Who comes back with what: a retrospective database study on reasons for emergency readmission to hospital in children and young people in England

Wijlaars, L.P.M.M. et al. Archives of Disease in Childhood.  Published Online: 25 April 2016

10998-2Objective: To determine the proportion of children and young people (CYP) in England who are readmitted for the same condition.

Design: Retrospective cohort study.

Setting: National administrative hospital data (Hospital Episode Statistics).

Participants: CYP (0-year-olds to 24-year-olds) discharged after an emergency admission to the National Health Service in England in 2009/2010.

Main outcome measures: Coded primary diagnosis classified in six broad groups indicating reason for admission (infection, chronic condition, injury, perinatal related or pregnancy related, sign or symptom or other). We grouped readmissions as ≤30 days or between 31 days and 2 years after the index discharge. We used multivariable logistic regression to determine factors at the index admission that were predictive of readmission within 30 days.

Results: 9% of CYP were readmitted within 30 days. Half of the 30-day readmissions and 40% of the recurrent admissions between 30 days and 2 years had the same primary diagnosis group as the original admission. These proportions were consistent across age, sex and diagnostic groups, except for infants and young women with pregnancy-related problems (15–24 years) who were more likely to be readmitted for the same primary diagnostic group. CYP with underlying chronic conditions were readmitted within 30 days twice as often (OR: 1.93, 95% CI 1.89 to 1.99) compared with CYP without chronic conditions.

Conclusions: Financial penalties for readmission are expected to incentivise more effective care of the original problem, thereby avoiding readmission. Our findings, that half of children come back with different problems, do not support this presumption.

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Nice Guideline update – Major Trauma: Assessment and Initial Management

This guideline covers the rapid identification and early management of major trauma in pre‑hospital and hospital settings, including ambulance services, emergency departments, major trauma centres and trauma units. It aims to reduce deaths and disabilities in people with serious injuries by improving the quality of their immediate care. It does not cover care for people with burns.

This guideline includes recommendations on:

Read the full guideline here

High volume emergency surgery units do not improve outcomes, report finds

Gulland, A. BMJ. 2016. 353:i2054

The move to centralised services for emergency general surgery would not improve outcomes or reduce mortality rates, a report has found.1

The Nuffield Trust looked at the problems facing emergency general surgery and found that the “widely held perception that centralisation will drive up quality” did not hold true. It found that there was no clear relationship between the number of procedures performed and surgical outcomes.

Image source: Nuffield Trust

The report, commissioned by the Royal College of Surgeons of England, found that there was little variation in mortality between sites that performed a large number of procedures and those that did not. The report looked at hospital episode statistics at 154 sites in England between 2009-10 and 2012-13 to compare mortality rates between those that performed a large number of procedures and those that did not.

It found that hospitals that performed around 50 or fewer major emergency surgical procedures annually had a mortality rate of just over 12%. Sites that performed more than 250 procedures a year had a mortality rate of just under 12%, and sites that performed 51 to 100 procedures annually had the lowest mortality rate of about 11%.

When researchers looked at very low volume sites—those performing less than 20 procedures annually—they found that there was no clear pattern of higher mortality.

View the full report here

View the full commentary here

Community characteristics associated with where urgent care centers are located: a cross-sectional analysis

Sidney T Le, Renee Y Hsia. BMJ Open 2016;6:e010663.

Objectives: To determine the community characteristics associated with non-hospital-based urgent care centres wherever they are located.

Design: National cross-sectional study evaluating the association between non-hospital-based urgent care centers, and their demographic characteristics in a community, using descriptive statistics and multivariate logistic regressions.

Setting: Communities in the USA with non-hospital-based urgent care centers, as identified using a 2014 national database from the Urgent Care Association of America.

Participants: 31 022 communities encompassing 6898 urgent care centers across the USA.

Primary and secondary outcome measures: Presence of a non-hospital-based urgent care center within a community.

Results: Communities with non-hospital-based urgent care centers are urban (75.7% with vs 22.2% without; p<0.001 across rural urban commuting area levels), and are located in areas with higher income levels (38.6% in highest quartile with vs 22.3% without; p<0.001 across quartiles) and higher levels of private insurance (29.6% in highest quartile with vs 23.9% without; p<0.001 across quartiles).

Conclusions: While the growth of the urgent care industry may have other promising implications, policymakers should recognise that it may exacerbate disparities in access to acute care faced by poorer, uninsured patients, and may also have financial implications for providers that are providing overlapping services, such as emergency departments and primary care practices.

Read the full article here

Quick guides: transforming urgent and emergency care services in England

avoid long stay
Image source: NHS England 

NHS England and partners have published a series of quick guides to support local health and care systems. The guides provide practical tips, case studies and links to useful documents, which can be used to implement solutions to commonly experienced issues. Use the information to manage upcoming winter pressures and plan for 2016 and beyond.

This guide has been produced by stakeholders [including hospital discharge teams; local authority adult services commissioners; continuing healthcare commissioners; independent care sector providers, including voluntary and housing sectors; patients; and carers] and provides:

• A checklist for local areas to use to identify areas for improvement;

• Information on existing solutions to common problems, including links to useful resources;

• A template policy and template patient letters to be adopted locally

avoid long stay2

Other guides include:

Better use of care at home (PDF, 257kb) Clinical input to care homes (PDF, 208kb)
Identifying local care home placements (PDF, 971kb) Improving hospital discharge into the care sector (PDF, 201kb)
Technology in care homes (PDF, 213kb) Sharing patient information (PDF, 723kb)

More information available here


A prospective quality improvement study in the emergency department targeting paediatric sepsis

Long, E. et al. Archives of Disease in Childhood. Published Online: 31st March 2016

Objective: Quality improvement sepsis initiatives in the paediatric emergency department have been associated with improved processes, but an unclear effect on patient outcome. We aimed to evaluate and improve emergency department sepsis processes and track subsequent changes in patient outcome.

Study design: A prospective observational cohort study in the emergency department of The Royal Children’s Hospital, Melbourne. Participants were children aged 0–18 years of age meeting predefined criteria for the diagnosis of sepsis. The following shortcomings in management were identified and targeted in a sepsis intervention: administration of antibiotics and blood sampling for a venous gas at the time of intravenous cannulation, and rapid administration of all fluid resuscitation therapy. The primary outcome measure was hospital length of stay.

Results: 102 patients were enrolled pre-intervention, 113 post-intervention. Median time from intravenous cannula insertion to antibiotic administration decreased from 55 min (IQR 27–90 min) pre-intervention to 19 min (IQR 10–32 min) post-intervention (p≤0.01). Venous blood gas at time of first intravenous cannula insertion was performed in 60% of patients pre-intervention vs 79% post-intervention (p≤0.01). Fluids were administered using manual push-pull or pressure-bag methods in 31% of patients pre-intervention and 84% of patients post-intervention (p≤0.01). Median hospital length of stay decreased from 96 h (IQR 64–198 h) pre-intervention to 80 h (IQR 53–167 h) post-intervention (p=0.02). This effect persisted when corrected for unequally distributed confounders between pre-intervention and post-intervention groups (uncorrected HR: 1.36, 95% CI 1.04 to 1.80, p=0.02; corrected HR: 1.34, 95% CI 1.01 to 1.80, p=0.04).

Conclusions: Use of quality improvement methodologies to improve the management of paediatric sepsis in the emergency department was associated with a reduction in hospital length of stay.

Read the full article here