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


METHODS
prospective systems redesign study over 2 years.


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


METHODS
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.


CONCLUSIONS
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.
Health Sciences Research Institute, Warwick Medical School, Warwick, Warwickshire, UK University of Warwick, Warwick, Warwickshire, UK.
Kate M
KM
Silvester
School of Health Studies, University of Bradford, Bradford, UK.
Mohammed A
MA
Mohammed
Service Improvement, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
Paul
P
Harriman
Service Improvement, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
Anna
A
Girolami
Geriatric Medicine Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
Tom W
TW
Downes
D000368:Aged; D000369:Aged, 80 and over; D003695:Delivery of Health Care / Q000592:standards*; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D016330:Frail Elderly; D015577:Geriatric Assessment; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008137:Longitudinal Studies; D008297:Male; D010359:Patient Readmission / Q000706:statistics & numerical data; D011446:Prospective Studies; D013222:State Medicine; D061665:Time-to-Treatment / Q000592:standards*; D016896:Treatment Outcome; D006113:United Kingdom
efficiency; frailty; improvement science; mortality; older people; systems thinking