Original article
Clinical outcomes in medical outliers admitted to hospital with heart failure

https://doi.org/10.1016/j.ejim.2009.09.010Get rights and content

Abstract

Background

Due to the lack of beds in medical wards, many patients are placed in other departments' wards (usually in surgical wards). These patients are called “medical outliers”. This is a common problem in countries with public national health services. We determined whether location influences progress and prognosis of patients.

Methods

This was a retrospective cohort study in a public university hospital in Madrid, Spain. 243 patients discharged from the Department of Internal Medicine during 2006 with the same diagnosis-related group (DRG) (congestive heart failure and cardiac arrhythmia with major complications or comorbidity) were studied. Patients admitted to departments other than the Internal Medicine department or Intensive Care Unit were excluded. “Medical outlier” was defined as a patient admitted to a ward different from the Internal Medicine ward. Medical outliers transferred to the Internal Medicine ward were not excluded.

Results

109 (45%) patients were medical outliers. They had a longer stay in hospital (mean difference 2.6 days, 95% confidence interval 0.6–4.7) but with no statistically significant differences in mortality, readmission, or intra-hospital morbidity. These patterns persisted after control for confounding in multivariate analysis.

Conclusion

Patients admitted to the Department of Internal Medicine with heart failure had a longer stay if they initially start in other departments' wards. Significant differences were not seen in this group of patients with respect to mortality, readmission, or intra-hospital morbidity.

Introduction

Many factors influence the prognosis and the length of stay of patients admitted to hospital. Many of these factors require a skilled practitioner to identify them. Patients with coronary heart disease, pulmonary embolism, chronic kidney disease, anaemia, hypoalbuminemia, cognitive impairment, or cancer have a higher morbidity than people without these conditions when they are admitted to hospital [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15]. Studying these factors allows the design of programs that improve the quality of hospital care.

Each hospital department manages one ward in which their patients are admitted. If there is a lack of beds within this ward, the department can choose between admitting more patients per ward or, if there are free beds in other wards of the hospital, placing them there. This latter option may not always be the best solution because patients located outside the ward may interfere with the activities of staff (e.g., medical staff doing the ward round, nursing staff caring for patients whose conditions may be different to those they are used to managing) and with the activities of the wards where they are placed (e.g., reducing elective admissions to surgical wards, increasing waiting lists) [16], [17]. In some hospitals, elective surgical patients are brought in overnight rather than on the day of admission to “protect” the bed [18].

Studies focusing on the differences in disease management between different specialists have been reported [6], [19], [20], [21], [22], [23], but publications about the influence of location in patient progress are lacking.

The aim of this study is to determine if location influences the progress and prognosis of patients.

Section snippets

Design

This was a retrospective cohort study using data from the minimum basic data set (MBDS), discharge summaries, and test records from La Princesa University Hospital (LPUH; a public centre with approximately 500 beds) in Madrid, Spain.

Participants

Patients discharged from the Department of Internal Medicine during 2006 with the All Patients Diagnosis-Related Group (AP-DRG) 544 (congestive heart failure and cardiac arrhythmia with major complications or comorbidity) were included. Patients who were admitted to

Results

243 patients met the inclusion criteria; none were excluded. 66 (27%) patients were male; the mean age was 82.2 ± 8.1 years; 109 (45%) patients were medical outliers. Table 1 shows the baseline characteristics of patients according to medical outlier status. Among these measures, we found a significantly different distribution in “admission at the weekend or bank holiday” that was more frequent in the medical outliers cohort (34% v 22%; p = 0.045).

Medical outliers had a longer stay in hospital (11.8 

Discussion

Attention is immediately drawn to the significant difference in the LOS between the two cohorts (2.6 days, 95% confidence interval (CI) 0.6–4.7). We could hypothesize that medical outliers have a longer stay in the hospital because they suffer from more complications, but no significant differences were found in the patients studied.

We consider that the longer stay in hospital of medical outliers was not related to worse care, but to worse management of hospital resources. Clinicians usually

Learning points

  • It is usual, as a solution to the lack of beds in a hospital ward, to place patients in other wards, which belong to other departments. These patients are often called “medical outliers”.

  • Medical outliers admitted to hospital with heart failure have a longer stay than those admitted to the department's ward, but we did not observe an increased prevalence of mortality, intra-hospital morbidity, or readmission in our study population.

  • Reducing the number of these patients will improve the

Conflict of interest

All authors declare that they do not have any financial or other substantive conflict of interest that might be construed to influence the results or interpretation of the manuscript.

Acknowledgements

We are grateful to Francisco Rodríguez and Guillermo Fernández from the Department of Admission and Clinical Documentation in La Princesa University Hospital. Francisco Rodríguez also provided valuable statistical input into the study design. Carlos Fuentes and María Esther Blanco assisted with the manuscript.

The study was not funded. Neither author has a conflict of interest.

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    Data from the manuscript were presented at the Spanish Society of Internal Medicine (SEMI) Congress 2007, in Sitges (Barcelona, Spain), on the 24th of November.

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