Traditional Medicare Spending on Inpatient Episodes as Hospitalizations Decline

OBJECTIVE: To describe Medicare inpatient episode spending trends between 2009 and 2017 as inpatient use declined among traditional Medicare beneficiaries. METHODS: Inpatient episodes included claims for all traditional Medicare inpatient, outpatient, and Part D services provided during the 30 days prehospitalization, the inpatient stay, and the 90 subsequent days. We describe the mean number of episodes per 1000 beneficiaries, mean episode-related spending per beneficiary, and mean spending per episode for all beneficiaries and for specific populations and types of episodes. Spending measures are reported with and without adjustment for payment rate increases over the study period. RESULTS: The number of inpatient-initiated episodes per 1000 beneficiaries declined by 18.2% between 2009 and 2017 from 326 to 267. After adjusting for payment rate increases, Medicare spending per beneficiary on episode-related care declined by 8.9%, although spending per episode increased by 11.4% over this period. Between 2009 and 2017, all subgroups defined by age, sex, race, or Medicaid status experienced declines in inpatient use accompanied by decreased overall episode-related spending per beneficiary and increased spending per episode. Larger declines in the number of episodes per 1000 beneficiaries were seen among episodes that began with a planned admission (28.8%) or involved no use of post–acute care services (23.9%). When comparing admissions according to medical diagnosis, the largest decline occurred for episodes initiated by a hospitalization for a cardiac or circulatory condition (31.8%). CONCLUSION: Medicare inpatient episodes per beneficiary decreased, but spending decreases due to declining volume were offset by increased spending per episode.

1574 Does Use of Intra-Operative PPE Affect Post-Operative Infection Rates in Hip Fracture Patients?

Aim COVID-19 has required significant change to theatre protocol. Regional guidelines dictate full PPE must be donned for all procedures where aerosol generating procedures (AGP) occur. Additionally, no one may enter or leave theatre whilst an operation is in progress, or until 20 minutes after an AGP. We hypothesized that adopting these protocols may lead to a reduction in post-operative infection in hip fracture patients. Method Multicentre retrospective cohort study comparing post-operative infection and return to theatre rates (<30-days post-op) from 18/03/20 to 27/04/20 with respective period in 2019. COVID-19 was considered endemic in Northern Ireland from 18/03/20. Patients were identified from the Fracture Outcomes Research Department database and relevant inpatient episode reviewed via Electronic Care Record. Results 464 patients were included– 261(2020) and 203(2019). In 2019, 4 patients (1.5%) returned to theatre within 30-days, however only one was due to wound dehiscence. In 2020, 1 patient (0.5%) returned to theatre for traumatic wound dehiscence, however they had no documented infection. Conclusions There was no difference in post-operative complication rate requiring return to theatre within 30 days between cohorts. Whilst PPE can be considered important for protection of patients and staff against COVID-19, it may not have significant effect on post-operative infection rates.

974 Improving Safety for Tracheostomy and Laryngectomy Patients Within A Regional Head and Neck Unit

Aim To improve the safety of tracheostomy and laryngectomy patients within a UK-based regional head and neck unit. Method This audit was conducted against standards taken from the National Tracheostomy Safety Project (NTSP). Inclusion criteria were all patients with a tracheostomy or laryngectomy on the ward, there were no exclusion criteria. Data was collected per inpatient episode for a one month period pre- and post- implementation of each intervention (1st March to 31st May 2020). Results Pre-intervention results showed that none of the 19 neck-breathing inpatients during March 2020 had a bedhead sign or emergency algorithm displayed, however all patients had required bedside equipment and the only unavailable ward equipment was capnography. Laminated bedhead signs and algorithms were implemented and 33% neck-breathing patients had signs displayed during April 2020. Further intervention in May 2020 to educate ward staff led to 90% of patients having a bedhead sign displayed and 80% having an algorithm displayed. Conclusions Overall, our unit has very high standards of care for neck-breathing patients. The use of bedhead signs and emergency airway algorithms is an integral part of providing safe care for neck-breathing patients and all members of staff are responsible for their use. The COVID-19 crisis has impacted on the number of elective procedures being performed which has impacted upon the numbers for the post-intervention arms of our audit. Reduced staffing due to sickness during the pandemic may have contributed to the substandard results.

What is an admission? A standardised approach to classifying inpatient episode data from multiple jurisdictions

IntroductionInpatient datasets in the UK are primarily organised by episodes (periods of care under an individual consultant), while researchers often want to measure admissions (periods of stay in hospital). We developed a standardized method for identifying admissions in inpatient data, while accounting for differences between the four UK nations. Objectives and ApproachAll UK inpatient datasets include date variables, permitting chronological sequencing of episodes. They include flags describing whether an episode is a transfer of care, although structures and definitions differ. Data quality is variable leading to concurrent and overlapping episodes, duplication and “orphan” or “childless” transfer episodes, where no originating or destination episode can be identified. Our objective was to define a method for classifying individual episodes into a continuous period of stay in hospital, which would be consistently applicable to the analysis of inpatient datasets of all four UK nations, while prioritising clinical meaningfulness. Three permutations were considered. ResultsFor each permutation, episodes for an individual were linked when they related to the same individual and met the following criteria: Zero or one day gap between episode end and subsequent episode start Evidence of transfer according to admission method or discharge destination variables Episode overlapping or completely nested within another episode Permutations: a and b a only a and c Permutation three was adopted, as it was felt to be the most clinically meaningful approach, was not dependent on accurate recording of transfers and captured nested or overlapping episodes, which may occur for example when a patient is in a long-stay psychiatric or elderly care ward but requires care from a different specialty. Importantly it permitted consistent analysis of episodes across all UK nations. Conclusion/ImplicationsThe output of this work provides a useful guide for the classification of inpatient episodes into more clinically meaningful periods of care, and is applicable to the inpatient datasets of all four UK nations. It describes important issues to consider when classifying episodes of care, particularly relating to data quality.

Children and young people’s versus parents’ responses in an English national inpatient survey

ObjectiveDespite growing interest in children and young people’s (CYP) perspectives on healthcare, they continue to be excluded from many patient experience surveys. This study investigated the feasibility of, and additional information gained by, measuring CYP experiences of a recent hospital admission.DesignCross-sectional analysis of national survey data.SettingInpatients aged 8–15 years in eligible National Health Service hospitals, July–September 2014.Participants6204 parents/carers completed the parent section of the survey. The CYP section of the survey was completed by CYP themselves (n=3592), parents (n=849) or jointly (n=1763).Main outcome measuresPain relief, involvement, quality of staff communication, perceived safety, ward environment, overall experience.AnalysesSingle-measures intraclass correlations (ICCs) were used to assess the concordance between CYP and parent responses about the same inpatient episode. Multilevel logistic regression models, adjusted for individual characteristics, were used to compare the odds of positive responses when the CYP section of the survey was completed by parents, by CYP themselves or jointly.ResultsThe CYP section of the survey was completed independently by 57.8% of CYP. Agreement between CYP and parent responses was reasonably good for pain relief (ICC=0.61 (95% CI 0.58 to 0.63)) and overall experience (ICC=0.70 (95% CI 0.68 to 0.72)), but much lower for questions comparing professionals’ communication with CYP and with their parents (ICC range=0.28 (95% CI 0.24 to 0.32) to 0.51 (95% CI 0.47 to 0.54)). In the regression models, CYP were significantly less likely than parents to report feeling safe (adjusted OR (AOR)=0.54 (95% CI 0.38 to 0.76)), involvement in decisions (AOR=0.66 (95% CI 0.46 to 0.94)) or adequate privacy (AOR=0.68 (95% CI 0.52 to 0.89)).ConclusionsIncluding CYP (8–15 years) in patient experience surveys is feasible and enhances what is known from parents’ responses.

People’s experiences of hospital care on the weekend: secondary analysis of data from two national patient surveys

ObjectiveTo determine whether patients treated in hospital on the weekend report different experiences of care compared with those treated on weekdays.DesignThis is a secondary analysis of the 2014 National Health Service (NHS) adult inpatient survey and accident and emergency (A&E) department surveys. Differences were tested using independent samples t-tests and multiple regression, adjusting for patient age group, sex, ethnicity, proxy response, NHS trust, route of admission (for the inpatient survey) and destination on discharge (for the A&E survey).SettingThe inpatient survey included 154 NHS hospital trusts providing overnight care; the A&E survey 142 trusts with major emergency departments.ParticipantsThree cohorts were analysed: patients attending A&E, admitted to hospital and discharged from hospital. From the inpatient survey’s 59 083 responses, 10 382 were admitted and 11 542 discharged on weekends or public holidays. The A&E survey received 39 320 responses, including 11 542 (29.4%) who attended on the weekend or on public holidays. Weekday and weekend attendees’ response rates were similar once demographic characteristics were accounted for.Main outcome measuresFor the A&E survey, six composite dimensions covered waiting times, doctors and nurse, care and treatment, cleanliness, information on discharge, and overall experiences. For the inpatient survey, three questions covered admissions and two dimensions covered information about discharge and about medicines.ResultsPeople attending A&E on weekends were significantly more favourable about ‘doctors and nurses’ and ‘care and treatment’. Inpatients admitted via A&E on a weekend were more positive about the information given to them in A&E than others. Other dimensions showed no differences between people treated on weekdays or on weekends.ConclusionsPatients attending emergency departments or admitted to or discharged from an inpatient episode on weekends and public holidays report similar or more positive experiences of care to other patients after adjusting for patient characteristics.

Strength in unity: the power of redesign to align the hospital team

Objective The aim of Queen Elizabeth II Jubilee Hospital (QEII) redesign project (QEII United) was to enhance timely access to an inpatient bed and maximise opportunities to value add during the inpatient episode of care. Methods A tripartite relationship between the hospital team, system manager and external consultants. The team, QEII United, was formed to ‘diagnose, solve and implement’ change under the unifying metaphorical banner of a football team. A marketing strategy and communication plan targeted the key ‘players’ and outlined the ‘game plan’. Baseline data were collected, analysed and reported in keeping with key aims. Strategies for systems improvement implementation were attached to key performance indicators (KPIs). Results Thematic KPIs were developed to embed internal process change to reflect the contributions made towards the National Emergency Access Target (NEAT) at each stage of the patient journey. As such, access block of under 20%, morning discharge rates of 50% before midday, reduced length of stay for selected elective orthopaedic and general medical diagnostic related groupings (DRGs; i.e. relative stay index ≤1) and hospital in the home (HITH) utilisation rates 1.5% of all admissions were all met. Key to sustainability was the transfer of clinical redesign skills to hospital staff and the fostering of emergent ground up leadership. Conclusions QEII United’s success has been underpinned by the development of themed solution areas developed by the hospital staff themselves. Robust baseline data analysis used in combination with nationally available benchmarking data provided a quantitative starting point for the work. The collaborative elements of the program re-energised the hospital team, who were kept informed by targeted communications, to establish quick wins and build trust and momentum for the more challenging areas. What is known about the topic? Clinical redesign is now commonly used to understand, define and improve those clinical processes that underpin the patient journey across the continuum of care. Different industry models exist and have been extended for use in healthcare settings to involve, engage and educate staff with the primary focus of providing the best possible patient care, in an effective and efficient manner. What does this paper add? The clinical redesign process outlined in this paper is instructive in its use of the metaphorical team. Team philosophy, composition and functionality was built up using the vernacular of a football competition. In this way, organisational learning and capability building occurred within empowered local action teams, across the ‘season’ to effect changes at all points of the patient journey. What are the implications for practitioners? The implications for practitioners are to fully understand the breadth of issues before deciding upon focus areas for improvement. Resistance to change is inevitable and there are a number of ways to mitigate this and create a sense of purpose within the broader clinical group by structuring teams across traditional reporting lines. Collaboration is crucial in keeping lines of communication open and the use of data and patient feedback is very instructive.