Consultant Input in Acute Medical Admissions and Patient Outcomes in Hospitals in England: A Multivariate Analysis

Abstract

Recent recommendations for physicians in the UK outline key aspects of care that should improve patient outcomes and experience in acute hospital care. Included in these recommendations are Consultant patterns of work to improve timeliness of clinical review and improve continuity of care. This study used a contemporaneous validated survey compared with clinical outcomes derived from Hospital Episode Statistics, between April 2009 and March 2010 from 91 acute hospital sites in England to evaluate systems of consultant cover for acute medical admissions. Clinical outcomes studied included adjusted case fatality rates (aCFR), including the ratio of weekend to weekday mortality, length of stay and readmission rates. Hospitals that had an admitting Consultant presence within the Acute Medicine Unit (AMU, or equivalent) for a minimum of 4 hours per day (65% of study group) had a lower aCFR compared with hospitals that had Consultant presence for less than 4 hours per day (p<0.01) and also had a lower 28 day re-admission rate (p<0.01). An ‘all inclusive’ pattern of Consultant working, incorporating all the guideline recommendations and which included the minimum Consultant presence of 4 hours per day (29%) was associated with reduced excess weekend mortality (p<0.05). Hospitals with >40 acute medical admissions per day had a lower aCFR compared to hospitals with fewer than 40 admissions per day (p<0.03) and had a lower 7 day re-admission rate (p<0.02). This study is the first large study to explore the potential relationships between systems of providing acute medical care and clinical outcomes. The results show an association between well-designed systems of Consultant working practices, which promote increased patient contact, and improved patient outcomes in the acute hospital setting.

‘The time it takes…’ How doctors spend their time admitting a patient during the acute medical take

“…Increased consultant presence has been shown to be associated with reduced case-adjusted mortality rates in at least one publication. 19 From our work, two principles of workload distribution are clear:…”

“…Delays in patients being seen and workload increases have the potential to impact on mortality, morbidity and length of stay in hospital. 6,7 In order to ascertain objective criteria for staffing requirements, there is a need to better understand the workload of doctors and the timing of processes involved in routine aspects of medical care. The admission process is a key part of the acute medical team's role and the time requirements for this and related tasks will have implications on the staffing models and the overall efficiency of units.…”

Safety in numbers: lack of evidence to indicate the number of physicians needed to provide safe acute medical care

“…Workload prevented doctors from fully discussing care with their patients and families, delayed discharges and affected the quality of handovers. 16 Both studies noted the negative impact of increased patient numbers and staffi ng shortages.…”

“…In the UK, Bell et al found that hospitals with more than 40 admissions per day had reduced case fatality rates (p≤0.03) but that patients on a high admission day had a longer mean length of stay (p≤0.02). 16 Conway et al analysed consultant admission numbers over a 10-year period in the UK. They found that patients admitted to consultants with the highest volume of admissions had shortened lengths of stay (p<0.001) and reduced 30-day in-hospital mortality (p<0.1) when compared to consultants with lower volume of admissions, suggesting that more practice does result in improved patient outcomes.…”

The urgent need to develop emergency EYE care in the UK: the way forward?

“…Getting senior opinions early is improving efficiencies in A&E and acute medical settings. 24,25 Consultant-led, strategic planning of MDT-delivered services driving aspirational standards in EEC provision is anticipated to be the future of EEC in the UK. …”