ABSTRACT
BACKGROUND: In countries with public health system, hospital bed reductions and increasing social and medical frailty have led to the phenomenon of "outliers" or "outlying hospital in-patients." They are often medical patients who, because of unavailability of beds in their clinically appropriate ward, are admitted wherever unoccupied beds are. The present work is aimed to systematically review literature about quality and safety of care for patients admitted to clinically inappropriate wards. METHODS: We performed a systematic review of studies investigating outliers, published in peer-reviewed journals with no time restrictions. Search and screening were conducted by two independent researchers (MLR and ER). Studies were considered potentially eligible for this systematic review if aimed to assess the quality and/or the safety of care for patients admitted to clinically inappropriate units. Our search was supplemented by a hand search of references of included studies. Given the heterogeneity of studies, results were analyzed thematically. We used PRISMA guidelines to report our findings. RESULTS: We collected 17 eligible papers and grouped them into six thematic categories. Despite their methodological limits, the included studies show increased trends in mortality and readmissions among outliers. Quality of care and patient safety are compromised as patients and health professionals declare and risk analysis displays. Reported solutions are often multicomponent, stress early discharge but have not been investigated in the control group. CONCLUSIONS: Published literature cannot definitely conclude on the quality and safety of care for patients admitted to clinically inappropriate wards. As they may represent a serious threat for quality and safety, and moreover often neglected and under valued, well-designed and powered prospective studies are urgently needed.
Subject(s)
Hospital Units/standards , Patient Admission/standards , Patient Care/standards , Patient Safety/standards , Quality of Health Care/standards , Humans , Patient Care/methodsABSTRACT
BACKGROUND: the burden of acute complex patients, increasingly older and poli-pathological, accessing to Emergency Departments (ED) leads up hospital overcrowding and the outlying phenomenon. These issues highlight the need for new adequate patients' management strategies. The aim of this study is to analyse the effects on in-hospital patient flow and clinical outcomes of a high-technology and time-limited Medical Admission Unit (MAU) run by internists. METHODS: all consecutive patients admitted to MAU from Dec-2017 to Nov-2019 were included in the study. The admissions number from ED and hospitalization rate, the overall in-hospital mortality rate in medical department, the total days of hospitalization and the overall outliers bed days were compared to those from the previous two years. RESULTS: 2162 patients were admitted in MAU, 2085(95.6%) from ED, 476(22.0%) were directly discharged, 88(4.1%) died and 1598(73.9%) were transferred to other wards, with a median in-MAU time of stay of 64.5 [0.2-344.2] hours. Comparing the 24 months before, despite the increase in admissions/year from ED in medical department (3842 ± 106 in Dec2015-Nov2017 vs 4062 ± 100 in Dec2017-Nov2019, p<0.001), the number of the outlier bed days has been reduced, especially in surgical department (11.46 ± 6.25% in Dec2015-Nov2017 vs 6.39 ± 3.08% in Dec2017-Nov2019, p=0.001), and mortality in medical area has dropped from 8.74 ± 0.37% to 7.29 ± 0.57%, p<0.001. CONCLUSIONS: over two years, a patient-centred and problem-oriented approach in a medical admission buffer unit run by internists has ensured a constant flow of acute patients with positive effects on clinical risk and quality of care reducing medical outliers and in-hospital mortality.
ABSTRACT
OBJECTIVES: The objective is to describe and analyze how outlier admission influences hospital stay and the appearance of complications in patients with a femoral neck fracture treated with arthroplasty. MATERIAL AND METHOD: A historical cohort study was carried out in which the group of patients with a displaced fracture of the femoral neck who had an outlier admission was defined as an exposed cohort, that is, they were admitted to a hospitalization area not belonging to the Orthopedic Surgery and Traumatology department, unlike the unexposed cohort, that included patients admitted to a hospitalization area assigned to the Orthopedic Surgery and Traumatology department. RESULTS: Outlier admission was a risk factor for requiring a postoperative transfusion (RR 1.52, 95% CI 1.05-2.21; P=.035), to have a postoperative stay longer than 5 days (RR 1.35, 95% CI 1.04-1.74; P=.038) and to suffer general postoperative complications (RR 1.35, 95% CI 1.02-1.78; P=.048). CONCLUSIONS: Outlier admission is a threat to the quality and safety of health care. In patients over 80 years of age, medical outliers is a risk factor for postoperative transfusion and systemic postoperative complications.