The effect of the employment of consultants in the Emergency Department on quality of care and equity – a quasi-experimental retrospective cohort study

Abstract

Background Crowding and bed occupancy are challenging issues in the hospitals with increasing acute admissions, caused by an aging population. Crowding in Emergency Departments (EDs) has a negative impact on length of hospitalisation, in-hospital mortality, patient safety, and flow. Thus, the Danish Health Authorities recommend the presence of specialist doctors in the ED who are dedicated to execute the clinical decision-making process. Thus, in 2016, the model of acute care was changed in the ED at Hvidovre Hospital, Denmark, to include consultant-led triage and continuous presence of consultants, referred to as Acute Medical Consultants. However, there is little evidence concerning the effect of consultants treating patients in the ED, and how it affects care for patients of varying socioeconomic status compared with other models of ED staffing. This study investigated whether the employment of Acute Medical Consultants in a Danish ED affected the quality of care for acutely admitted medical patients in terms of length of stay, readmission, mortality, and secondly how this effect was distributed across socioeconomic status in patients. Methods Admission data for 9,869 adult medical patients admitted for up to 48 hours in the ED was collected in two separate 7-month periods, one prior to and one after the organisational intervention. Linear regression and Cox proportional hazards regression analyses adjusted for age, sex, comorbidities, level of education, and employment status were applied. Results Following the employment of Acute Medical Consultants, an overall 11% increase in index-admissions was observed, and 90% of patients were discharged by an Acute Medical Consultant with a reduced mean length of stay by 1.4 hours (95% CI: 1.0 – 1.9). No significant change was found in in-hospital mortality, readmission, or mortality within 90 days after discharge. No difference was found in quality of care across socioeconomic status. Conclusion The employment of Acute Medical Consultants in the ED was associated with reduced length of admission without a negative effect on the quality of care for ED-admitted medical patients in general, or for patients with lower socioeconomic status. Yet, in order to reduce readmission and mortality among acutely admitted patients, other means must be initiated.

Shared Decision Making with Acutely Hospitalized, Older Poly-Medicated Patients: A Mixed-Methods Study in an Emergency Department

“…In recent years, there has been a growing interest in implementing SDM in the ED [ 23 , 24 , 25 ] because more than 70% of patients are discharged directly from the ED without further treatment in a specialized ward [ 26 ]. Several studies highlight that many patients would like to become involved in decisions about their treatment in the ED and to be made aware of this possibility [ 27 , 28 ].…”