acute patients allows anticipation of the required number of beds, which could prevent incorrect ward admissions1 . Previous studies2,8 have shown that acute admission wards can increase the percentage of patients discharged within 48 h from 31 per cent up to 40 per cent. Additionally, some studies1 – 5,7 – 9 have reported © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
a reduction in length of hospital stay (LOS), with no increase in the 30-day readmission rate. Implementation of an acute admission ward can also increase the quality of care delivered and reduce mortality2,7,10 . However, it is unclear whether these potential benefits are also true for surgical patients. An acute surgical unit (ASU) was recently established in the authors’ hospital. The primary aim of the present study was to assess the impact of an ASU on LOS. Secondary outcomes were the impact on ED waiting times, discharge home within 48 h, incorrect ward admissions, readmissions, mortality and patient satisfaction. Methods
This study was conducted and described according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement11 .
Study design This cohort study investigated patients admitted to an ASU during a 2-month interval (February and March 2012), BJS 2014; 101: 1434–1438
Implementation of an acute surgical admission ward
Table 1
1435
Patient characteristics Admitted to ASU (n = 249)
Age (years)* Sex ratio (M : F) Specialty Gastrointestinal surgery Trauma surgery Orthopaedics Urology Vascular surgery Oral and maxillofacial surgery Internal medicine Plastic surgery Cardiology Neurology Patients who underwent surgery Entry portal Emergency department Outpatient clinic Day treatment centre Interventional radiology Other Diagnosis Fractures/ligament injuries Urinary tract pathology Wound/soft tissue infection Peritonitis Abdominal symptoms NOS Appendicitis Observation after trauma Ileus Peripheral vascular syndromes Cholecystitis Perianal abscess Abdominal aneurysm Other Type of referral Self-referral Recent discharge General practitioner Tertiary referral Nursing home
Reference group (n = 211)
P†
57 (39–69) 147 : 102
53 (38–67) 129 : 82
0⋅266‡ 0⋅647
73 (29⋅3) 69 (27⋅7) 36 (14⋅5) 34 (13⋅7) 9 (3⋅6) 9 (3⋅6) 13 (5⋅2) 3 (1⋅2) 2 (0⋅8) 1 (0⋅4) 90 (36⋅1)
86 (40⋅8) 42 (19⋅9) 22 (10⋅4) 30 (14⋅2) 13 (6⋅2) 6 (2⋅8) 6 (2⋅8) 4 (1⋅9) 0 (0) 2 (0⋅9) 92 (43⋅6)
0⋅010 0⋅051 0⋅194 0⋅862 0⋅202 0⋅643 0⋅202 0⋅546 0⋅192 0⋅124 0⋅103
213 (85⋅5) 23 (9⋅2) 6 (2⋅4) 3 (1⋅2) 4 (1⋅6)
206 (97⋅6) 5 (2⋅4) 0 (0) 0 (0) 0 (0)
< 0⋅001 0⋅002 0⋅023 0⋅110 0⋅064
64 (25⋅7) 32 (12⋅9) 31 (12⋅4) 19 (7⋅6) 14 (5⋅6) 8 (3⋅2) 33 (13⋅3) 9 (3⋅6) 2 (0⋅8) 10 (4⋅0) 3 (1⋅2) 4 (1⋅6) 20 (8⋅0)
53 (25⋅1) 29 (13⋅7) 27 (12⋅8) 25 (11⋅8) 14 (6⋅6) 14 (6⋅6) 13 (6⋅2) 10 (4⋅7) 6 (2⋅8) 4 (1⋅9) 4 (1⋅9) 3 (1⋅4) 9 (4⋅3)
0⋅886 0⋅779 0⋅911 0⋅125 0⋅651 0⋅087 0⋅011 0⋅546 0⋅095 0⋅190 0⋅546 0⋅872 0⋅154
141 (56⋅6) 101 (40⋅6) 4 (1⋅6) 3 (1⋅2) 0 (0)
125 (59⋅2) 77 (36⋅5) 4 (1⋅9) 3 (1⋅4) 2 (0⋅9)
0⋅571 0⋅372 0⋅808 0⋅838 0⋅124
Values in parentheses are percentages unless indicated otherwise; *values are median (i.q.r.). ASU, acute surgical unit; NOS, not otherwise specified. †χ2 test, except ‡Mann–Whitney U test.
shortly after its opening on 1 February 2012. This group was compared with a historical reference group of similar patients admitted during the same period the year before (February and March 2011).
urology. Before the implementation of the ASU in 2012, all acute patients were admitted directly to one of the specialized surgical wards under the care of the attending surgeon. The ASU is a 12-bed facility where all acute surgical patients are clustered following admission.
Setting The setting was a university medical centre in the Netherlands. Annually, about 32 000 patients are seen in the ED, of whom 5000 are acute surgical patients. Approximately 2000 patients are admitted to a surgical ward. The surgical department includes seven subspecialties: trauma, gastrointestinal, vascular, plastic and reconstructive, oral and maxillofacial, orthopaedic surgery and © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
Participants All patients admitted to the ASU were included in the study. Acute patients who had recently been discharged from a specialty ward (in the previous 6 weeks) were not admitted to the ASU but transferred directly to the same specialty ward. The historical reference group included all acute surgical patients admitted during the same www.bjs.co.uk
BJS 2014; 101: 1434–1438
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C. F. H. Eijsvoogel, R. W. Peters, A. J. Budding, D. T. Ubbink, H. Vermeulen and N. W. L. Schep
Outcome of acute surgical patients admitted to the acute surgical unit and specialized surgical wards (reference group)
Table 2
Total length of hospital stay (days)* ED waiting time (h)* Discharged home within 48 h Incorrect ward admission† 30-day readmission 30-day mortality
Admitted to ASU (n = 249)
Reference group (n = 211)
P‡
2⋅0 (1⋅0–6⋅0)
4⋅0 (2⋅0–8⋅0)
0⋅004§
3⋅2 (2⋅2–4⋅6) 108 (43⋅4)
3⋅6 (2⋅2–4⋅9) 64 (30⋅3)
0⋅414§ 0⋅004
0 (0) 39 (15⋅7) 7 (2⋅8)
20 (9⋅5) 38 (18⋅0) 11 (5⋅2)
Continuous data are shown as median (i.q.r.), and were analysed by means of Mann–Whitney U test. Differences in proportions were tested using the χ2 test. P < 0⋅050 was considered statistically significant. Data were analysed using SPSS® version 18.0 (IBM, Armonk, New York, USA).
< 0⋅001 0⋅514 0⋅189
Values in parentheses are percentages unless indicated otherwise; *values are median (i.q.r.). †Surgical patients admitted to surgical wards other than their own specialty. ASU, acute surgical unit; ED, emergency department. ‡χ2 test, except §Mann–Whitney U test.
2-month period of the previous year, before the ASU was opened. Patients were admitted from either the ED or the outpatient clinic. Patients admitted from the outpatient clinic were not included in the time analysis as exact time data were not available. All diagnostic procedures, including laboratory testing and radiological examinations, were done in the ED before admission to the ASU. All patients were immediately assigned to a specialist within a surgical specialty. This specialist remained responsible for the care of the patient during the entire stay in the ASU and on the specialized ward. All patients had to be discharged from the hospital or transferred to one of the surgical (specialty) wards within 48 h of admission to the ASU.
Variables and data sources Patient demographics were extracted from the digital hospital information system and digital patient records. Patients were classified according to their diagnosis. Peritonitis was defined as perforation of a hollow viscus or an intra-abdominal abscess following recent surgery. The diagnostic group ‘other’ included non-surgical diagnoses (for example pneumonia, arrhythmia, problems with feeding tubes or drains, and non-specific complaints). Data were collected on LOS (time between admission and discharge from hospital), ED waiting time (time spent in the ED before admission to the ASU), percentage of patients discharged within 48 h, and incorrect ward admissions (admission to a ward of another specialty owing to lack of beds on the surgical ward). The number of patients readmitted to hospital within 30 days was used to calculate the readmission rate. Mortality was recorded as the number of patients who died within 1 month after discharge. © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
Statistical analysis
Results
Between February and March 2012, 249 patients were admitted to the ASU. The reference group consisted of 211 patients. Patient characteristics are shown in Table 1. There were significantly fewer gastrointestinal admissions and slightly more trauma admissions in 2012. The most frequently occurring diagnoses in both groups were fractures and ligament injuries, urinary tract pathology, wound and/or soft tissue infections, peritonitis and abdominal symptoms not otherwise specified, and observation following trauma. The median LOS in the ASU was 21⋅0 (14⋅3–33⋅8) h. Some 220 patients (88⋅4 per cent) were either discharged or transferred to a specialized department within 48 h. The patient satisfaction survey was filled out by 99 (39⋅8 per cent) of the 249 patients; respondents gave an overall median satisfaction score of 8. Primary and secondary outcomes are shown in Table 2. Median LOS decreased significantly from 4⋅0 days before implementation of the ASU to 2⋅0 days in 2012 (P = 0⋅004). The percentage of patients discharged home within 48 h increased significantly by 13 per cent. There was no difference in ED waiting time between the groups (3⋅6 versus 3⋅2 h; P = 0⋅414). The rate of incorrect ward admissions dropped from 9⋅5 to 0 per cent. Readmission rates and 30-day mortality did not change from 2011 to 2012. Discussion
The aim of this study was to assess the impact of an ASU on the admission and discharge of surgical patients. Implementation of the ASU was associated with a decreased LOS and an increase in the percentage of patients discharged within 48 h. Incorrect ward admissions were avoided following implementation of the ASU, without comprising readmission and mortality rates or patient satisfaction. Previous studies also reported a reduction in LOS ranging from 0⋅2 to 2⋅5 days2,9 , and an increase in the percentage of patients discharged home within 48 h2,8 . Implementation of the ASU did not lead to a decrease in ED waiting times. Multiple factors, such as waiting for a www.bjs.co.uk
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Implementation of an acute surgical admission ward
physician or diagnostic tests, influence the patient’s duration of stay in the ED. According to the protocol in the authors’ hospital, all diagnostic tests are performed in the ED before admission to the ASU. This could explain why implementation of the ASU had a limited effect on the ED waiting time. The decision not to transfer diagnostics from the ED to the ASU was budget-driven. Other hospitals have allowed diagnosis on the ASU, located the acute admission ward close to the ED, or given priority to diagnostic tests for patients on the acute admission ward. Within this setting, a decrease in ED waiting times has been reported3,6,7 . Transferring part of diagnostic testing from the ED to the ASU will have an impact on logistics. Priority should be given to laboratory or radiological diagnosis of patients in the ASU to facilitate discharge within 48 h. Few studies have presented data on incorrect ward admissions. Some studies1,3,6,7 reported an increase in quality of care when the number of wrong admissions was reduced. Following implementation of the ASU in the present study, there were no incorrect ward admissions among surgical patients. However, more non-surgical patients (such as internal medicine, cardiology and neurology) were admitted; the diagnosis category ‘other’ in Table 1 consisted predominantly of such non-surgical patients. This finding may be explained by an increase in available beds while other departments were struggling with lack of beds. Similar to findings in other studies2,3,7 , the present study found no increase in the 30-day readmission rate. In the present study, patients rated their stay in the ASU as more than satisfactory. Chandra and colleagues12 compared patient satisfaction before and after implementation of an acute admission ward, and found an increase in patient satisfaction. The patients in the historical reference group in this study did not fill out a questionnaire, which made a comparison impossible. On the basis of a review of various types of acute admission ward, a number of key differences between the ASU and other acute admission wards can be pointed out. Unlike most acute admission wards, the ASU does not have doctors trained to deal exclusively with acute admissions. ED physicians at the authors’ hospital are not allowed to admit patients themselves; a surgeon or senior resident decides whether an acute surgical patient in the ED should be admitted to the ASU. Furthermore, the ASU does not have improved access to diagnostic facilities or a location near the ED. These differences may have mitigated the positive effects found in this study. Further improvement in efficiency may be expected from implementation of fixed twice-daily discharge evaluations. © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
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This study has some limitations. The prospectively collected data were compared with data from a historical control group, which introduces known and unknown sources of bias. There were differences in diagnosis between the two groups, which may have influenced the results. The percentage of patients in the gastrointestinal surgery specialty also differed significantly. However, there was no difference between the groups in the proportion of patients diagnosed with peritonitis, abdominal symptoms not otherwise specified, appendicitis, ileus or cholecystitis. Therefore, the shorter LOS was probably not explained by the lower proportion of gastrointestinal admissions in the ASU cohort. The number of patients admitted for clinical observation following trauma was significantly greater after implementation of the ASU. This may have influenced the LOS because most of these patients were discharged within 48 h. The study was conducted immediately after implementation of the new ASU and its effects may become more pronounced over time. A substantial number of patients admitted to the AUS exceeded the 48-h limit. Regulations stated that patients who were soon to be discharged could extend their stay by a few more hours, to avoid unnecessary patient transfers. Disclosure
The authors declare no conflict of interest. References 1 Cooke MW, Higgins J, Kidd P. Use of emergency observation and assessment wards: a systematic literature review. Emerg Med J 2003; 20: 138–142. 2 Scott I, Vaughan L, Bell D. Effectiveness of acute medical units in hospitals: a systematic review. Int J Qual Health Care 2009; 21: 397–407. 3 Moloney ED, Smith D, Bennett K, O’Riordan D, Silke B. Impact of an acute medical admission unit on length of hospital stay, and emergency department ‘wait times’. Q J Med 2005; 98: 283–289. 4 Daly S, Campbell DA, Cameron PA. Short-stay units and observation medicine: a systematic review. MJA 2003; 178: 559–563. 5 Vork JC, Brabrand M, Folkestad L, Thomsen KK, Knudsen T, Christiansen C. A medical admission unit reduces duration of hospital stay and number of readmissions. Dan Med Bull 2011; 58: A4288. 6 Scott IA, Wills RA, Coory M, Watson MJ, Butler F, Waters M et al. Impact of hospital-wide process redesign on clinical outcomes: a comparative study of internally versus externally led intervention. BMJ Qual Saf 2011; 20: 539–548. 7 Li JY, Yong TY, Bennett DM, O’Brien LT, Roberts S, Hakendorf P et al. Outcomes of establishing an acute
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assessment unit in the general medical service of a tertiary teaching hospital. Med J Aust 2010; 192: 384–387. 8 St Noble VJ, Davies G, Bell D. Improving continuity of care in an acute medical unit: initial outcomes. Q J Med 2008; 101: 529–533. 9 Leykum LK, Huerta V, Mortensen E. Implementation of a hospitalist-run observation unit and impact on length of stay: a brief report. J Hosp Med 2010; 5: E2–E5. 10 Rooney T, Moloney ED, Bennett K, O’Riordan D, Silke B. Impact of an acute medical admission unit on hospital
mortality: a 5-year prospective study. Q J Med 2008; 101: 457–465. 11 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61: 344–349. 12 Chandra A, Sieck S, Hocker M, Gerardo CJ, Villani J, Harrison D et al. An observation unit may help improve an institution’s Press Ganey satisfaction score. Crit Pathw Cardiol 2011; 10: 104–106.
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