Modeling the effect of short stay units on patient admissions

Impact of emergency short-stay unit opening on in-hospital global and cardiology indicators

RATIONALE, AIMS AND OBJECTIVES

Emergency short-stay unit (SSU) alleviates emergency department (ED) overcrowding, but may affect in-hospital indicators. Cardiology patients comprise a substantial part of patients admitted at SSU. This study evaluated whether SSU opening differentially modified in-hospital indicators at a whole general hospital and at its cardiology division (CARD).

METHODS

We retrospectively analysed indicators based on 859 686 ED visits, and 171 547 hospital admissions, including 12 110 CARD admissions, from 2007 to 2018 at a general tertiary hospital, and compared global ED indicators and in-hospital indicators at the hospital and CARD before (2007-2011) and after (2011-2018) SSU opening.

RESULTS

After SSU opening, monthly ED bed occupancy rate decreased (mean ± SD 200 ± 18% vs 187 ± 22%; P < .001) and in-hospital admissions from ED increased at the hospital (median [interquartile range] 460 [81] vs 524 [41], P < .001) and CARD (50 [12] vs 54 [12], P = .004). In parallel, monthly in-hospital elective admissions decreased at CARD (34 [18] vs 28 [17], P = .019), but not at the hospital (712 [73] vs 700 [104], P = .54). Average length of stay (LOS) increased at both hospital (8.5 ± 0.3 vs 8.7 ± 0.4 days, P < .001) and CARD (9.2 ± 1.5 vs 10.3 ± 2.3 days, P = .002) after SSU opening, but percent admissions at SSU showed a direct relationship with LOS solely at CARD. Furthermore, cardiology patients admitted at SSU had greater LOS, prevalence of coronary heart disease and age than those admitted at the conventional cardiology ward.

CONCLUSIONS

SSU opening improved ED crowding, but was associated with changes in in-hospital indicators, particularly at CARD, and in the characteristics of hospitalized cardiology patients. These findings suggest that in-hospital cardiology services may need re-evaluation following SSU opening at a general hospital.

New Zealand's emergency department target - did it reduce ED length of stay, and if so, how and when?

Background

In 2009, the New Zealand government introduced a hospital emergency department (ED) target – 95% of patients seen, treated or discharged within 6 h - in order to alleviate crowding in public hospital EDs. While these targets were largely met by 2012, research suggests that such targets can be met without corresponding overall reductions in ED length-of-stay (LOS). Our research explores whether the NZ ED time target actually reduced ED LOS, and if so, how and when.

Methods

We adopted a mixed-methods approach with integration of data sources. After selecting four hospitals as case study sites, we collected all ED utilisation data for the period 2006 to 2012. ED LOS data was derived in two forms-reported ED LOS, and total ED LOS - which included time spent in short-stay units. This data was used to identify changes in the length of ED stay, and describe the timing of these changes to these indicators. Sixty-eight semi-structured interviews and two surveys of hospital clinicians and managers were conducted between 2011 and 2013. This data was then explored to identify factors that could account for ED LOS changes and their timing.

Results

Reported ED LOS reduced in all sites after the introduction of the target, and continued to reduce in 2011 and 2012. However, total ED LOS only decreased from 2008 to 2010, and did not reduce further in any hospital. Increased use of short-stay units largely accounted for these differences. Interview and survey data showed changes to improve patient flow were introduced in the early implementation period, whereas increased ED resources, better information systems to monitor target performance, and leadership and social marketing strategies mainly took throughout 2011 and 2012 when total ED LOS was not reducing.

Conclusions

While the ED target clearly stimulated improvements in patient flow, our analysis also questions the value of ED targets as a long term approach. Increased use of short-stay units suggests that the target became less effective in ‘standing for’ improved timeliness of hospital care in response to increasing acute demand. As such, the overall challenges in managing demand for acute and urgent care in New Zealand hospitals remain.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2617-1) contains supplementary material, which is available to authorized users.