title: Patient outcomes vs. service workload: an analysis of outcomes in the burn service of England and Wales.
abstract: BACKGROUND
  Patient outcomes in specialist burns units have been used as a metric of care needs and quality. Besides patient factors there are service factors that might influence Length of Stay (LOS) and mortality, e.g. pressure on beds. Although the bed needs of UK hospitals have dropped significantly over the past three decades, with changes in policies and practices, recent reports suggest that hospitals have 90% bed occupancy for 48 weeks of the year. In the UK, the specialist burn injury service is organised so that patients are assessed on arrival at hospital, and those needing admission are found a nearby bed in a suitable unit through the National Burn Bed Bureau. The aim of this study was to investigate the effect on outcomes of service pressures due to shortages of beds.
  
  
  METHODS
  We took an extract of the anonymised patient data from the specialised burn injury database, iBID, and created a new database based on matching that data with bed availability data provided by the national Burn Bed Bureau. Cox proportional hazard modelling was used for analysis to investigate if there is an impact of bed occupancy (a proxy measure of workload) on LOS.
  
  
  RESULTS
  Cox proportional hazard modelling indicated that half of the services in England and Wales are less likely to discharge a patient if the bed availability is high. Two of the services have abnormally high bed availability and LOS, therefore a model without these two services indicates a general reluctance to discharge patients when beds are available.
  
  
  CONCLUSIONS
  It is possible that the effect we observed is a result of gaming as service providers are paid by the number of admissions. In addition, providers many not all give the same level of accuracy of bed availability information to the NBBB: some may under report availability, for example at times of high pressure on staff. Furthermore, burn services may not empty beds to avoid being filled up by work from other specialties, thus making them unable to admit a burn when referred.
authors.affiliation: Centre for Health Informatics, Institute of population Health, University of Manchester, Manchester, UK. neophytos.stylianou@hotmail.co.uk.
authors.forename: Neophytos
authors.initials: N
authors.lastname: Stylianou
authors.affiliation: Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK. matthew.carr@manchester.ac.uk.
authors.forename: Matthew
authors.initials: M
authors.lastname: Carr
authors.affiliation: Centre for Health Informatics, Institute of population Health, University of Manchester, Manchester, UK. e.kontopantelis@manchester.ac.uk.|Institute of Population Health, University of Manchester, Manchester, UK. e.kontopantelis@manchester.ac.uk.
authors.forename: Evangelos
authors.initials: E
authors.lastname: Kontopantelis
authors.affiliation: Centre for Health Informatics, Institute of population Health, University of Manchester, Manchester, UK. buchan@manchester.ac.uk.
authors.forename: Iain
authors.initials: I
authors.lastname: Buchan
authors.affiliation: University Hospital South Manchester and Honorary, Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK. Ken.dunn@uhsm.nhc.uk.
authors.forename: Ken
authors.initials: K
authors.lastname: Dunn
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002053:Burn Units / Q000458:organization & administration*; D002056:Burns / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D004739:England; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008875:Middle Aged; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data*; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D013222:State Medicine / Q000458:organization & administration*; D016896:Treatment Outcome; D014852:Wales; D016526:Workload / Q000706:statistics & numerical data*; D055815:Young Adult