Abstract
Objective
To use the Appropriateness Evaluation Protocol (AEP) to assess the extent of inappropriate utilisation of hospital beds by acute medical patients. To determine whether clinicians viewed the AEP decisions as valid.
Design
Retrospective review of the medical records of a 10% random sample of 8,210 patients admitted as medical emergencies. An objective independent review instrument (AEP) was used to assess the medical necessity for hospitalisation at admission and on each subsequent day. To test the validity of the screening instrument, a subsample of the reviewed records was further assessed by a panel of physicians.
Setting
A district general hospital in the West Midlands region of England.
Subjects
Eight hundred and twenty-one adult patients admitted to general medicine during one calendar year.
Main outcome measures
Proportions of admissions and days of care for which inpatient medical care was judged appropriate. Reasons for inappropriate utilisation and potential bed-days that could be saved by the development and use of alternative services were also considered. Validity of the AEP was tested by assessing agreement between the majority decision of an expert panel and the criterion-based AEP decision.
Results
AEP identified 51/821 (6%) admissions and 2,195/4,885 (45%) days of care as inappropriate. Over half the patients had a hospital stay in which at least half the days were judged inappropriate. The commonest reason for inappropriate days was remaining in hospital after the medical purpose for admission had been accomplished. This accounted for 38% of inappropriate days reviewed. In validity testing there was a high level of agreement between the physicians and the AEP, with kappa values greater than 0.80 for admissions and days of care.
Conclusions
The AEP is a valid and useful instrument for assessing the utilisation of acute medical beds in a NHS hospital. In this study acute medical admissions were largely appropriate at the time of admission but a substantial proportion of subsequent days of care was considered inappropriate by AEP criteria. Most inappropriate utilisation was due to organisational issues within the hospital. As a result of this study, several service and policy developments were identified that should improve the efficiency of bed utilisation at the hospital.
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Contributor Information
Helen E Smith, Senior Lecturer University of Southampton.
Alison Pryce, Statistician, North Staffordshire Hospital NHS Trust.
Leah Carlisle, Senior Clinical Auditor, North Staffordshire Hospital NHS Trust.
J Mary Jones, Statistician, North Staffordshire Hospital NHS Trust.
John Scarpello, Director, Clinical Audit and Consultant Physician, North Staffordshire Hospital NHS Trust.
Charles Pantin, Lead Consultant Physician for Clinical Audit, Medical Directorate, North Staffordshire Hospital NHS Trust.