Reducing hospital mortality: Incremental change informed by structured mortality review is effective.

Hospital mortality rates have frequently been improved by identifying diagnostic groups with high mortality and targeting interventions to those specific groups. We found that high residual inpatient mortality persisted after targeted measures had achieved an initial reduction, and that the causes were spread across a wide range of diagnostic groups. Further interventions were put in place consisting of a structured electronic mortality form and systematised mortality scrutiny and reporting (primary intervention) accompanied by a number of quality improvement interventions arising from the mortality analysis (secondary interventions). We found that those interventions were associated with progressive improvements in mortality rates and average lengths of inpatient stay over the 5-year study period. Winter quarter mortality improvements reached a high level of statistical significance but could not be attributed to changes in any particular diagnostic groups. We conclude that progress with mortality improvements is probably best achieved by applying both code-targeted and general interventions simultaneously.

Managing older medical patients in hospital: a study of the outcomes from a shift of resources to the 'front door'.

We performed a retrospective cohort comparison study to look at the processes for concentrating geriatric resources in the acute admissions area in a general hospital in the UK and compare key outcomes. The number of consultant geriatricians and other staff working at the 'front door' - acute medical unit (AMU) and short stay ward (SSW) - was increased. We compared 'front door' outcomes with whole department outcomes in 2013 and 2014, looking at the proportion of patients discharged within 3 and 5 days of admission, the proportion discharged from the 'front door', mean lengths of stay (LOS) and readmissions within 28 days of discharge. There were 1,147 and 1,381 discharge episodes in 2013 and 2014, respectively. 'Front door' discharges rose from 36% to 46% (p<0.001) between 2013 and 2014, and the proportion of 'front door' discharges occurring within 3 days rose from 56% (2013) to 68% (2014), compared with 35% and 33% for the department as a whole (p=0.006). The mean LOS at the 'front door' fell from 6.1 to 3.8 days (p=0.007). Readmissions from 'front door' discharges rose from 12% to 14% (p=0.004). The change in the configuration of the acute geriatric service was associated with more favourable discharge performance outcomes at the 'front door' but modest improvements in discharge performance for the geriatric service as a whole.