Instrument for objective assessment of appropriateness of surgical bed occupancy: validation study

Abstract

The number of hospital beds per head of population has fallen by more than 2% a year since 1980.1 Levels of bed occupancy have risen during this period. 1 Appropriate bed occupancy is crucial to the NHS, as occupancy rates exceeding 85% in acute hospitals are associated with problems in dealing with emergency and elective admissions. 1 We aimed to develop a valid instrument for the objective assessment of appropriateness of occupancy of surgical beds. Participants, methods, and resultsWe drew potential criteria for the instrument from analyses of the medical notes of 200 general surgical inpatients. We chose criteria such that if any one was met we could judge that particular day of surgical care to be appropriate. We shortlisted the criteria after each had been scrutinised by a consultant physician or surgeon of the relevant subspecialty, and we structured them into an instrument. We modified the instrument (box) after a pilot study of 40 bed days.We conducted a validation study on 100 bed days in a general surgical unit with an interest in colorectal surgery. We selected 10 bed days once a week for 10 weeks by using computer generated random numbers. Two research registrars and a committee of three consultant surgeons in charge of the unit assessed patients independently on the same day. The registrars used the instrument separately to assess the appropriateness of patients' stay; they obtained data from medical notes, charts, history, and clinical examination. The consultants recorded their collective decision, reached by consensus, during a grand ward round. They were blind to instrument criteria and the outcome of registrars' assessments. A geriatrician assessed the elderly patients ( > 65 years) who were judged by the instrument to have stayed inappropriately and determined the best placement for the patients on the basis of preset criteria on discharge destination.We used the degree of agreement between the registrars to measure the interassessor reliability of the instrument. The resistrars reached a consensus on cases about which they disagreed. We measured the predictive clinical validity of the instrument by using the degree of agreement between the registrars' assessment using the instrument and the consultants' collective decision (as the gold standard for valid discharge). We used the assessment by the geriatrician as a control measure.We studied 100 patients (43 male; 55 emergency, 45 elective), with a median age of 70 (interquartile range 55-81) years. Seventy seven patients had undergone surgery during that admission. The instrument determined that 31% (95% confidence interval 23% to 41%) of patients were occupying beds inappropriately. Of these patients, 26/31-84% (67% to 93%)-were elderly. The instrument had a reliability of 89% (81% to 94%; =0.75), a validity of 88% (80% to 93%; =0.69), a sensitivity of 93% (84% to 97%), and a specificity of 79% (62% to 89%). We found no pattern of agreement or disagreement between consultants and registrars. The geriatrician agreed with the instrument's ...

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