Improving patient flow: the impact of consultant work pattern on trauma ward efficiency.

OBJECTIVE: To determine the effect on trauma ward efficiency of altering consultant shift patterns. DESIGN: Outcome measures were compared for neck of femur fracture patients before and after the consultant rota changed (Feb 2007) from a single day on-call to a full week on-call. SETTING: Patients admitted to Stirling Royal Infirmary with neck of femur fractures. PARTICIPANTS: 359 patients were identified from the Scottish Hip Fracture Audit database for the year preceding the rota change and 379 after. MAIN OUTCOME MEASURES: Time to surgery for medically fit patients and overall length of stay on the acute trauma ward. RESULTS: Patients were operated on quicker after the rota change (Mann-Whitney U-test, before v after: z=2.67, p=0.008), with a greater percentage being operated within the first 24h (60% before v 78% after; Chi-square test, before v after: χ(1)(2)=19.9, p<0.001). Overall, the length of stay on the acute trauma ward was reduced (Chi-square test, before v after by intervals: χ(3)(2)=21.1, p<0.001). The proportion of patients discharged from the ward within one week increased from 47% before the rota change to 63% after. CONCLUSION: By applying the industry-based methods of 'process management', we have shown that a simple intervention (alteration of consultant shift patterns) has had a significant impact in reducing time to theatre for neck of femur trauma patients and reducing the length of stay on the acute trauma ward. Thus, the 'patient flow' has been made more efficient making more acute trauma beds available for new admissions.

Effect of patients' age on management of acute intracranial haematoma: prospective national study.

OBJECTIVE: To determine whether the management of head injuries differs between patients aged > or =65 years and those <65. DESIGN: Prospective observational national study over four years. SETTING: 25 Scottish hospitals that admit trauma patients. PARTICIPANTS: 527 trauma patients with extradural or acute subdural haematomas. MAIN OUTCOME MEASURES: Time to cranial computed tomography in the first hospital attended, rates of transfer to neurosurgical care, rates of neurosurgical intervention, length of time to operation, and mortality in inpatients in the three months after admission. RESULTS: Patients aged > or =65 years had lower survival rates than patients <65 years. Rates were 15/18 (83%) v 165/167 (99%) for extradural haematoma (P=0.007) and 61/93 (66%) v 229/249 (92%) for acute subdural haematoma (P<0.001). Older patients were less likely to be transferred to specialist neurosurgical care (10 (56%) v 142 (85%) for extradural haematoma (P=0.005) and 56 (60%) v 192 (77%) for subdural haematoma (P=0.004)). There was no significant difference between age groups in the incidence of neurosurgical interventions in patients who were transferred. Logistic regression analysis showed that age had a significant independent effect on transfer and on survival. Older patients had higher rates of coexisting medical conditions than younger patients, but when severity of injury, initial physiological status at presentation, or previous health were controlled for in a log linear analysis, transfer rates were still lower in older patients than in younger patients (P<0.001). CONCLUSIONS: Compared with those aged under 65 years, people aged 65 and over have a worse prognosis after head injury complicated by intracranial haematoma. The decision to transfer such patients to neurosurgical care seems to be biased against older patients.