Improved mortality outcomes over time for weekend emergency medical admissions

Conway, Richard; Cournane, Seán; Byrne, Declan; O’Riordan, Deirdre; Silke, Bernard

doi:10.1007/s11845-017-1627-7

Cited by 9 publications

(10 citation statements)

References 43 publications

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“…For urgent stroke care, recent studies have shown that temporal variation in mortality is now decreasing17 18 including in London’s centralised ‘hub and spoke’ model19 and in the USA ‘comprehensive stroke centres’ 6. London has eight ‘hub’ units which are designated as hyperacute stroke units (HASUs).…”

Section: Introductionmentioning

confidence: 99%

What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units

et al. 2019

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ObjectivesSeven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units (HASUs).DesignInterview and observation study to explain patterns of variation in delivery and outcomes of care described in a quantitative partner paper (Melnychuk et al).SettingEight HASUs in London.ParticipantsWe interviewed HASU staff (n=76), including doctors, nurses, therapists and administrators. We also conducted non-participant observations of delivery of care at different times of the day and week (n=45; ~102 hours). We analysed the data for thematic content relating to the ability of staff to provide evidence-based interventions consistently at different times of the day and week.ResultsStaff were able to deliver ‘front door’ interventions consistently by taking on additional responsibilities out of hours (eg, deciding eligibility for thrombolysis); creating continuities between day and night (through, eg, governance processes and staggering rotas); building trusting relationships with, eg, Radiology and Emergency Departments and staff prioritisation of ‘front door’ interventions. Variations by time of day resulted from reduced staffing in HASUs and elsewhere in hospitals in the evenings and at the weekend. Variations by day of week (eg, weekend effect) resulted from lack of therapy input and difficulties repatriating patients at weekends, and associated increases in pressure on Fridays and Mondays.ConclusionsEvidence-based service standards can facilitate 7-day working in acute stroke services. Standards should ensure that the capacity and capabilities required for ‘front door’ interventions are available 24/7, while other services, for example, therapies are available every day of the week. The impact of standards is influenced by interdependencies between HASUs, other hospital services and social services.

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Section: Introductionmentioning

confidence: 99%

What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units

et al. 2019

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“…29 Recent research, such as the High-Intensity Specialist-Led Acute Care study, 30,31 have taken this approach to examine the intensity of specialist-led care in emergency medical admissions, focusing particularly on the organisation and delivery of care, and medical staffing. 30,31 In the case of urgent stroke care, recent studies have shown that temporal variation in mortality is now decreasing, 32,33 including in London's hyperacute stroke unit (HASU) model. 34 However, there has been no large-scale, organisational research to understand what creates temporal in consistency, particularly in services that aim to operate consistently over 7 days, such as the London stroke services.…”

Section: Chapter 1 Contextmentioning

confidence: 99%

Temporal variations in quality of acute stroke care and outcomes in London hyperacute stroke units: a mixed-methods study

Simister

Black

Melnychuk

et al. 2020

Health Serv Deliv Res

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Background Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of the day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units. Objectives To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units, and to identify factors influencing such variations. Design This was a prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. Factors influencing variations in care and outcomes were studied through interview and observation data. Setting The setting was acute stroke services in London hyperacute stroke units. Participants A total of 7094 patients with a primary diagnosis of stroke took part. We interviewed hyperacute stroke unit staff (n = 76), including doctors, nurses, therapists and administrators, and 31 patients and carers. We also conducted non-participant observations of delivery of care at different times of the day and week (n = 45, ≈102 hours). Intervention Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards was designed to deliver uniform access to high-quality hyperacute stroke unit care across the week. Main outcome measures Indicators of quality of acute stroke care, mortality at 3 days after admission, disability at the end of the inpatient spell and length of stay. Data sources Sentinel Stroke National Audit Programme data for all patients in London hyperacute stroke units with a primary diagnosis of stroke between 1 January and 31 December 2014, and nurse staffing data for all eight London hyperacute stroke units for the same period. Results We found no variation in quality of care by day and time of admission across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor in 3-day mortality nor disability at hospital discharge. Other quality-of-care measures significantly varied by day and time of admission. Quality of care was better if the nurse in charge was at a higher band and/or there were more nurses on duty. Staff deliver ‘front-door’ interventions consistently by taking on additional responsibilities out of hours, creating continuities between day and night, building trusting relationships and prioritising ‘front-door’ interventions. Limitations We were unable to measure long-term outcomes as our request to the Sentinel Stroke National Audit Programme, the Healthcare Quality Improvement Partnership and NHS Digital for Sentinel Stroke National Audit Programme data linked with patient mortality status was not fulfilled. Conclusions Organisational factors influence 24 hours a day, 7 days a week (24/7), provision of stroke care, creating temporal patterns of provision reflected in patient outcomes, including mortality, length of stay and functional independence. Future work Further research would help to explore 24/7 stroke systems in other contexts. We need a clearer understanding of variations by looking at absolute time intervals, rather than achievement of targets. Research is needed with longer-term mortality and modified Rankin Scale data, and a more meaningful range of outcomes. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 34. See the NIHR Journals Library website for further project information.

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“…The adverse effect of this reduction in services upon acute care is well established, and a higher mortality has been reported for patients undergoing procedures on the weekend . Furthermore, the admission of a patient to hospital on the weekend has been associated with increased mortality when compared with admission during the week although it is unclear whether these differences in mortality persist after adjustment for weekend differences in patient comorbidities and illness severity …”

Section: Introductionmentioning

confidence: 99%

The effect of the weekend upon admissions to General Medicine

Potezny

Horwood

Hakendorf

et al. 2018

Evaluation Clinical Practice

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Improved mortality outcomes over time for weekend emergency medical admissions

Abstract: No increase in 30-day in-hospital mortality for weekend admissions was found in this study. There has been a substantial reduction in mortality for both weekday and weekend admissions over time.

Cited by 9 publications

References 43 publications

What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units

What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units

Temporal variations in quality of acute stroke care and outcomes in London hyperacute stroke units: a mixed-methods study

The effect of the weekend upon admissions to General Medicine

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