Timely care for frail older people referred to hospital improves efficiency and reduces mortality without the need for extra resources

Abstract

Background: hospitals are under pressure to reduce waiting times and costs. One strategy that may be effective focuses on optimising the flow of emergency patients.

Objective: we undertook a patient flow analysis of older emergency patients to identify and address delays in ensuring timely care, without additional resources.

Design: prospective systems redesign study over 2 years.

Setting: the Geriatric Medicine Directorate in an acute hospital (Sheffield Teaching Hospitals NHS Foundation Trust) with 1920 beds.

Subjects: older patients admitted as emergencies.

Methods: diagnostic patient flow analysis followed by a series of Plan Do Study Act cycles to test and implement changes by a multidisciplinary team using time series run charts.

Results: 60% of patients aged 75+ years arrived in the Emergency Department during office hours, but two-thirds of the admissions to GM wards were outside office hours highlighting a major delay. Three changes were undertaken to address this, Discharge to Assess, Seven Day Working and the establishment of a Frailty Unit. Average bed occupancy fell by 20.4 beds (95% confidence interval (CI) -39.6 to -1.2, P = 0.037) for similar demand. The risk of hospital mortality also fell by 2.25% (before 11.4% (95% CI 10.4-12.4%), after 9.15% (95% CI 7.6-10.7%) which equates to a number needed to treat of 45 and a 19.7% reduction in relative risk of mortality. The risk of re-admission remained unchanged.

Conclusion: redesigning the system of care for older emergency patients led to reductions in bed occupancy and mortality without affecting re-admission rates or requiring additional resources.

Keywords: efficiency; frailty; improvement science; mortality; older people; systems thinking.