Postoperative critical care and high-acuity care provision in the United Kingdom, Australia, and New Zealand.

BACKGROUND: Decisions to admit high-risk postoperative patients to critical care may be affected by resource availability. We aimed to quantify adult ICU/high-dependency unit (ICU/HDU) capacity in hospitals from the UK, Australia, and New Zealand (NZ), and to identify and describe additional 'high-acuity' beds capable of managing high-risk patients outside the ICU/HDU environment. METHODS: We used a modified Delphi consensus method to design a survey that was disseminated via investigator networks in the UK, Australia, and NZ. Hospital- and ward-level data were collected, including bed numbers, tertiary services offered, presence of an emergency department, ward staffing levels, and the availability of critical care facilities. RESULTS: We received responses from 257 UK (response rate: 97.7%), 35 Australian (response rate: 32.7%), and 17 NZ (response rate: 94.4%) hospitals (total 309). Of these hospitals, 91.6% reported on-site ICU or HDU facilities. UK hospitals reported fewer critical care beds per 100 hospital beds (median=2.7) compared with Australia (median=3.7) and NZ (median=3.5). Additionally, 31.1% of hospitals reported having high-acuity beds to which high-risk patients were admitted for postoperative management, in addition to standard ICU/HDU facilities. The estimated numbers of critical care beds per 100 000 population were 9.3, 14.1, and 9.1 in the UK, Australia, and NZ, respectively. The estimated per capita high-acuity bed capacities per 100 000 population were 1.2, 3.8, and 6.4 in the UK, Australia, and NZ, respectively. CONCLUSIONS: Postoperative critical care resources differ in the UK, Australia, and NZ. High-acuity beds may have developed to augment the capacity to deliver postoperative critical care.

Do expanded seven-day NHS services improve clinical outcomes? Analysis of comparative institutional performance from the "NHS Services, Seven Days a Week" project 2013-2016.

BACKGROUND: The cause of adverse weekend clinical outcomes remains unknown. In 2013, the "NHS Services, Seven Days a Week" project was initiated to improve access to services across the seven-day week. Three years on, we sought to analyse the impact of such changes across the English NHS. METHODS: Aggregated trust-level data on crude mortality rates, Summary Hospital-Level Mortality Indicator (SHMI), mean length of stay (LOS), A&E admission and four-hour breach rates were obtained from national Hospital Episode Statistics and A&E datasets across the English NHS, excluding mental and community health trusts. Trust annual reports were analysed to determine the presence of any seven-day service reorganisation in 2013-2014. Funnel plots were generated to compare institutional performance and a difference in differences analysis was performed to determine the impact of seven-day changes on clinical outcomes between 2013 and 2014, 2014-2015 and 2015-2016. Data was summarised as mean (SD). RESULTS: Of 159 NHS trusts, 79 (49.7%) instituted seven-day changes in 2013-2014. Crude mortality rates, A&E admission rates and mean LOS remained relatively stable between 2013 and 2016, whilst A&E four-hour breach rates nearly doubled from 5.3 to 9.7%. From 2013 to 2014 to 2014-2015 and 2015-2016, there were no significant differences in the change in crude mortality (2014-2015 p = 0.8, 2015-2016 p = 0.9), SHMI (2014-2015 p = 0.5, 2015-2016 p = 0.5), mean LOS (2014-2015 p = 0.5, 2015-2016 p = 0.4), A&E admission (2014-2015 p = 0.6, 2015-2016 p = 1.0) or four-hour breach rates (2014-2015 p = 0.06, 2015-2016 p = 0.6) between trusts that had implemented seven-day changes compared to those which had not. CONCLUSIONS: Adverse weekend clinical outcomes may not be ameliorated by large scale reorganisations aimed at improving access to health services across the week. Such changes may negatively impact care quality without additional financial investment, as demonstrated by worsening of some outcomes. Detailed prospective research is required to determine whether such reallocation of finite resources is clinically effective.

Evaluating Services at a Major Trauma Center Before Helipad Construction.

INTRODUCTION: Two of the 4 hospitals designated as major trauma centers in London, UK, currently operate on-site helicopter landing pads. King's College Hospital (KCH) is constructing a third. We evaluate current trauma services at King's College Hospital, before the helipad entering service, establishing baseline workload and mortality measures. METHODS: We retrospectively analyzed data from patients admitted January 1, 2014, to December 31, 2015, to KCH after major trauma with on-scene helicopter emergency medical services involvement (N = 427) using the Trauma Audit and Research Network database. RESULTS: The median Injury Severity Score of the cohort was 22 (interquartile range [IQR], 13-30). The median length of stay was 11 days (IQR, 5-24). Fifty-seven percent of the patients received intensive care unit (ICU) admission, with a median ICU length of stay (LOS) of 5 days (IQR, 2-12) in this subgroup. There was no significant difference in Injury Severity Score, LOS, or ICU LOS between 2014 and 2015. One hundred ninety-three patients (45.2%) underwent ≥ 1 operation, accounting for 1,276.5 hours of operating room time in total. Cox proportional hazards regression showed no difference in survival outcomes between 2014 and 2015. CONCLUSION: Baseline workload and mortality measures were obtained, forming the basis of future service evaluation to assess the impact of helipad construction.