BACKGROUND This study investigated the association between nadir anemia and mortality and length of stay (LOS) in a general population of hospitalized patients. STUDY DESIGN AND METHODS A retrospective cohort study of tertiary hospital admissions in Western Australia between July 2010 and June 2015. Outcome measures were in‐hospital mortality and LOS. RESULTS Of 80,765 inpatients, 45,675 (56.55%) had anemia during admission. Mild and moderate/severe anemia were independently associated with increased in‐hospital mortality (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.36‐1.86, p = 0.001; OR 2.77, 95% CI 2.32‐3.30, p < 0.001, respectively). Anemia was also associated with increased LOS, demonstrating a larger effect in emergency (mild anemia—incident rate ratio [IRR] 1.52, 95% CI 1.48‐1.56, p < 0.001; moderate/severe anemia—IRR 2.18, 95% CI 2.11‐2.26, p < 0.001) compared to elective admissions (mild anemia—IRR 1.30, 95% CI 1.21‐1.41, p < 0.001; moderate/severe anemia—IRR 1.69, 95% CI 1.55‐1.83, p < 0.001). LOS was longer in patients who developed anemia during admission compared to those who had anemia on admission (IRR 1.13, 95% CI 1.10‐1.17, p < 0.001). Red cell transfusion was independently associated with 2.23 times higher odds of in‐hospital mortality (95% CI 1.89‐2.64, p < 0.001) and 1.31 times longer LOS (95% CI 1.25‐1.37, p < 0.001). CONCLUSION More than one‐third of patients not anemic on admission developed anemia during admission. Even mild anemia is independently associated with increased mortality and LOS; however, transfusion to treat anemia is an independent and additive risk factor.

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Introduction: Out of hours inpatient care within Australia, defined as the hours outside of 0800 to 1600 hours Monday to Friday, is traditionally provided by on-call medical teams, working in silos, supported by onsite junior medical staff. This model can be associated with poor communication both between and within teams, lack of accountability, failure of escalation, and a reactive model of care. International literature reveals that the outcomes of patients admitted to hospital out of hours are poorer, resulting in a discrepancy in mortality between in and out of hours admissions.Methods: We aimed to reduce the discrepancy in mortality between in and out of hours admissions, as well as reducing overall inpatient mortality. Using a resilience engineering approach, we introduced a novel model of out of hours care - the ‘Safety After Hours for Everyone’ (SAFE) Team. This incorporated a departmental model, with clear and robust internal leadership, external accountability, and formal processes for identification, review and follow up of at risk patients, as well as protocolised escalation processes.Results: The introduction of the SAFE model has been associated with a continuous reduction in the overall Hospital Standardised Mortality Ratio (HSMR) from 0.71 to 0.54 (periods January to March 2015 vs January to March 2018. In addition, the SAFE model has been associated with a reduction in out of hours mortality (defined as admissions from 1600 to 0800) from 0.98 to 0.38 (periods January to March 2015 vs January to March 2018). This has been accompanied by a qualitative improvement in the quality of care delivered out of hours, and improved satisfaction with working conditions and training delivered out of hours. Due to a drastic reduction in unplanned Resident Medical Officer (RMO) overtime associated with the introduction of the model, implementation was near cost neutral.Conclusion: The introduction of the SAFE model has been associated with improved hospital outcomes, in conjunction with improved medical and nursing staff experiences, at a low marginal cost. This model has scope to be applied to similar tertiary level hospitals, or modified to fit within most hospital structures. A key component to the success of this model’s innovation, is acknowledgement of the importance of after hours care provision to patients, highlighted by the formation of a department of after hours medicine as part of the SAFE model.