Measuring the incidence of hospital-acquired complications and their effect on length of stay using CHADx.

OBJECTIVES: To use an automated Classification of Hospital Acquired Diagnoses (CHADx) reporting system to report the incidence of hospital-acquired complications in inpatients and investigate the association between hospital-acquired complications and hospital length of stay (LOS) in multiday-stay patients. DESIGN: Retrospective cross-sectional study for calendar years 2010 and 2011. SETTING: South Metropolitan Health Service in Western Australia, which consists of two teaching and three non-teaching hospitals. MAIN OUTCOME MEASURES: Incidence of hospital-acquired complications and mean LOS for multiday-stay patients. RESULTS: Of 436 841 inpatient separations, 29 172 (6.68%) had at least one hospital-acquired complication code assigned in the administrative data, and there were a total of 56 326 complication codes. The three most common complications were postprocedural complications; cardiovascular complications; and labour, delivery and postpartum complications. In the subset of data on multiday-stay patients, crude mean LOS was longer in separations for patients with hospital-acquired complications than in separations for those without such complications (17.4 days v 5.4 days). After adjusting for potential confounders, separations for patients with hospital-acquired complications had almost four times the mean LOS of separations for those without such complications (incident rate ratio, 3.84; 95% CI, 3.73-3.96; P < 0.001). CONCLUSIONS: An automated CHADx reporting system can be used to collect data on patients with hospital-acquired complications. Such data can be used to increase emphasis on patient safety and quality of care and identify potential opportunities to reduce LOS.

Can we monitor heart attack in the troponin era? Evidence from a population-based cohort study.

BACKGROUND: Troponins (highly sensitive biomarkers of myocardial damage) increase counts of myocardial infarction (MI) in clinical practice, but their impact on trends in admission rates for MI in National statistics is uncertain. METHODS: Cases coded as MI or other cardiac diagnoses in the Hospital Morbidity Data Collection (MI-HMDC) in Western Australia in 1998 and 2003 were classified using revised criteria for MI developed by an International panel convened by the American Heart Association (AHA criteria) using information on symptoms, ECGs and cardiac biomarkers abstracted from samples of medical notes. Age-sex standardized rates of MI-HMDC were compared with rates of MI based on AHA criteria including troponins (MI-AHA) or traditional biomarkers only (MI-AHAck). RESULTS: Between 1998 and 2003, rates of MI-HMDC decreased by 3.5% whereas rates of MI-AHA increased by 17%, a difference largely due to increased false-negative cases in the HMDC associated with marked increased use of troponin tests in cardiac admissions generally, and progressively lower test thresholds. In contrast, rates of MI-AHAck declined by 18%. CONCLUSIONS: Increasing misclassification of MI-AHA by the HMDC may be due to reluctance by clinicians to diagnose MI based on relatively small increases in troponin levels. These influences are likely to continue. Monitoring MI using AHA criteria will require calibration of commercially available troponin tests and agreement on lower diagnostic thresholds for epidemiological studies. Declining rates of MI-AHA ck are consistent with long-standing trends in MI in Western Australia, suggesting that neither MI-HMDC nor MI-AHA reflect the true underlying population trends in MI.

The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments.

OBJECTIVE: To examine the relationship between hospital and emergency department (ED) occupancy, as indicators of hospital overcrowding, and mortality after emergency admission. DESIGN: Retrospective analysis of 62 495 probabilistically linked emergency hospital admissions and death records. SETTING: Three tertiary metropolitan hospitals between July 2000 and June 2003. PARTICIPANTS: All patients 18 years or older whose first ED attendance resulted in hospital admission during the study period. MAIN OUTCOME MEASURES: Deaths on days 2, 7 and 30 were evaluated against an Overcrowding Hazard Scale based on hospital and ED occupancy, after adjusting for age, diagnosis, referral source, urgency and mode of transport to hospital. RESULTS: There was a linear relationship between the Overcrowding Hazard Scale and deaths on Day 7 (r=0.98; 95% CI, 0.79-1.00). An Overcrowding Hazard Scale>2 was associated with an increased Day 2, Day 7 and Day 30 hazard ratio for death of 1.3 (95% CI, 1.1-1.6), 1.3 (95% CI, 1.2-1.5) and 1.2 (95% CI, 1.1-1.3), respectively. Deaths at 30 days associated with an Overcrowding Hazard Scale>2 compared with one of <3 were undifferentiated with respect to age, diagnosis, urgency, transport mode, referral source or hospital length of stay, but had longer ED durations of stay (risk ratio per hour of ED stay, 1.1; 95% CI, 1.1-1.1; P<0.001) and longer physician waiting times (risk ratio per hour of ED wait, 1.2; 95% CI, 1.1-1.3; P=0.01). CONCLUSIONS: Hospital and ED overcrowding is associated with increased mortality. The Overcrowding Hazard Scale may be used to assess the hazard associated with hospital and ED overcrowding. Reducing overcrowding may improve outcomes for patients requiring emergency hospital admission.

Emergency department-based intervention with adolescent substance users: 12-month outcomes.

We evaluated the 12-month outcomes of a brief intervention, enhanced by a consistent support person, which aimed to facilitate referral attendance for substance use treatment following a hospital alcohol or other drug (AOD) presentation. Outcomes were assessed as: attendance for substance use treatment; the number of hospital AOD ED presentations; change in AOD consumption and psychological wellbeing (GHQ-12). We recruited 127 adolescents, with 60 randomised to the intervention and 67 receiving usual care. At 12 months, 87 (69%) were re-interviewed. Significantly more of the intervention than the usual care group (12 versus 4) had attended a treatment agency. Excluding the index presentations, there were 66 AOD hospital presentations post intervention, with the proportion of AOD events falling for the intervention group, whilst no change occurred for the usual care group. Irrespective of randomisation, those who attended for substance use treatment had a greater decline in total self-reported drug use than the remainder. Both intervention and usual care groups had improved GHQ-12 scores by 12 months, with reduction in GHQ scores correlated with reduced drug use. In conclusion, while brief intervention in ED only has limited success in facilitating adolescents to attend for subsequent AOD treatment, it can significantly reduce the number of AOD related ED presentations.

A double-blind, randomized trial of intravenous versus intramuscular antivenom for red-back spider envenoming.

OBJECTIVE: To compare the efficacy of intravenous versus intramuscular antivenom (AV) in the treatment of Red-back spider (RBS) envenoming. METHODS: Randomized, double-dummy, double-blind, multicentre trial of patients with red-back spider envenoming requiring AV treatment recruited from five hospital EDs in Western Australia. RESULTS: Thirty-five patients were recruited; two were excluded; 33 were available for initial analysis, but two who were unblinded after one ampoule of trial AV and given i.v. AV had limited data; 31 remained in the study and had more complete data. After AV, pain scores for both i.m. and i.v. groups improved rapidly. At 24 h, the i.v. group was better with a 55% absolute difference (76% vs. 21%; 95% CI 25-85% difference) in the proportion pain-free. There were no safety issues. CONCLUSIONS: Red-back spider antivenom was initially effective by both i.m. and i.v. routes. The study generates the hypothesis that at 24 h, significantly more patients are pain-free with i.v. administration. Definitive recommendations on the optimal route of administration of RBS AV await the results of further studies.

After-hours general practice clinics are unlikely to reduce low acuity patient attendances to metropolitan Perth emergency departments.

OBJECTIVE: To model the effectiveness of after-hours general practice (GP) in reducing metropolitan Perth emergency departments' (ED) low acuity patient (LAP) attendances and costs. METHODS: We estimated LAP attendances by comparison of the product of (A) the difference between self-referred and GP-referred ED discharge rates and (B) total self-referred attendances (LAP attendances = A x B). We then compared after-hours ED LAP attendance rates and costs with inner metropolitan "working-week" ED LAP attendance rates and costs, when GP services are maximally available. RESULTS: Working-week LAP attendances comprised 8.2% (95% CI, 8.0%-8.4%) of inner metropolitan ED attendances. Excess weekend and evening LAP attendances were estimated to comprise 16.5% (95%CI, 15.9%-17.0%) and 4.5% (95%CI, 4.1%-4.9%) of outer and inner metropolitan ED attendances respectively and totalled less than 3.0% of ED costs. CONCLUSIONS: Low acuity patients form a relatively constant, inexpensive proportion of ED workloads. After-hours GP LAP services are unlikely to significantly reduce ED attendances or costs.