Ismail Sharif A, Pope Ian, Bloom Benjamin, Catalao Raquel, Green Emilie, Longbottom Rebecca E, Jansen Gwyneth, McCoy David, Harris Tim
Barts Health NHS Trust, London, UK.
Homerton University Hospital NHS Foundation Trust, London, UK.
BMJ Open. 2017 Jun 22;7(6):e011547. doi: 10.1136/bmjopen-2016-011547.
To investigate factors associated with unscheduled admission following presentation to emergency departments (EDs) at three hospitals in England.
Cross-sectional analysis of attendance data for patients from three urban EDs in England: a large teaching hospital and major trauma centre (site 1) and two district general hospitals (sites 2 and 3). Variables included patient age, gender, ethnicity, deprivation score, arrival date and time, arrival by ambulance or otherwise, a variety of ED workload measures, inpatient bed occupancy rates and admission outcome. Coding inconsistencies in routine ED data used for this study meant that diagnosis could not be included.
The primary outcome for the study was unscheduled admission.
All adults aged 16 and older attending the three inner London EDs in December 2013. Data on 19 734 unique patient attendances were gathered.
Outcome data were available for 19 721 attendances (>99%), of whom 6263 (32%) were admitted to hospital. Site 1 was set as the baseline site for analysis of admission risk. Risk of admission was significantly greater at sites 2 and 3 (adjusted OR (AOR) relative to site 1 for site 2 was 1.89, 95% CI 1.74 to 2.05, p<0.001) and for patients of black or black British ethnicity (AOR 1.29, 1.16 to 1.44, p<0.001). Deprivation was strongly associated with admission. Analysis of departmental and hospital-wide workload pressures gave conflicting results, but proximity to the "4-hour target" (a rule that limits patient stays in EDs to 4 hours in the National Health Service in England) emerged as a strong driver for admission in this analysis (AOR 3.61, 95% CI 3.30 to 3.95, p<0.001).
This study found statistically significant variations in odds of admission between hospital sites when adjusting for various patient demographic and presentation factors, suggesting important variations in ED-level and clinician-level behaviour relating to admission decisions. The 4-hour target is a strong driver for emergency admission.
调查英格兰三家医院急诊科就诊后非计划入院的相关因素。
对英格兰三家城市急诊科患者的就诊数据进行横断面分析：一家大型教学医院及主要创伤中心（地点1）和两家地区综合医院（地点2和3）。变量包括患者年龄、性别、种族、贫困评分、到达日期和时间、是否乘救护车到达、多种急诊科工作量指标、住院床位占用率及入院结局。本研究使用的常规急诊科数据中的编码不一致意味着无法纳入诊断信息。
本研究的主要结局是非计划入院。
2013年12月在伦敦市中心三家急诊科就诊的所有16岁及以上成年人。收集了19734例不同患者就诊的数据。
有19721例就诊（>99%）的结局数据可用，其中6263例（32%）入院。地点1被设为分析入院风险的基线地点。地点2和3的入院风险显著更高（地点2相对于地点1的调整后比值比（AOR）为1.89，95%置信区间为1.74至2.05，p<0.001），黑人或英国黑人种族患者也是如此（AOR为1.29，1.16至1.44，p<0.001）。贫困与入院密切相关。对科室和全院工作量压力的分析结果相互矛盾，但在本分析中，接近“4小时目标”（英格兰国民医疗服务体系中一项将患者在急诊科停留时间限制在4小时的规定）成为入院的一个重要驱动因素（AOR为3.61，95%置信区间为3.30至3.95，p<0.001）。
本研究发现，在调整各种患者人口统计学和就诊因素后，不同医院地点之间的入院几率存在统计学显著差异，这表明在急诊科层面和临床医生层面与入院决策相关的行为存在重要差异。4小时目标是紧急入院的一个重要驱动因素。
