Using HIPE data as a research and planning tool

Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings

AIMS

To identify the costs associated with nurse sensitive adverse events and the impact of these events on patients' length of stay.

DESIGN

Retrospective cohort study using administrative hospital data.

METHODS

Data were sourced from patient discharge information (N = 5544) from six acute wards within three hospitals (July 2016-October 2017). A retrospective patient record review was undertaken by extracting data from the hospitals' administrative systems on inpatient discharges, length of stay and diagnoses; eleven adverse events sensitive to nurse staffing were identified within the administrative system. A negative binomial regression is employed to assess the impact of nurse sensitive adverse events on length of stay.

RESULTS

Sixteen per cent of the sample (n = 897) had at least one nurse sensitive adverse event during their episode of care. The model revealed when age, gender, admission type and complexity are controlled for, each additional nurse sensitive adverse event experienced by a patient was associated with an increase in the length of stay beyond the national average by 0.48 days (p = .001). Applying this to the daily average cost of inpatient stay per patient (€1456), we estimate the average cost associated with each nurse sensitive adverse event to be €694. Extrapolating this nationally, the economic cost of nurse sensitive adverse events to the health service in Ireland is estimated to be €91.3 million annually.

CONCLUSION

These potentially avoidable events are associated with a significant economic burden to health systems. The estimates provided here can be used to inform and prepare the way for future economic evaluations of nurse staffing initiatives that aim to improve care and safety.

IMPACT

As many of these nurse sensitive adverse events are avoidable, in addition to patient benefits, there is a potential substantial financial return on investment from strategies such as improved nurse staffing that can reduce their occurrence.

Assessing the concordance and accuracy between hospital discharge data, electronic health records, and register books for diagnosis of inpatient admissions of miscarriage: A retrospective linked data study

BACKGROUND

Despite the high prevalence of miscarriage, there are few studies which assess the concordance of a diagnosis of miscarriage in routinely collected health databases.

OBJECTIVES

To determine agreement and accuracy for the diagnosis of miscarriage between electronic health records (EHR), the Hospital Inpatient-Enquiry (HIPE) system, and hospital register books in Ireland.

METHODS

This is a retrospective study comparing agreement of diagnosis of miscarriage between three hospital data sources from January to June 2017. All inpatient admissions for miscarriage were reviewed from a single, tertiary maternity hospital in Ireland. Kappa, sensitivity, specificity, positive and negative predictive value were calculated.

RESULTS

In this retrospective concordance study, EHR records confirmed 96.2% diagnosis of miscarriage of HIPE records, and 95.1% of register books records. A total of 95 records were not recorded in the register books but were recorded in HIPE and EHR. This study found a considerable variability when comparing definitions of type of miscarriage (i.e., missed miscarriage, incomplete, and complete) between the three data sources.

CONCLUSION

Although this study found a high concordance in inpatient admissions for miscarriage between EHR, HIPE, and register books, a considerable discrepancy was found when classifying miscarriage between the three data sources.

Miscarriage hospitalisations: a national population-based study of incidence and outcomes, 2005-2016

Background

Early miscarriage is one of the most common obstetric causes of maternal morbidity early in pregnancy. However, data concerning non-fatal complications among hospitalisations for early miscarriage are lacking. The aim of this study was to determine whether there were changes in the incidence, management and outcomes of early miscarriage hospitalisations between 2005 and 2016.

Methods

This is a nationwide population-based study of 50,538 hospitalisations with a diagnosis of early miscarriage of all acute maternity hospitals in Ireland. Electronic health records were retrieved using the Hospital In-Patient Enquiry database. Main outcomes include the incidence rates of hospitalisations and management for early miscarriage, and rates of blood transfusion and length of stay over 2 days.

Results

Overall, 50,538 hospitalisations for early miscarriage were identified from 2005 to 2016. The risk of hospitalisation decreased from 70.6 per 1000 deliveries (95% CI 68.4 to 72.8) in 2005 to 49.7 per 1000 deliveries (95% CI 49.7 to 53.3) in 2016; however, the risk of blood transfusion increased over time (ratio: 2.0; 95% CI 1.6 to 2.4). Women of advanced maternal age had a higher risk of hospitalisations. There were less blood transfusions among women who undertook medical treatment (ratio: 0.3; 95% CI 0.1 to 0.5), but they had an increased risk of staying over 2 days at the hospital (ratio: 1.5; 95% CI 1.2 to 1.9) compared to evacuation of retained products of conception.

Conclusions

Hospitalisation rates for early miscarriage decreased over time with an increase in risk of blood transfusion and an extended length of stay at the hospital. Women who underwent medical management did not have as many blood transfusions as those undergoing surgical management. However, they had an increased risk of an extended stay. Research is needed to explore both outpatient and inpatient settings in order to improve the management and care provided.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0720-y) contains supplementary material, which is available to authorized users.

A protocol to measure the impact of intentional changes to nurse staffing and skill-mix in medical and surgical wards

AIM

The aim of this research is to measure the impact that planned changes to nurse staffing and skill-mix have on patient, nurse, and organizational outcomes.

BACKGROUND

It has been highlighted that there are several design limitations in studies that explore the relationship between nurse staffing and patient, nurse and organizational outcomes; not least that the vast majority of research in this area emanates from studies that are predominantly observational in design. There are limited studies that measure nurse, patient, organizational, and economic outcomes using a longitudinal design following a planned change in nurse staffing.

DESIGN

The research will employ a longitudinal, multimethod approach to evaluate the impact that planned changes in nurse staffing and skill-mix have on wards in three pilot hospitals.

METHODS

Administrative data collection will take place on a shift-by-shift basis prospectively over a three-year period including the measurement of nursing sensitive outcomes: cross-sectional patient experience data and nurse outcomes (nursing work, job satisfaction, burnout, missed care) will be collected at intervals prior to, during and after the implementation of planned changes in nurse staffing and skill-mix. Data will be analysed using interrupted time-series models, adjusted for key hospital, ward and patient-level factors. An economic costing of the changes will further investigate the resources required for the intervention that can then be aggregated to a national level for future roll-out plans.

DISCUSSION

The study aims to provide evidence on the impact of planned changes to nurse staffing and skill-mix based on a systematic approach using a longitudinal design and to determine the extent to which the approach can be implemented at a national level.

Air quality impacts mortality in acute medical admissions

BACKGROUND

Air quality degraded by black smoke (particulate matter, PM10), sulphur dioxide (SO2) and nitrogen oxide (NO(x)) affects human health. Improvements following national legislation have lowered death rates. Whether background air pollution levels continue to affect human health remains unclear.

AIM

To determine impact of air pollutant concentrations (PM10, SO2 and NO(x)) on in-hospital mortality for acute medical admissions to St James's Hospital over a decade (2002-11).

DESIGN

All emergency admissions (55,596 episodes in n = 32,581 patients) were tracked prospectively and mortality assessed. Daily levels of PM10, SO2 and NO(x) were obtained from monitoring stations in our catchment area.

METHODS

Univariate and multivariate logistic regression was employed to examine relationships between pollutant concentration and odds ratio (OR) for death following adjustment for other mortality predictors.

RESULTS

Mortality related to each pollutant variable assessed (as quintiles of increasing atmospheric concentration) was significantly predictive. For PM10 and SO2, mortality in the highest three quintile concentrations (compared with base quintile) was significantly increased (P < 0.001) with univariate ORs of 1.24, 1.36 and 1.25 for PM10 and 1.43, 1.54 and 1.58 for SO2, respectively. Mortality in all quintile concentrations (compared with base quintile) was significantly increased (P < 0.05) for NO(x) with univariate ORs of 1.14, 1.18, 1.28 and 1.35, respectively. Following adjustment for other mortality predictors such as acute illness severity, all three air pollutants were independently predictive of mortality.

CONCLUSION

Despite improvement to air quality in Dublin, the prevailing background pollutant concentrations continue to affect human health at levels considered safe and below that previously recognized.

Increased winter mortality: the effect of season, temperature and deprivation in the acutely ill medical patient

BACKGROUND

Studies examining seasonal mortality have found excess winter mortality, particularly in the elderly. We examined the seasonal mortality variations for all emergency medical admissions to St James' Hospital, Dublin, over 10 years (2002-2011). We explored the effects of ambient temperature, deprivation markers, case-mix, co-morbidity and illness severity on seasonal mortality.

METHODS

All emergency admissions to an acute hospital were categorised by season. We examined season as a predictor of 30-day hospital mortality.

RESULTS

30-day in-hospital mortality was lowest in autumn (7.5%) and highest in winter (9.6%). Winter admission had 17% (p=0.009) increased unadjusted risk of a death by day 30 (OR 1.17: 95% CI 1.07, 1.28). A clinical classification system identified that chronic obstructive disease, pneumonia, epilepsy/seizures and congestive heart failure had more presentations in the winter. Multivariate analysis found that winter was not an independent predictor (OR 1.08: 95% CI 0.97, 1.19). Predictors including illness severity and the Charlson Index accounted for the increased risk of winter admission. The minimum daily temperature independently predicted outcome; there was a 20% increased in-hospital death rate when it was colder (OR 1.20: 95% CI 1.09, 1.33; p<0.001). Deprivation was a univariate and multivariate (OR 1.22 95%CI 1.07, 1.39; p=0.002) predictor of mortality, but did not show marked seasonal variation.

CONCLUSION

Patients admitted in the winter have an approximate 17% increased risk of an in-hospital death by 30 days; this is related to cold along with increased illness severity and co-morbidity burden. The disease profile is different with winter admissions.

Use of a laboratory only score system to define trajectories and outcomes of older people admitted to the acute hospital as medical emergencies

AIM

Increasing numbers of older people are admitted to hospital as medical emergencies. They are a heterogeneous population with uncertain trajectories and outcomes. Our aim was to retrospectively characterize subgroups of older inpatients based on their acuity trajectories.

METHODS

This was a single-center patient series from St James's Hospital Dublin, Ireland (2002-2010). The Medical Admissions Risk System (MARS) score was used to classify a sample of 14,607 patients aged ≥ 65 years, from admission to end of episode, into four trajectory groups: (i) static high acuity (group 1); (ii) static low acuity (group 2); (iii) inpatient deterioration (group 3); and (iv) inpatient improvement (group 4). K-means cluster analysis was used for the classification.

RESULTS

Group 1 (4.1%): median length of stay (LOS) 7.4 days, 23.6% used intensive care, mortality rate 79.2%; sepsis and renal failure were the dominant features. Group 2 (76.6%): median LOS 8.0 days, 5.2% used intensive care, mortality rate 9.5%; younger age, low comorbidity and diseases of non-vital organs were predominant. Group 3 (7.6%): median LOS 17.2 days, 17.4% used intensive care, mortality rate 76.1%; high comorbidity and sepsis/respiratory disease featured. Group 4 (11.7%): median LOS 12.1 days, 12.8% used intensive care, mortality rate 22.7%; sepsis and renal/metabolic disease were frequent, and comorbidity levels were intermediate.

CONCLUSIONS

In older acute medical inpatients, the outcome seemed more driven by specific diagnoses (such as sepsis and renal failure) and comorbidity, than by age. Using the MARS score to retrospectively categorize older inpatients might help to understand their heterogeneity and promote the design of appropriate care pathways.

Length of stay and associated costs of obesity related hospital admissions in Ireland

BACKGROUND

Obesity is the cause of other chronic diseases, psychological problems, obesity shortens the lifespan and puts strain on health systems. The risk associated with childhood obesity in particular, which will accelerate the development of adult morbidity and mortality, has been identified as an emerging public health problem.

METHODS

To estimate the length of stay and associated hospital costs for obesity related illnesses a cost of illness study was set up. All discharges from all acute hospitals in the Republic of Ireland from 1997 to 2004 with a principal or secondary diagnostic code for obesity for all children from 6 to 18 years of age and for adults were collected.A discharge frequency was calculated by dividing obesity related discharges by the total number of diagnoses (principal and secondary) for each year. The hospital costs related to obesity was calculated based on the total number of days care.

RESULTS

The discharge frequency of obesity related conditions increased from 1.14 in 1997 to 1.49 in 2004 for adults and from 0.81 to 1.37 for children. The relative length of stay (number of days in care for obesity related conditions per 1000 days of hospital care given) increased from 1.47 in 1997 to 4.16 in 2004 for children and from 3.68 in 1997 to 6.74 in 2004 for adults. Based on the 2001 figures for cost per inpatient bed day, the annual hospital cost was calculated to be 4.4 Euromillion in 1997, increasing to 13.3 Euromillion in 2004. At a 20% variable hospital cost the cost ranges from 0.9 Euromillion in 1997 to 2.7 Euromillion in 2004; a 200% increase.

CONCLUSION

The annual increase in the proportion of hospital discharges related to obesity is alarming. This increase is related to a significant increase in economic costs. This paper emphasises the need for action at an early stage of life. Health promotion and primary prevention of obesity should be high on the political agenda.