Adult emergency services:
Acute medicine and emergency
general surgery
Case for change
June 2011 v0.26
Table of contents
Table of contents......................................................................................................... 2
Foreword ...................................................................................................................... 5
Executive summary..................................................................................................... 5
Summary of key messages ...................................................................................... 10
1.
1.1.
1.2.
1.3.
1.4.
1.5.
1.6.
Introduction .................................................................................................. 13
The scope of the review ................................................................................. 13
Defining an emergency admission ................................................................. 14
Growing pressures on acute and emergency admission services.................. 14
Delivering the QIPP agenda in London .......................................................... 14
Method ........................................................................................................... 15
Survey of London hospitals’ adult emergency services .................................. 15
2.
2.1.
2.2.
Variation in outcomes across London ....................................................... 16
Hospital standardised mortality ratios ............................................................ 16
Differences in-hours and out-of-hours mortality for emergency admissions
Error! Bookmark not defined.
Length of hospital stay ................................................................................... 19
Re-admission rates ........................................................................................ 20
2.3.
2.4.
3.
The process of emergency admissions ..................................................... 22
3.1.
Acute medical and surgical units .................................................................... 22
3.2.
On-take working patterns ............................................................................... 22
3.2.1 Senior involvement in the initial assessment ................................................ 23
3.2.2 Consultant presence on-site ......................................................................... 23
3.2.3 Timeframe for the initial assessment ............................................................ 25
3.2.4 Other commitments whilst on-take................................................................ 27
3.2.5 Ward rounds for emergency admissions ...................................................... 27
3.2.6 System for on-take consultants..................................................................... 29
3.3.
Ambulatory care ............................................................................................. 29
3.4.
Discharge ....................................................................................................... 30
4.
Diagnostics ................................................................................................... 32
4.1.
Imaging .......................................................................................................... 32
4.1.1 Timely access to scans ................................................................................. 32
4.1.2 Quality interpretation of scans ...................................................................... 33
4.2.
Interventional radiology .................................................................................. 34
4.3.
Pathology ....................................................................................................... 35
4.4.
Endoscopy ..................................................................................................... 36
5.
5.1.
5.2.
5.3.
5.4.
5.5.
Acute medicine............................................................................................. 38
Activity in London ........................................................................................... 38
Length of stay................................................................................................. 38
Re-admission rates ........................................................................................ 39
Medical outliers .............................................................................................. 40
Treatment regimes for common medical admissions ..................................... 41
2
6.
Emergency general surgery ........................................................................ 42
6.1.
Effective and safe treatment planning ............................................................ 43
6.1.1. Consultant involvement in the decision to operate........................................ 43
6.1.2. Consultant surgeons commitments whilst on-take ........................................ 43
6.2.
Delays in access to an emergency theatre .................................................... 44
6.3.
Emergency surgery at night ........................................................................... 45
6.4.
Best practice in the operating theatre............................................................. 46
6.4.1. Seniority and supervision of surgeon performing the operation .................... 46
6.4.2. Seniority and supervision of the anaesthetist supporting the operation ........ 47
6.4.3. Speciality of the surgeon performing the operation....................................... 49
6.5.
Emergency general surgery in London .......................................................... 50
6.5.1. Activity in London.......................................................................................... 50
6.5.2. Surgical techniques ...................................................................................... 50
6.5.3. Appendicectomy ........................................................................................... 51
6.5.4. Cholecystectomy .......................................................................................... 52
6.5.5. Emergency day case surgery ....................................................................... 53
6.5.6. Hernias ......................................................................................................... 54
6.5.7. Procedures on the colon ............................................................................... 55
6.6.
Population and volume demands on an emergency general surgery service 56
7.
Hospital infrastructure ................................................................................. 58
7.1.
Access to mental health services ................................................................... 58
7.1.1. Liaison services for dementia ....................................................................... 59
7.2.
Alcohol misuse ............................................................................................... 59
7.3.
Older people................................................................................................... 60
7.3.1. Falls service .................................................................................................. 61
7.4.
Critical and intensive care services ................................................................ 62
7.4.1 Poor recognition of deteriorating patients and escalation protocols .............. 62
7.4.2 Early warning systems .................................................................................. 62
7.4.3 Referral process ........................................................................................... 63
7.4.4 Admission process........................................................................................ 63
7.5.
Hospital at night ............................................................................................. 63
8.
8.1.
8.2.
Patient experience ....................................................................................... 64
Communication and information..................................................................... 64
Raising concerns about care and complaints procedures .............................. 65
9.
Workforce and training ................................................................................ 66
9.1.
Impact of reduced number of medical and surgical trainees .......................... 66
9.2.
The impact of surgical specialisation on the on-call rota ................................ 66
9.3.
Impact of the European Working Time Directive ............................................ 66
9.3.1. On all rotas ................................................................................................... 66
9.3.2. On training .................................................................................................... 67
9.4.
Developing sustainable services .................................................................... 67
10.
Conclusion.................................................................................................... 68
11.
Glossary of terms ......................................................................................... 69
12.
Appendices ................................................................................................... 73
Appendix 1 – Membership of clinical expert panels and project board ........................ 73
Appendix 2 – Membership of patient panel ................................................................. 76
3
Appendix 3 – Acute medicine data, length of stay ....................................................... 77
Appendix 4 – Acute medicine data, 30 day re-admission rates ................................... 80
Appendix 5 – Emergency general surgery data, length of stay ................................... 83
Appendix 6 – Emergency general surgery data, 30 day re-admission rates ............... 85
Appendix 7 – Disclaimers ............................................................................................ 88
4
Foreword
There are over half a million emergency admissions to London’s hospitals each year.
These represent the sickest of our patients. Their acute medical or surgical problems
do not recognise the time of day, nor day of the week.
Maintaining safe, reliable, high quality services throughout twenty four hours for every
day of the year, in order to meet their needs, is a challenge for all our hospitals.
Such services ought to ensure that individuals with the right skills are available at all
times, in appropriate settings, and with the right supporting infrastructure to establish a
diagnosis and begin effective treatment. This is what the general public quite rightly
expect.
And yet it appears that in many instances we do not achieve this. The system does not
function as well as it could, or should. Although there are many areas of excellent
practice, there are widespread inconsistencies which render the service inequitable
and may result in avoidable death.
Several recent reports from influential professional bodies, the Royal Colleges and the
National Confidential Enquiry into Patient Outcome and Death (NCEPOD), have
highlighted deficiencies of care in many areas. There is too often a dependency on
doctors in training to provide service; they may be exposed to circumstances beyond
their capability; the necessary senior clinical leadership and wisdom is absent at times
when it is most needed and could be most effective. The service is at its most fragile
overnight and at weekends.
This review explored the extent to which services across London were reliably safe
throughout twenty four hour periods and at weekends by considering the availability of
key staff, namely consultants, as well as the necessary therapeutic and diagnostic
support systems. It considered evidence from the literature with regard to the impact
on outcomes for patients treated ‘out of hours’. It also examined ‘Hospital Episodes
Statistics’ (HES) data in relation to mortality in London.
Significant variability in practice emerges. In keeping with national and international
literature, London data suggests that across the whole health system patients are
more likely to die if admitted at weekends with medical or surgical emergencies.
In contrast, where London has made significant improvements in its service provision,
however, for example in stroke, trauma, or heart disease, and where reliable 24 hour
services are available, this difference diminishes significantly.
We can only conclude that our hospital emergency services are not as reliably safe as
might be expected. This situation needs to improve.
In the course of the review discussions were held with the Medical Director of every
acute trust in London. All emphasised the high priority that Trusts place on safety,
with direct reporting mechanisms to the Board within their clinical governance
structures.
The need for change in the system to improve out-of-hours provision was widely
acknowledged. Some Trusts had made it an explicit aim that for the emergency
medical and surgical pathways there would be consistency throughout day and night.
5
Many Trusts however, perhaps mindful of the limitations of resource, had not made
this commitment.
Although the scope of this review was limited to inpatient management, it was
repeatedly emphasised that avoiding admission to hospital is the best and safest
outcome for many patients. London has a high rate of conversion from attendance at
emergency departments to admission, with subsequent short lengths of stay.
Ambulatory services, whereby an assessment can be made and management plan
determined by a consultant, with care continued close to home in conjunction with
GPs and community staff, can be cost effective, personalised and of high quality.
Excellent examples of innovative practice within integrated care systems were
described, with impressive results in terms of reducing admissions. And yet their
development remains patchy.
Similarly, exemplars were cited of medical and surgical assessment units staffed by
consultants with generalist skills and an holistic approach to patient management ,
limiting lengths of stay and ensuring a specialist focus only in the circumstances where
this was a genuine requirement.
The key to change lies in adaptation of working practice to ensure greater availability
of senior medical leadership. Many Medical Directors stated that this was a journey
that their Trusts had embarked upon, with the co-operation of consultants, in
developing dynamic working practices that were responsive to patient needs. Others,
however, admitted that they remained locked into traditional and often inflexible
models.
Notwithstanding the limited scope of this review, it establishes a compelling case for
change and demonstrates the need for robust minimum standards which should be
adopted by all services. This process will in itself, given the interdependencies that
exist, impact on other disciplines, and draw other vitally important professional groups
into the debate as we build a model of care for acute medicine and emergency
general surgery that is fit for purpose in the future.
6
Executive summary
This review of adult emergency services was commissioned by NHS London to
determine existing practice for the provision of services for patients admitted to NHS
hospitals on an unplanned, emergency basis in London. The review looked at how
providers in London compared with national standards and guidelines in the
management of adults admitted to hospital with acute medical or emergency general
surgical conditions.
The review was prompted by recognition of the pressures in the system caused by the
reduced working hours of junior doctors consequent of the implementation of the
European Working Time Directive and by the increasing demand for consultant
delivered care as a means of quality improvement.
The review does not cover services provided by emergency departments but the
services patients receive after a decision to admit the patient to a hospital bed has
been taken.
While the NHS in London provides a high quality service for the majority of patients
admitted as an emergency, the case for change sought to ascertain existing practice
in acute trusts in London in regard to key resource allocation for emergency inpatient
care and to highlight areas where services could be improved to provide better
outcomes for patients and to raise the standards of care provided by a modern health
service.
To establish the existing practice and best practice the following methods were used:




Desk-based research of relevant literature, including PubMed and NCEPOD
reports;
Analysis of hospital episode statistics data;
A self-reported survey of acute trusts to understand the current situation and
how these services compare with best practice outlined in recent literature;
Safety assurance discussions with all trust medical directors undertaken by Dr
Andy Mitchell, Medical Director, NHS London.
The review was further informed by two clinical expert panels – one for acute medicine
and one for emergency general surgery – as well as a patient panel.
Variations in outcomes across London
Influential bodies such as The Royal College of Physicians, Royal College of
Surgeons and the National Confidential Enquiry into Patient Outcome and Death
(NCEPOD) have all published recommendations to address poor standards of care
and these messages are consistent across the board – there is often inadequate
involvement from senior medical personnel in the assessment and management of
acutely ill patients, and this situation is worsened outside of core working hours.
Patients admitted as an emergency do not have the time to exercise choice in
healthcare. The vast majority of patients will attend their nearest hospital. This means
that it is even more important to ensure that services are not only equitable, but also of
a consistently high standard.
However, significant variations in outcomes for patients admitted as an emergency
exist across London. This variation is seen across several measures, including
7
mortality, length of stay and 30-day re-admission rates. Some of the key determinants
for these outcomes are the organisation of staff and the hospital systems and
processes in place which are significantly variable across London.
Regional data for London shows that the probability of dying as a result of many
emergency conditions is significantly higher if the admission is at the weekend,
compared to a weekday. Each year, there are around 25,000 deaths in London’s
hospitals following emergency admission. If the weekend mortality rate in London was
the same as the weekday rate, there would be around 520 fewer deaths. Reduced
service provision at weekends is associated with this higher mortality rate.
[Placeholder – Insert 30 day mortality data analysis]
The acute trust survey found that there is significant variation between London’s
hospitals in the involvement of consultants in the assessment and management of
acutely ill patients. There is variation between the number of hours that consultants
are expected to be onsite, the number of ward rounds taking place during the week
and at the weekend and whether or not consultants are expected to undertake other
clinical duties whilst responsible for emergency admissions.
Diagnostics
Across London, there is variation in the number of qualified staff available to
undertake diagnostic imaging and interpret the results, particularly outside of normal
working hours. This can lead to misdiagnosis and the administering of incorrect
treatment.
Acute medicine
A variation in the clinical management and working patterns of staff in acute medicine
can be linked to a significant variation in the length of stay for patients with the same
diagnosis. It can also contribute to a variation in re-admission rates.
Emergency general surgery
A lack of consultant involvement in surgical decision making and emergency surgery is
associated with higher patient mortality and morbidity. In London, there is significant
variation in the number of hours that a consultant is expected to be onsite, some are
not freed from elective surgery commitments to carry out emergency work and surgical
trainees are often not supervised out-of-hours.
The survey of acute trusts also found that there is inadequate access in almost a third
of London’s hospitals to an emergency theatre – this is detrimental to patient
outcomes and can increase mortality and morbidity.
Other areas where London is not meeting national guidance and best practice
recommendations include the use of laparoscopic surgery, which is less invasive for
patients; and increasing emergency day case surgery, which provides a higher quality
service at a lower cost.
Patient experience
Patients have reported poor communication and a lack of accessible information when
being admitted to hospital as an emergency. Improvements can also be made to the
timeliness of patient discharge to improve their experience of the health service.
Workforce and training
8
Currently, trusts are facing increasing pressure from workforce issues. Some London
trusts struggle to fill their acute rotas with adequately trained, permanent staff and the
European Working Time Directive means that trainees cannot be relied on to cover
gaps in the rotas.
Additionally, increasing sub-specialisation in general surgery has resulted in a
reduction in the pool of appropriately skilled surgeons to staff the emergency rota.
9
Summary of key messages
The key messages from the full case for change are as follows:
Variation in outcomes across London

Patients admitted to hospital as an emergency at weekends have a higher mortality
rate and poorer outcomes than those admitted on a weekday. Data for London
shows that the probability of dying as a result of many emergency conditions is
significantly higher if the admission is at the weekend, compared to a weekday.
Each year, there are around 25 000 deaths in hospital following emergency
admission. If the weekend mortality rate in London was the same as the weekday
rate, there would be around 520 fewer deaths. Reduced service provision at
weekends is associated with this higher mortality rate.

[Placeholder – Insert 30 day mortality data analysis]

Evidence has also demonstrated that where services in London have the same
provision in place, seven days per week, there is no observed difference in
mortality rates in the week and at the weekendi.
Process of emergency admissions

National recommendations state that consultants should be available on site for
emergency admissions. The London survey shows trusts are not meeting these
recommendations, and weekend provision is especially poor.

Best practice recommendations state that emergency admissions should be seen
by a consultant within 12 hours. The London survey of acute trusts shows that only
three sites in London always meet this recommendation in both acute medical and
emergency surgery patients.

On-take consultants should not have any other planned commitments when they
are responsible for emergency admissions. More than half of London hospitals do
not meet this recommendation.

Best practice is for twice daily ward rounds to take place, seven days a week. More
than half of London hospitals are not meeting this recommendation.

National recommendations state that on-take consultants should work consecutive
days. Most hospitals in London operate a ‘consultant of the day’ system which
does not meet best practice.

Ambulatory care is efficient, saves money and improves patient experience. In
London only half of hospitals provide an ambulatory care service.
Diagnostics

It is recommended that for those patients requiring diagnostics, there should be
prompt access to imaging and consultant reporting. The London survey of acute
trusts shows that this access is variable across London.
10

The need for comprehensive 24-hour interventional radiology provision has
increased significantly yet few sites in London offer this level of provision.

National recommendations state that all hospitals should have access to out-ofhours endoscopy services. However, in London access to this service is poor and
often out of hours provision is reliant on goodwill.
Acute medicine

There is significant variation in length of hospital stay and readmission rates across
London’s hospitals for patients with the same diagnosis. Whilst many factors can
affect these outcomes, some of which are beyond the control of the hospital, it is
an important marker of quality as it signals both the efficiency and timeliness of
care.

Over half of London’s hospitals have medical outliers on a weekly basis. Evidence
shows that medical outliers have longer lengths of stay.

Across London, there is considerable variation in the clinical management of many
common acute medical admissions. Evidence shows that standardised
management practices improves outcomes for patients.
Emergency general surgery

A lack of consultant involvement in surgical decision making and emergency
surgery is associated with higher patient mortality and morbidity. In London there is
considerable variation in the number of hours consultants are expected to be
onsite each day.

National recommendations state that the on-take emergency general surgeon
should not have any other planned duties when they are responsible for
emergency admissions. Just 45.3% of hospitals in London meet this standard.

Delays in conducting emergency surgery can prolong length of stay and can
increase mortality and morbidity. Over one quarter of London’s trusts reported
delays in emergency general surgery occurred “sometimes” or “very often”.

The provision of emergency general surgery during the week and at weekends in
London is inequitable. Consultant general surgeons are on-site for significantly
fewer hours at weekends than they are during the week. Patients admitted at
weekends are less likely to have a consultant involved in their care.

A consultant anaesthetist’s direct involvement in emergency operations is
associated with better outcomes for patients. In London, consultant anaesthetists
are not always available on-site, particularly at weekends.

All emergency general surgical services should be able to offer laparoscopic
surgery. However, half of the hospitals in London do not have all emergency
general surgeons on their rota trained and able to offer this modern technique.
11

Best practice is for cholecystectomy to be undertaken during the first admission for
the majority of patients with acute cholecystitis, and is associated with reduced
length of stay and fewer unplanned re-admissions for patients. In the majority of
London hospitals patients are not offered this service.

Emergency day case surgery provides a high quality service at lower cost, yet is
not widely practised in London.

Higher surgeon and hospital volumes of cases are associated with better patient
outcomes for many complex operations.
Hospital infrastructure

National recommendations state that hospitals should provide patients admitted as
an emergency with prompt access to mental health services. In London, especially
at weekends, this is not being achieved.

Nearly 40% of emergency admissions in London are for patients aged over 70
years. Over half of London hospitals do not have a dedicated on-take service for
older people.

Patients requiring intensive care need to be identified at the earliest opportunity
and appropriate escalation followed to improve outcomes.

Consultant involvement in critical care referrals and admissions falls short of best
practice standards leading to inappropriate admissions and extended ICU stays.
Patient experience

Poor communication, listening skills and the provision of accessible information
has a marked impact on the experience of patients and their families.
Workforce and training

Due to the development of sub-specialties in general surgery, hospitals in London
will find it increasingly difficult to appropriately staff the consultant emergency
general surgery rota.

Implementation of the European Working Time Directive means that medical and
surgical trainees have less time to undertake their training. Trainees should not be
used to cover gaps in the emergency rota as this affects their training by reducing
the time they have available for training even more.
12
1. Introduction
The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has
identified issues relating to the provision of emergency care services over a number of
years. Messages have been consistent, namely that there is often inadequate
involvement of senior medical personnel in the assessment and subsequent
management of many acutely ill patients. Outcomes are therefore not as good as
could be achieved, nor as patients should expect. There should be early senior
medical involvement in patient care, and the roles of consultants should be developed
so that they have more direct involvement in out-of-hours work.
Many emergency care services remain dependent on trainees for service provision.
Trainees are often called upon to practise beyond their level of competence and
without supervision. Patients are placed at unnecessary risk and trainees themselves
may well be compromised. This is neither an appropriate nor a sustainable position,
especially given the expected reduction in junior doctor training numbers.
This document identifies why and where services need to change in order to offer
patients a consistently high quality service throughout a 24-hour period, seven days a
week. The following model of care document will address how this should be achieved
by changing the way emergency services are delivered.
1.1.
The scope of the review
The focus of the adult emergency services review is on adult patients who have been
admitted to hospital on an unplanned basis. The review has examined hospital
emergency care services, in both medical and surgical specialties.
The scope of the review was agreed by the project board, and was guided and
advised by a multidisciplinary group, including secondary care physicians and
surgeons, GPs and patients. Table 1 provides a high level summary of the services
and disease areas included in the review and those that have been excluded.
Table 1: Summary of the adult emergency services review scope
Included
Excluded
Disease
areas –
acute
medicine
Disease
areas –
emergency
general
surgery
Service
areas



Acute infections
Respiratory disease
Heart failure



Stroke
Myocardial infarction (heart attack)
Cancer care

Emergency surgical presentations of
abdominal pain and mainly affecting
the GI system



Orthopaedic surgery
Vascular surgery
All patients admitted for major
trauma to a designated major
trauma centre


Acute assessment units
Intensive care and high dependency
units
Diagnostic services

Accident and Emergency
departments
The role of ambulance services prior
to arriving at a hospital with an


13


The hospital component of
discharge planning
Ambulatory care services



emergency patient
Primary care, GP and non-hospital
based emergency/ urgent care
services
Rehabilitation services
Community and social care services
The review examined the quality of care and the services needed for patients once a
decision to admit to a London hospital had taken place. This is not therefore a review
of London’s Emergency Departments (ED). A full outline of the project scope can be
found online.
1.2.
Defining an emergency admission
An emergency admission can be defined as an admission that is unpredictable and at
short notice because of clinical need1 and this includes re-admissions. The review
considered adult patients only (aged 18 or over) receiving hospital based care only
and did not review services based outside of the hospital setting.
1.3.
Growing pressures on acute and emergency admission services
In recent years there has been much focus on improving the patient journey through
emergency departments (EDs). The Government’s four hour performance standard
has significantly reduced the amount of time patients have spent waiting in an ED.
However, there remains significant pressure on hospitals to cope with the attendance
and admissions rates to hospital.2, 3 In London alone, there were over 580,000
emergency admissions in 2009/10, an increase of 14% since 2007/08 (see table 2).
This review focuses on acute medical and surgical admissions as these contribute to
the majority of inpatient bed demand and use in most hospitals.
Table 2: Emergency admissions to London hospitals from 2007/08 to 2009/10
Year
2007/8
2008/9
2009/10
Number of emergency admissions
542,533
586,136
616,682
1.4.
Delivering the QIPP agenda
This review takes place in a heightened financial climate where the NHS in England
has been tasked with delivering a £20 billion saving over the spending review period. 4
In order to deliver these savings, the Department of Health introduced the Quality,
Innovation, Productivity and Prevention (QIPP) programme. The programme aims to
1
2
3
4
National Confidential Enquiry into Patient Outcome and Death. (2007). Emergency admissions: A
step in the right direction, NCEPOD
Wanless, D., Appleby, J. & Harrison, A. D. P. (2007). Our future health secured? A review of NHS
funding and performance. London: Kings Fund. Also available at:
http://www.kingsfund.org.uk/research/publications/our_future.html
Robinson, P. (2007). Four-hour target fuels admissions. Health Service Journal, 117(6078): 23
Department of Health. (2011). The Operating Framework for the NHS in England 2011/12. Also
available at:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_122736.p
df
14
support commissioners, clinical teams and NHS organisations to improve the quality of
care and the efficiency of services.
London needs to contribute to the national figure of £20 billion of savings. There
remains a responsibility to review services and improve the quality of care while
reducing costs, inline with the QIPP agenda. It is therefore accepted that the review of
London’s adult emergency services, in addition to examining issues of clinical safety
and quality, should also look at how to ensure services are more efficient. Improving
efficiency and quality together through innovation and best practice, are driving
principles behind this review.
1.5.
Method
This review was clinically led. A clinical director and clinical leads for both acute
medicine and emergency general surgery were appointed to lead the development of
the medical and surgical components of the review. Each clinical lead chaired a
multidisciplinary clinical expert panel, appointed via an application process. The
panels also included representation from outside of London.
Patients were an integral part of this review. A patient panel met regularly to contribute
their experiences and expertise to the work. Members from the patient panel were also
present at all of the clinical meetings, to ensure that the patient perspective could be
heard and incorporated throughout the review. Full details of the individuals involved
in this review can be found in appendices 1 and 2.
1.6.
Survey of London hospitals’ adult emergency services
A survey of the emergency care services at NHS hospitals in London was undertaken
to establish more information on the organisation, design and delivery of the services
that cannot be determined from activity data alone. In the context of emergency
admissions, a quality service has a range of factors, beyond just those that are
measured and reported to traditional data sources. These include staffing levels, rota
and out-of-hours arrangements, availability of diagnostics and systems of care.
Full details on how the survey was constructed, piloted, administered, responded to
and the results are available online at www.londonhp.nhs.uk (Survey of current
arrangements: acute medicine and emergency general surgery 2011).
15
2. Variation in outcomes across London
Significant variation in patient outcomes for those admitted as an emergency exists
today across London. This variation is not only seen in terms of length of hospital
stays and re-admission rates, but also in terms of mortality rates. Evidence suggests
that the workforce, systems and processes in place at hospitals to manage emergency
admissions can have an influence on patient outcomes.
Patients admitted as an emergency do not have time to exercise choice in healthcare.
The vast majority of patients will attend their nearest hospital. This means that it is
even more important to ensure that services are not only equitable, but also of a
consistently high standard. Data collected on outcome measures suggests that this is
currently not the case in London.
2.1.
Hospital Standardised Mortality Ratios
The independent Dr Foster Ltd organisation routinely publishes Hospital Standardised
Mortality Ratio (HSMR) data for all hospitals in the UK. The HSMR measures whether
the death rate at a hospital is higher or lower than expected, and is therefore an
important indicator of healthcare quality. The data is adjusted for a range of factors
including age, co-morbidities, primary diagnosis and socio-economic deprivation.
The majority of deaths in hospitals occur following an unplanned, emergency
admission. In London in 2009/10, 89.2% of hospital deaths resulted from patients
admitted as an emergency. Therefore the vast majority of deaths in figure 1, which
shows the overall mortality ratio for London Trusts, will have resulted from an
emergency admission.
Figure 1 Overall mortality HSMR for London trusts in 2009/10*. Source and ©:
Dr Foster Ltd. Green equates to well below the average, yellow equates to inline
with expected and red indicates a rate well above expected rates.
*trusts are grouped according to foundation status as per Dr Foster groupings.
It is clear that there is substantial and significant variation across London. Whilst a
large proportion of trusts demonstrate a ratio that puts them below the average, there
are trusts which sit closer to or higher than the average. The current service is
inequitable, meaning that the quality of care a patient receives and their subsequent
outcome will be dependent on the hospital to which they are admitted.
16
A similar pattern of variation and inequitable care is seen when looking at surgical
mortality outcomes. Figure 2 shows the mortality ratios for London Trusts following all
surgery.
Approximately one half of all general surgery is undertaken on an emergency basis5.
Figure 2 Deaths following all surgery HMSR in London trusts, 2009/10. Source
and ©: Dr Foster Ltd. Green equates to well below the average, yellow equates
to inline with expected and rates.
*trusts are grouped according to foundation status as per Dr Foster groupings.
The HSMR for deaths following surgery varies considerably across London. This
means that patients cannot be assured of a universally high quality emergency
surgical service in every hospital across the capital.
2.2.
Differences between weekday and weekend mortality for emergency
admissions
International and UK based evidence shows that patients admitted as an emergency
at weekends have a significantly higher rate of mortality than those admitted during
the week.6,7, 8 9 Aylin et al found in their national study that during 2005/06 in hospital
mortality rates were 0.3% higher for patients admitted at the weekend compared to
those admitted during the week. These mortality rates are risk and case mix adjusted,
meaning that the observed differences in death rates are unrelated to the severity of
the illness, the age of the patient and any co-morbidities. This means that there are
other factors contributing to these high death rates at weekends.
5
6
7
8
9
Mai-Phan, T. A. (2008) Emergency room surgical workload in an inner city UK teaching hospital.
World Journal of Emergency Surgery. 3: 19
Aylin. P. et al (2010). Weekend mortality for emergency admissions. A large multicentre study,
Quality and Safety in Health Care, 19: 213-217
Bell, M. D., Redelmeier, D. A. (2001). Mortality among patients admitted to hospitals on weekends
compared with weekdays The New England Journal of Medicine 345: 9
Barba, R., Losa, J. E., Velasco, M., Guijarro, C., Garcia de Casasola, G. & Zapatero, A. (2006).
Mortality among adult patients admitted to the hospital on weekends The European Journal of
Internal Medicine 17: 322-324
Riciardi, P. (2011) Mortality rate after non-elective hospital admission. Arch. Surg. 2011; 146(5):
545-551
17
These studies suggest that there is an association with reduced numbers of senior
staff at weekends, and the observed increases in mortality seen at these times. During
weekends, London hospitals, like other trusts in the UK, run a reduced medical shift
system, with fewer senior staff available and less direct specialist input. It follows
therefore, that patients admitted at weekends and out-of-hours in London may be at
an increased risk of mortality than those admitted in the week.
National findings are consistent with the findings of the latest available data for
London.10 In hospital mortality rates in 2009/10 were found to be 0.32% higher for
patients admitted at the weekend compared to those patients admitted during the
week. Even when the data is risk and case mix adjusted, taking into account sex, age,
social deprivation, primary diagnosis and co-morbidity of the patient group, the
probability of dying from many emergency conditions in London is significantly higher if
the admission is at the weekend compared to a weekday11. Each year, there are
around 25 000 deaths in London’s hospital following emergency admission. If the
weekend mortality rate in London was the same as the weekday rate, there would be
around 520 fewer deaths every year.
[Placeholder – Insert 30 day mortality data analysis]
In a recent evaluation the RCP found that only a small minority of acute physicians
work at the weekend.12 This was echoed in the results of the London survey for both
acute physicians and emergency general surgeons. Figure 3 shows the average hours
of onsite availability of on-call consultants in London is significantly less at weekends
compared to weekdays.
Figure 3. Average hours that consultant physicians and consultant surgeons
are expected to be on-site during weekdays and weekends. Source: Survey of
acute trusts (2011)
Weekday London average
Weekend London average
12
Hours on site
10
8
6
4
2
0
Consultant medicine
10
11
12
Consultant surgeon
Aylin. P. et al (2010). Weekend mortality for emergency admissions. A large multicentre study,
Quality and Safety in Health Care, 19: 213-217
The probability ratio is 1.12 (95% CI from 1.08 to 1.15). P value = <0.001.
An Evaluation of Consultant Input into Acute Medical Admissions Management in England, Wales
and Northern Ireland (2010) Royal College of Physicians
18
Hospitals should strive to provide equality of care during the week and at weekends.
This means admission units should be adequately staffed with senior review and
access to diagnostics available in the early phase of critical illness.13
Evidence has also demonstrated that where a service has the same provision in place,
seven days per week, there is no observed difference in mortality rates in the week
and at the weekendii. In London today, all patients suffering a heart attack access the
same, consultant delivered service, seven days per week. Data collected for 2009/10
shows that no observed difference is found in mortality rates for patients suffering a
heart attack and admitted during the week or at the weekend. This suggests that
where systems are in place to respond seven days a week, this has a direct effect on
mortality rates.
Key message
In London, around 520 lives could be saved if the rate of mortality for patients
admitted at the weekend was the same as the mortality rate for those admitted
during the week. Reduced service provision at weekends is associated with this
higher mortality rate.
2.3.
Length of hospital stay
Significant variation also exists for outcome measures other than just mortality rates.
Whilst many factors can affect length of stay, some of which are beyond the control of
the hospital, it is still an important marker of quality as it signals both the efficiency and
timeliness of care. It is also important from the patient’s perspective, as the less time
spent in hospital reduces the risk of acquiring a hospital based infection. Figure 4
shows the average length of stay (days) at London hospitals for patients with a
diagnosis of respiratory disease to demonstrate the variation that exists.
Figure 4: The average length of stay (days) for patients admitted as an
emergency with a diagnosis of respiratory disease admitted to London hospitals
in 2009/10. Source: HES 09/10
Mean LOS
London average
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
London site
Depending on hospital site, the difference in average length of stay for patients
admitted as an emergency with a diagnosis of respiratory disease can be as low as
2.5 days and as high as 6 days. This same pattern of variation in outcomes can be
13
Schmulewitz, L., Proudfoot, A. & Bell, D. (2005). The impact of weekends on outcome for emergency
patients. Clinical Medicine, 5: 621-5
19
seen across a range of diagnoses and treatments in both the medical and surgical
specialties, as detailed in appendix 2 - 6. If those Trusts in London, that are currently
above the average length of stay for respiratory disease reduced their length of stay to
the average, London would save over 17,000 bed days per year. This would not only
improve patient experience but be a huge efficiency gain and a significant saving to
hospitals.
2.4.
Re-admission rates
30 day re-admission rates are another recognised marker of quality and again have
many influencing factors some of which are beyond the control of the hospital. The
government is addressing high re-admission rates as a priority for this year, stating
that hospitals will not be reimbursed for emergency re-admissions within 30 days of
discharge following an elective admission, and all other re-admissions within 30 days
of discharge will be subject to locally agreed thresholds.14 Figure 5 shows the 30-day
re-admission rates for patients with a diagnosis of respiratory disease in London
hospitals to demonstrate the variation that exists.
Figure 5. 30-day re-admission rates for patients admitted as an emergency with
a diagnosis of respiratory disease in London hospitals. Source HES inpatients
09/10
Re-admission rate
London average
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
London site
As shown in figure 5, re-admission rates vary considerably. London is failing to provide
patients with a high quality, equitable service while this level of variation persists. For
patients admitted to some Trusts, more than four out of every ten patients find
themselves back in hospital, within 30 days of their original admission, compared with
only one out of ten in other units. This marked disparity in outcomes means that at
present, London cannot be delivering the best care to all patients and that there is
significant opportunity for both improvements to the patient experience and efficiency
gains.
Whilst mortality, length of stay and emergency re-admission rate are important
markers of quality, it is recognised that there are still a limited number of outcome
measures available to measure the effectiveness of adult emergency services.
14
Department of Health (2011). The Operating Framework for the NHS in England 2011/12
20
Key message
Significant variation exists for outcome measures such as length of stay and readmission rates. Whilst many factors can affect these outcomes, some of which
are beyond the control of the hospital, it is still an important marker of quality.
21
3. The process of emergency admissions
The majority of patients presenting to an acute admissions service come from the
hospital emergency department (ED), although a significant proportion of patients
come directly from GPs, primary care and other inpatient wards within the hospital. Set
out below is the typical pathway of care available to patients admitted as an
emergency.
Although the diagram outlines the pathway in a simple format, it is important to note
that the journey can be complex and patients can sometimes move back and forth
along the pathway.
3.1.
Acute medical and surgical units
The Acute Medical Unit (AMU) and Acute Surgical Unit (ASU) are dedicated hospital
facilities that act as the focus for acute medical and surgical care for patients that have
presented as emergencies to hospital, or who have developed an acute illness whilst
in hospital.15 The role of the unit is to ensure that the assessment and management of
admissions is concentrated in one area, allowing rapid transfer from the ED, or other
areas of the hospital. Although the majority of patients on the unit will have come from
the ED, some hospitals have systems in place to allow local GPs to refer directly to the
unit, meaning that patients can bypass the ED.
The unit operates around the clock and focuses on care within the first 24 to 72 hours
of admission, and is normally staffed by multidisciplinary teams of senior nurses and
experienced doctors.16 Once on the unit, patients should be able to access senior
clinical teams who are able to make a prompt diagnosis and can then implement a
management plan.17
3.2.
On-take working patterns
The on-take consultant is the individual responsible for assessing all patients admitted
as an emergency to the hospital over a given period of time (can be a day or longer).
Normally, there will be separate consultant(s) on-take who have responsibility for the
medical and surgical admissions that arrive at the hospital during that time. This
individual and their team have a particularly important role as they make the early
decisions about what the management plan should be and what treatment regime
should be followed.
It is vital that the outcome from this initial assessment is the right one. The quality of
the initial assessment is a strong indicator as to the quality of subsequent care the
15
16
17
Royal College of Physicians. (2007). Acute Medical Care: The right person, in the right setting – first
time. Report of the acute medicine task force. Royal College of Physicians
Royal College of Surgeons. (2007). Separating emergency and elective surgical care:
recommendations for practice. Royal College of Surgeons of England.
NCEPOD (2007) op. cit.
22
patient will receive.18 Evidence shows that a poor initial assessment can lead to
misdiagnosis, inappropriate management and sometimes avoidable death.19 It is
crucial therefore that the initial assessment results in the appropriate management
plan being agreed and acted upon.
Over a number of years, NCEPOD and the Royal Colleges have made a series of
recommendations around how those consultants who are designated to be on-take
should work. The survey of Trusts in London demonstrates that across several
measures Trusts are not achieving these standards. This means that patients are not
guaranteed a quality service in all London hospitals, and this puts patients at risk.
3.2.1 Senior involvement in the initial assessment
Evidence in this area is clear, the earlier consultants, are involved in making decisions
about the care of patients the better. Senior doctors make more accurate diagnoses20
and if initial diagnosis is left to junior doctors, NCEPOD found they often
underestimate the severity of patients’ physiological dysfunction, leading to delays in
diagnosis and definitive care and a worse patient outcome.21 Patients also need to see
a consultant of an appropriate specialty. For patients reviewed by an inappropriate
speciality, it has been show to have affected diagnosis and outcome in at least one in
five cases.22 This reinforces the message that senior doctors need to be at the front
line, making decisions about patient care.
Currently, consultants and senior doctors are not routinely involved in early
assessments of all emergency admissions. The 2010 Association of Surgeons of
Great Britain and Ireland’s (ASGBI) survey of surgeons, found that there is a lack of
support and input from doctors with sufficient experience in order to make a correct
diagnosis. They highlighted inadequate senior input and clinical leadership23 as key
problems. This message is echoed in the results to the London survey of acute Trusts,
which can be seen in the following sections.
3.2.2 Consultant presence on-site
In order for consultants to assess patients and be fully involved in the decision making
process, they need to be on-site. The NCEPOD reports from 2005 and 2007 have
reported that the most significant problems at admission were sub-optimal involvement
of consultants24 and that consultant physician involvement in the first 24 hours of
patients’ admission remains low.25 The Royal College of Physicians recommend that
18
19
20
21
22
23
24
25
NCEPOD. (2007). Op. cit.
Nafsi et al. (2007). Audit of deaths less than a week after admission through an emergency
department: how accurate was the ED diagnosis and were any deaths preventable? Emergency
Medicine Journal. 24: 691 - 695
Seward, E., Greig, E. Preston, S., Harris, R. A., Borrill, Z., Wardle, T. D. Burnham, R., Driscoll, P.,
Harrison, B. D. W., Lowe, D. C. & Pearson, M. G. (2003). A confidential study of deaths after
emergency medical admission: issues relating to quality of care. Clinical Medicine, 3: 425-434
NCEPOD. (2007). Op. cit.
NCEPOD. (2009). Op. cit.
ASGBI (2007) Emergency General Surgery: The Future. A consensus statement. Association of
Surgeons of Great Britain and Ireland.
NCEPOD (2007). Op. cit
National Confidential Enquiry into Patient Outcome and Death. (2005). An acute problem? NCEPOD
23
hospitals accepting acute admissions should have a consultant physician on-site for at
least 12 hours per day, seven days per week.26
The survey of London hospitals’ found large variation in the hours consultants were on
site, both between different sites and at the same sites between weekdays and
weekends.
Figure 6: Number of hours admitting medical consultants are expected to be on
site each day
Monday - Friday
Weekday London Average
Saturday - Sunday
Weekend London average
14
12
10
8
6
4
2
0
London sites
London is not meeting the Royal College of Physician’s guidance on the hours
consultants are required on site. At some sites consultants assessing the medical
admissions are expected to be on site for just four hours at weekends, whilst others
are expected to be on site for twelve hours.
26
Royal College of Physicians. (2011). Position statement on seven day working. Available at:
http://www.healthcare-events.co.uk/presentations/downloads/Sir_Richard_Thompson.pdf
24
Figure 7: Number of hours on-call consultant surgeons expected to be onsite
Monday - Friday
Saturday - Sunday
Weekday London average
Weekend London average
12
10
8
6
4
2
0
London site
For consultant surgeons on-take, the variance in the number of hours they are
expected to be on site is even greater than that of physicians. On weekends, the
disparity is even greater, ranging from 0 – 12 hours between sites.
Key message
The current situation in London is that there are huge variations in the number
of hours that a consultant is expected to be on-site when on-take. . Variation
exists between sites and within individual sites huge variation exists between
week days compared to that at weekends.
3.2.3 Timeframe for the initial assessment
The time to consultant review can affect the diagnosis and outcome for the patient.
The 2007 NCEPOD report makes a clear recommendation in this area that ‘patients
admitted as an emergency should be seen by a consultant at the earliest opportunity.
Ideally this should be within 12 hours and should not be longer than 24 hours’. 27
However, the time period in which patients undergo an initial consultant assessment
differs across all hospitals in London and varies depending on the time and day of the
week of the admission. Figure 8 shows this variation across London’s acute trusts.
27
Ibid.
25
Figure 8: Acute medical admissions reviewed by a consultant physician within
12 hours
Monday - Friday
Weekend
3%
23%
16%
52%
29%
77%
Very Often
Always
Undisclosed
Sometimes
Very often
Always
For patients admitted as a medical emergency in the week, about three quarters are
‘always’ seen by a consultant within 12 hours. For those admitted at the weekend, this
reduces to just over half. This means there are thousands of patients, especially at
weekends that do not see a consultant within 12 hours – this goes against national
recommendations.
Figure 9: Emergency general surgical admissions reviewed by a consultant
surgeon within 12 hours
Monday - Friday
Weekend
8%
25%
21%
38%
54%
54%
Sometimes
Very often
Always
Sometimes
Very often
Always
For surgical emergencies the situation is worse. Only a quarter of all surgical
admissions are ’always’ seen by a consultant within 12 hours in the week and this
drops to just 8% at the weekend.
26
Key message
Best practice recommendations state that emergency admissions should see a
consultant within 12 hours. The London survey shows this standard is not being
met consistently.
3.2.4 Other commitments whilst on-take
Consultants should be available to deal with emergency admissions without undue
delay and their work plans should include protected session time for on-take
commitments.28 However, job plans are not always arranged so that, when on-take,
consultants are released from other clinical duties (such as outpatient clinics and
elective operating) in order to deal with emergency admissions.
In the survey of London acute trusts, results show significant numbers of consultants
are not always freed from other clinical duties (figures 10).
Figure 10: Do consultants have any other planned duties while they are on take?
Consultant physicians
26%
Consultant surgeons
No
48%
26%
25%
46%
Sometimes
Yes
No
29%
Sometimes
Yes
London hospitals are failing to meet best practice guidance and allow on-take
consultants to deal appropriately with emergency admissions. Many patients will
therefore not be receiving appropriate levels of consultant input into their care.
Key message
On-take consultants should not have any other planned commitments when
they are on-take. More than half of London hospitals do not achieve this
standard.
3.2.5 Ward rounds for emergency admissions
28
RCP. (2007). Op. cit.
27
Many patients, admitted as an emergency, are still only seen once per day in a formal
consultant ward round. Best practice recommendations indicate that consultant ward
rounds should take place twice a day, seven days a week, with appropriate nursing
involvement29. Figure 11 outlines the routine daily practice for consultant ward rounds
on the acute medical take, during the week across London hospitals. Sites that offer
continuous consultant cover mean that they offer a system whereby all patients are
seen upon their admission to the hospital, but they are not necessarily seen twice.
Therefore hospitals with this system in place cannot be assumed to be meeting
national recommendations.
Figure 11: Routine weekday daily practice for consultant ward rounds on the
acute medical take
6%
Once daily
26%
Twice daily
More frequent
55%
13%
Continuous Consultant
cover
Just 17 of 31 sites in London have twice daily ward rounds and are meeting national
recommendations for acute medical admissions.
Figure 12: Routine weekend daily practice for consultant ward rounds on the
acute medical take
3%
Once daily
13%
32%
Twice daily
Continuous Consultant
cover
52%
29
Undisclosed
Royal College of Physicians (2007) op. cit.
28
Key message
Best practice is for twice daily consultant ward rounds to take place, seven days
a week. More than half of London hospitals are not meeting this standard.
3.2.6 System for on-take consultants
The recommended working pattern for consultant physicians is that of ‘consultant of
several days’. 30 This is to help give patients continuity of care, especially for those
that have a short stay of just a couple of days or less. Results from the London survey
show that only four sites in London meet this national recommendation. Figure 13
highlights that ‘consultant of the day’ remains the most common system of on-take
during the week and at weekends in London. This system of on-take does not support
continuity and seamless care for patients.
Figure 13: System of consultant physician on-take across London hospitals
Consultant of the week
Consultant of consecutive days
Consultant of the day with 2 consecutive days at
weekend
Consultant of the day
(weekday & weekend)
0
2
4
6
8
10
12
Key messages
National recommendations state that on-take consultants should work
consecutive days. Most hospitals in London operate a consultant of the day
system which does not meet best practice and does not promote patient
continuity.
3.3.
Ambulatory care
Emergency ambulatory care applies to both acute medicine and emergency general
surgery and is care whereby emergency patients are diagnosed, managed, treated
30
RCP. (2007) op. cit.
29
and discharged without an overnight hospital stay31. It offers an alternative to routine
hospital admission and can improve the patient experience. In order for the service to
work it requires prompt clinical assessment, access to diagnostics and decisions about
care to be taken by a competent clinical decision-maker.32 The NHS Institute has
identified 49 clinical scenarios which present acutely but could potentially be managed
in an ambulatory manner.
A national survey showed that ambulatory services were largely informal and ad-hoc
in nature33, with few established protocols. The London survey also found that uptake
was poor with just 48% of sites offering an emergency day surgery service. This
opportunity to improve services and efficiency is being missed by many London
Trusts.
Key message
Ambulatory care is efficient, saves money and improves patient experience. In
London less than half of hospitals have an ambulatory care service.
3.4.
Discharge
Nationally, the majority of patients have relatively simple discharge needs with 80% of
patients not requiring the input of any other agencies following discharge.34 Delays in
setting treatment plans after admission, getting tests done promptly, infrequent ward
rounds and a lack of proactive planning for discharge on admission can lead to a
longer length of stay and a poorer patient experience. Patients cite that delays in
discharge and poor organisation of services following discharge is a major failing.
The Department of Health35 recommends four key points to reduce delay and improve
discharge arrangements:
31
32
33
34

All patients should have a treatment plan within 24 hours of arrival.

An expected date of discharge should be set within 24 hours of arrival and
communicated to the patient and all staff in contact with the patient.

The expected date of discharge should be proactively managed against the
treatment plan on a daily basis and changes communicated to the patient.

Ward rounds should be scheduled in a way that allows at least daily, a senior
clinical review of all patients.
McCallum, L. et al (2010). National ambulatory emergency care survey: current level of adoption and
considerations for the future, Clinical Medicine, 10(6): 555-9
NHS Institute for Innovation and Improvement, Directory of Emergency Ambulatory Care for Adults,
March 2010
McCallum, L et al (2010). Op. cit.
Department of Health. (2004). Achieving timely “simple” discharge from hospital. Also available at:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_40
88367.pdf
35
Ibid.
30
Members of the multi-disciplinary team need to be empowered to achieve effective
and timely discharge. The multi-disciplinary team can speed up the discharge process
and manage the care pathway to an expected or predicted date of discharge.
Nursing teams have an important role to play in timely and safe discharge. They need
to be empowered within an organisation to manage the discharge process seven days
a week, and take on more responsibility for initiating discharges against agreed clinical
protocols. For patients with more complex needs they can coordinate the process with
the involvement of the multi-disciplinary team.
Importantly, an efficient discharge system needs to work on a seven day basis.
Ensuring tests and treatment continue through weekends and bank holidays are key
parts of reducing longer than clinically needed lengths of stay. Establishing weekend
discharge is key to reducing length of stay and freeing up beds.
Results from the London survey of acute services identify that access to therapy
services (physiotherapy, occupational therapy), which are needed to support timely
and safe discharges is variable at the weekend. This may have a significant impact on
the discharge of patients over the weekend.
31
4. Diagnostics
Rapid access, 24 hours a day, seven days a week, to key diagnostic services is
crucial to facilitate timely decision making, commencement of treatment and support
timely discharge36. The survey of London Trusts demonstrates that access to these
diagnostics is patchy, especially out of hours, and that the provision of some of these
services does not meet national recommendations.
4.1.
Imaging
In an emergency situation there are two aspects of the service that are important.
Firstly, how promptly the diagnostic test can be undertaken and secondly, that the
report that is returned is of sufficient quality to support effective decision-making about
subsequent care required.
4.1.1 Timely access to scans
Both NCEPOD37 and the Royal College of Radiologists38 state that severely and
critically ill patients should have immediate access to radiological services to allow
timely and accurate diagnosis to enable appropriate treatment. In London today this is
not universally the case. Emergency computerised tomography (CT) scanning is an
integral diagnostic tool for an emergency service and is an example of where
availability to a diagnostic service is poor in London.
All trusts reported that they had CT scanning facilities available 24 hours a day,
however, as shown in figure 15 less than two thirds could access a consultant report
on the scan within the timeframe of an hour on an out of hours basis as opposed to a
report by an imaging trainee.
Figure 14: Availability of immediate consultant reporting for CT in hours and
out of hours in less than an hour.
36
37
38
Royal College of Physicians Edinburgh. (2008). Consensus statement on acute medicine. Also
available at: http://www.lumison.co.uk/~rcpe/journal/issue/journal_39_1/consensus.pdf
NCEPOD. (2007). Op. cit.
Royal College of Radiologists. (2009). Standards for providing a 24-hour radiology diagnostic service
32
100%
90%
80%
70%
60%
50%
No
40%
Yes
30%
20%
10%
0%
Immediate in hours reporting by
consultant
Immediate out of hours reporting
by consultant
4.1.2 Quality interpretation of scans
There is evidence showing that non-radiologists (i.e. non-specialist radiology trained
doctors) misinterpret a significant number of both plain radiographs and CT scans. 39
Furthermore, training grade radiologists have been found to make significantly more
errors in the interpretation of scan results than consultant radiologists. 40 41 This means
that access to a consultant radiologist, both in hours and out of hours is an important
marker of a quality service.
Ultrasound is another vital diagnostic tool for an increasing number and range of
clinical conditions. In ultrasound, there is a current shortage of trained staff and the
continued use of unqualified staff may have adverse implications for diagnostic
accuracy42. The patchy provision of services, especially out-of-hours can be seen in
the recent survey of London trusts, as shown in figure 16.
Figure 15: Availability of immediate consultant reporting for ultrasound in
hours and out of hours in less than an hour.
39
40
41
42
Kripalani, S. Williams, M. V. & Rask, K. Reducing errors in the interpretation of plain radiographs and
computed tomography scans. In: Shojania, K. G., Duncan, B. W., McDonald, K. M. & Wachter, R. M.
(2001). Making healthcare safer. A critical analysis of patient safety practices. Agency for Healthcare
Research and Quality
Hillier, J. (2009) Trainee reporting of computed tomography examinations: do they make mistakes
and does it matter? Clinical Radiology Volume 59. 2: 159-162
Briggs, R.H. et al. (2010) Provisional reporting of polytrauma CT by on-call radiology registrars. Is it
Safe? Clinical Radiology, 65(8): 616-622
Bates, J. (2003). Extending the provision of ultrasound services in the UK. British Medical
Ultrasound Society. Also available at: http://www.bmus.org/policies-guides/pg-protocol01.asp
33
100%
90%
80%
70%
60%
50%
No
40%
Yes
30%
20%
10%
0%
Immediate in hours reporting by
consultant
Immediate out of hours reporting by
consultant
This poor and patchy provision of diagnostic services for emergency patients in
London will cause delays in care. Delays in access to scans, coupled with lack of
consultant interpretation are contributors to error rates and misdiagnosis.
Key message
Access to key diagnostic services is crucial to facilitate timely decision making,
commencement of treatment and support timely discharge. The London survey
shows that marked variation in the provision of radiology services across
London hospitals, particularly out-of-hours.
4.2.
Interventional radiology
Interventional radiology (IR) represents a range of minimally invasive procedures
which are performed using image guidance and most are performed under local
anaesthesia. Some of these procedures are done for purely diagnostic purposes but
the majority are for treatment meaning that IR is now at the forefront of managing
many life-threatening emergencies.43 This includes locating and stopping internal
bleeding, restoring blood flow, managing sepsis, relieving urinary obstruction and
inserting stents in the colon to relieve bowel obstruction. IR techniques minimise
physical trauma, reduce the need for open surgery, avoid general anaesthesia, reduce
infection rates and shorten recovery time and hospital stays.
All patients should have access to the full range of emergency IR services but IR
manpower is limited and few UK hospitals provide a 24-hour service. At the same
time the need for comprehensive IR provision has increased significantly. 44 London
43
44
NCEPOD (2007). Op. cit.
Royal College of Radiologists. (2008). Standards for providing a 24 hour interventional radiology
service
34
based work demonstrated only 28% of hospitals had a 24 hour rota, 59% of hospitals
provided ’ad-hoc’ out of hours services and 14% provided no out of hours cover.45
Figure 16. Provision of interventional radiology services out of hours at London
Hospitals
14%
28%
24 hour rota
Adhoc out of hours provision
No out of hours provision
59%
Source: adapted from 2010 report - Provision of out of hours interventional radiology services in the
London Strategic Health Authority
A similar picture was seen in the survey of London Trusts with only just over half of
hospitals in London reporting access to a consultant interventional radiologist service
out of hours.
This continuing situation, with low provision and ad-hoc arrangements in London puts
patients at risk, is not sustainable and is neither safe or reliable. Where sites are
unable to provide a comprehensive in house service the Royal College of
Radiologists46 recommends hospitals collaborate to provide a networked service or
develop a hub and spoke service arrangement.
Key message
The need for comprehensive interventional radiology provision has increased
significantly however almost half of London hospitals reported having
inadequate access to this service out of hours.
4.3.
Pathology
Pathology services are central to the delivery of high quality, patient centred
healthcare in London. At least 70% of clinical decisions are made on the basis of
pathology test results, yet pathology results could contribute even more to ensure the
clinical pathway and treatment is right for each individual patient. National reviews
45
Illing, R.O., Ingham-Clark, C.L., Allum, C., (2009) Provision of out of hours interventional radiology
services in the London Strategic Health Authority. Clinical Radiology 65: 297-301
46 Royal College of Radiologists. (2008). Op. cit.
35
such as the Carter Review of Pathology Services47, the baseline review of pathology
services in London there is believed to be a strong case for change in pathology
services to improve quality, patient safety and the efficiency resource use.
To respond to these reviews, there is currently a review of pathology services in
London taking place. The clinical expert panel advising that review will be making their
recommendations for change later this year. Therefore this review will not seek to
address pathology but will maintain links with the London pathology review and ensure
recommendations are aligned.
4.4.
Endoscopy
Conditions such as upper gastrointestinal bleeding and decompensated liver disease
are emergency conditions that require urgent endoscopic treatment. Despite the
apparent need, surveys of UK hospitals have shown that out-of-hours provision of
diagnostic and therapeutic endoscopy is poor48 and in some instances it was “unsafe”.
49 The British Society of Gastroenterology recommend that all acute hospitals should
have arrangements in place, so that out of hours endoscopy can be carried out by
appropriately trained endoscopists50. They recommend that clinical networks be
formed covering a population of 400,000 to 500,000.
The London survey confirmed that the picture in London is consistent with national
under-provision and is not meeting the British Society of Gastroenterology guidance.
Only 45% of sites in London reported that they had a comprehensive consultant
endoscopy service available within an hour.
Figure 17: Percentage of sites with a comprehensive 24/7 on-site endoscopy
service available within an hour
47
Department of Health. (2006). Report of the review of NHS pathology services in England. Chaired by
Lord Carter of Coles
48 Douglass, A., Bramble, M., Barrison, I. (2005). National survey of UK emergency endoscopy units.
British Medical Journal, 330: 1000-1001
49 Gyawali, P., Suri, D., Barrison, J., Smithson, J., Thompson, N., Denyer, M. E., Hughes, S. &
Gilmore, I. (2007). A discussion of the British Society of Gastroenterology survey of emergency
gastroenterology workload. Clinical Medicine, 7(6): 585-588
50 Hellier, M. D., Sanderson, J. D., Morris, A. I., Elias, E. & De Caestecker, J. (2006). Care of patients
with gastrointestinal disorders in the United Kingdom: A strategy for the future. British Society of
Gastroenterology. Also available at: http://www.bsg.org.uk/images/stories/clinical/strategy06_final.pdf
36
45%
Yes
55%
No
The current arrangements that exist in London are unsustainable and ultimately pose
a safety risk for patients – especially those admitted out of hours.
Key message
National recommendations state that all hospitals should have access to out-ofhours endoscopy services. However, in London access to out-of-hours
endoscopy is poor.
37
5. Acute medicine
Approximately three quarters of emergency admissions are medical in nature. The
most common forms of acute medical admissions in London in 2009/10 were
respiratory disease (including chronic lower respiratory disease), influenza and
pneumonia, heart failure, diseases of the urinary system, skin infections and diseases
of the digestive system and abdomen.
5.1.
Activity in London
There were over 220,000 admissions for the six most common acute medical
admissions in London in 2009/10. Of this, 70,000 admissions alone were for patients
with a diagnosis of respiratory disease. This formed the single biggest reason for
acute admissions that year.
Figure 18. Total number of medical admissions into London hospitals with a
diagnosis of either respiratory disease, disease of the digestive system, heart
failure, urinary disease, flu and pneumonia or skin infection in 2009/10. Source:
HES 09/10
Respiratory
Digestive
Heart
Urinary
Flu
Skin
18000
16000
14000
12000
10000
8000
6000
4000
2000
0
London sites
There is significant variation in activity across London. For the purposes of this review,
this means that although all hospitals should deliver care to a defined quality and
standard, the manner in which this standard is achieved may vary to address their
population needs.
5.2.
Length of stay
Across London there is significant variation in length of stay for patients with the same
diagnosis. Figure 20 ranks Trusts in order of the proportion of their patients discharged
with a zero day length of stay (i.e. the patient remained in hospital for less than 24
hours).
Figure 19. The proportion of all adult emergency admissions staying in hospital
for different time bands by London hospital site/Trust in 2009/10. Source: HES
09/10
38
0
1-2
3-5
6-10
11-20
21+
No valid Disdate
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
London sites
This reinforces the message of variation in outcomes across London. Whilst many
factors can affect length of stay, some of which are beyond the control of the hospital it
is an important quality marker and provides an indication as to where services are
operating efficiently. Dependent on where a patient presents they have an inequitable
chance of having access to short length of stay. If the Trusts with the longest lengths
of stay were to improve to that of the average there would result significant savings
and improvements to patient experience.
Key message
There is significant variation in length of hospital stay across London hospitals
for patients with the same diagnosis.
5.3.
Re-admission rates
Thirty day readmission rates into hospital are also an important marker of the quality of
an emergency service. Figure 21 shows the readmission rates across London for the
common acute medical admissions.
Figure 20: 30-day all cause re-admission rates for patients admitted as an
emergency admission to London hospitals. Source: HES 09/10
39
Rate
London average
45.0%
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
London site
In some parts of London, almost one in three (30%) patients, admitted as an
emergency return for another inpatient spell within 30 days of their original discharge.
Whilst many factors can affect re-admission rates, some of which are beyond the
control of the hospital, other key contributing factors to these outcomes are the
processes and systems in place at different Trusts. In order to improve outcomes,
London needs to change it’s systems of emergency admissions to meet best practice
guidance.
Key message
Variation in working practices in acute medicine across London’s hospitals
results in a variation in re-admission rates.
5.4.
Medical outliers
Due to a lack of beds in medical wards, many patients with a medical diagnosis are
placed on other wards (usually surgical wards) in hospitals. These patients are called
‘medical outliers’. These patients are not reviewed in ward rounds as often as those on
other specialty wards and on assessment units. The results of the London survey of
acute trusts found that over half of London’s hospitals have medical outliers on a
weekly basis, and 40% of hospitals have medical outliers on a daily basis. Only a
couple of hospitals reported that they “never” had outliers.
Figure 21. Proportion of sites that reported having medical outliers on a daily,
weekly or monthly basis.
How often do you have
medical outliers?
Daily
Weekly
Monthly
Never
42%
32%
16%
6%
Medical outliers are an important issue. Patients being managed on a non-medical
ward are less likely to be seen during consultant ward rounds and evidence has now
40
proven that this group of patients have an increased length of stay51 and thus receive
a poorer service. If Trusts achieved recommended standards, and allowed consultants
to be free from other duties when on-take, it would be more likely these patients would
be seen. In order to tackle prolonged length of stay, Trusts must ensure that medical
admissions are cared for on a medical ward. Currently in London this is not always
happening.
Key message
Over half of London’s hospitals have medical outliers on a weekly basis.
Evidence shows that medical outliers have longer lengths of stay.
5.5.
Treatment regimes for common medical admissions
There is evidence that patients treated through an organised process of acute medical
care achieve better outcomes.52 Across multiple different clinical areas, there is
growing evidence that the development and adherence to standardised management
and treatment practices improves patient outcomes.53, 54 Despite many of these
guidelines already being available, their uptake and implementation has been mixed
nationally.
51
52
53
54
Alameda, C. & Suarez, C. (2009). Clinical outcomes in medical outliers admitted to hospital with
heart failure’, European Journal of Internal Medicine, 20(8):764-7
Langlands, A., Dowdle, R., Elliot, A., Gaddie, J., Graham, A., Johnson, G., Lam, S., McGowan, A.,
McNamee, P., Morrison, J., Murphy, T., Reynard, K., Rudge, P. & Trueland, J. (2009). RCPE UK
consensus statement on acute medicine. Journal of the Royal College of Physicians Edinburgh, 39:
27-28
De Silva, R., Nikitin, N. P., Witte, K. K. A., Rigby, A. S., Loh, H., Nicholson, A., Bhandari, S., Clark,
A. L. & Cleland, J. G. F. (2007). Effects of applying a standardised management algorithm for
moderate to severe renal dysfunction in patients with chronic stable heart failure. European Journal
of Heart Failure, 9: 415-423
Celli, B. R., MacNee, W., et al. (2004). Standards for the diagnosis and treatment of patients with
COPD: a summary of the ATS/ERS position paper. European Respiratory Journal, 23: 932-946
41
6.
Emergency general surgery
General surgical emergencies make up about half of all surgical admissions and about
one-quarter of all emergency admissions.55 The case-mix is largely emergencies
concerning the digestive system.56 The most common presentation is of abdominal
pain, although other symptoms include vomiting with constipation, bleeding
and abscesses. The most common emergency general surgery diagnoses are
appendicitis, cholecystitis, pancreatitis and diverticulitis.57
In terms of emergency operations, the most common are appendicectomy and
drainage of abscesses. In London during 2009/10, over 56.8% of emergency surgery
procedures were appendicectomies and abscess surgery. Colorectal surgery, often
the most complex surgery, made up 10.1% of all emergency surgery procedures. The
vast majority of emergency general surgery takes place in the daytime; surgery at
night should only take place for life or limb threatening emergencies.
Figure 22 Proportion of all emergency general surgery procedures carried out
in London 2009/10. Source: HES 2009-2010
Appendicetomy
Abscess drainge
Hernia repair
Colorectal
Upper GI
Cholecystectomy
4.0%
10.1%
37.7%
10.1%
19.0%
19.2%
55
56
57
Mai-Phan, T. A. (2008) Emergency room surgical workload in an inner city UK teaching hospital.
World Journal of Emergency Surgery. 2008, 3:9
Dunkley et al (2007) The emergency general surgeon: a new career pathway. Annals of Royal
College of Surgeons England. 2007; 89: 32-36
Jeyarajah, S. et al (2009) Diverticular disease hospital admissions are increasing with poor
outcomes in the elderly and emergency admissions.
42
Not all surgical patients will require surgery; a significant part of an emergency general
surgical case-mix involves decisions not to operate in that admission or the
conservative management of a condition.
6.1.
Effective and safe treatment planning
6.1.1.
Consultant involvement in the decision to operate
For very sick general surgical patients the decision of whether or not to offer them an
operation is very complex and significant. It is important therefore that decisions to
operate are taken in agreement with a consultant as a senior, surgical decision
maker58 with input from anaesthesia and medicine, as well as the patient and/or their
carer.59 Several major reports have identified a link with inadequate early consultant
involvement and poor outcomes, including increased mortality60, 61.
In London today consultants are not always involved in decision making about every
surgical admission, especially at weekends. The London survey showed the average
amount of time a consultant surgeon was expected to be onsite at the weekend was
just 4 hrs and in some places it was a low as 2 hours (see figure 7 in section 3). With
this low level of consultant presence, it is not possible to input into the decision making
process patients need and best practice demands.
Key message
A lack of consultant involvement in surgical decision making and emergency
surgery is associated with higher patient mortality and morbidity. In London
consultants are not on site enough to be involved with every emergency
admission.
6.1.2.
Consultant surgeons commitments whilst on-take
A consultant general surgeon should have no elective commitments whilst on-take so
that they are free to assess and review every patient admitted as an emergency under
their care.62, 63 The direct involvement of a consultant in the care emergency patients
receive can be associated with decreased morbidity, lower lengths of stay and
reduced unnecessary admissions. Leaving consultants to cope with multiple
commitments at any one time will not achieve this. There is now evidence showing
58
ASGBI (2007). Op. cit
McFarlane (2009) The Scottish Audit of Surgical Mortality: a review of areas of concern related to
anaesthesia over 10 years. Anaesthesia 64: 1324-1331
60 NCEPOD (2010). Op. cit
61 NCEPOD (2007). Op. cit.
62 Royal College of Surgeons. (2004). The emergency department: medicine and surgery interface
problems and solutions. A report of the working party. Royal College of Surgeons of England.
63 Royal College of Surgeons. (2011). Emergency Surgery: standards for unscheduled surgical care.
Guidance for providers, commissioners and service planners. The Royal College of Surgeons of
England.
59
43
that mortality increases if surgery in the elderly is delayed by more than 24 hours after
admission.64
The survey of London Trusts found that slightly more than half of all general surgeons
are free of all elective commitments whilst on take.
Figure 23: Do emergency general surgeons undertake any elective activity when
on-take?
25%
46%
No
Sometimes
Yes
29%
This position needs to change if London is to deliver high quality care for all
emergency surgical admissions, and meet best practice guidance.
Key message
National recommendations state that the on-take emergency general surgeon
should not have any other planned duties when they are on-take. Only 46% of
hospitals in London meet this standard.
6.2.
Delays in access to an emergency theatre
Surgical emergencies do not recognise time of day therefore it is vital that an
emergency theatre is available 24/7. Recommendations state that emergency general
surgical patients should have access to a dedicated emergency theatre ‘available at
all times’. 65, 66, 67 Poor theatre provision can be detrimental to the patient and their
64
NCEPOD (2010). Op. cit.
NCEPOD (1997) Who operates when? NCEPOD
66 ASGBI (2007). Op. cit.
67 Royal College of Surgeons (2011) Emergency Surgery: standards for unscheduled surgical care.
Guidance for providers, commissioners and service planners. The Royal College of Surgeons of
England.
65
44
outcomes68 and can be a factor in increased post-surgical mortality.69 A 2010 review
demonstrated that delays which were judged to affect the appropriate timeliness of the
operation, occurred in one in five of cases.70
Delays in getting patients into surgery are occurring in London today. The results of
the London survey of acute trusts found that 33% of trusts reported that emergency
surgery delays happened ‘very often’ or ‘sometimes’ and that theatre access was cited
the main reason for the delays. This aligns with national reports which found that 55%
of surgeons experienced inadequate emergency theatre access. 71 There is a risk to
patients of delays to surgery, beyond just having a prolonged length of stay.
Figure 24: Do limitations on imaging or theatre capacity prevent patients having
emergency surgery on the day that they should?
10%
14%
Never
21%
Rarely
Sometimes
Very often
55%
The results of the 2011 London survey also found that more than 40% of Trusts did
not ‘always’ operate on appropriate emergency cases within 24 hours of admission.
Across London, Trusts are falling short of national recommendations in this area.
Key message
Delays in conducting emergency surgery can prolong length of stay and can
increase mortality and morbidity. Almost one-third of London’s trusts reported
delays in emergency general surgery occurred ‘sometimes’ or ’very often’.
6.3.
68
69
70
71
Emergency surgery at night
Mullen et al (2011) Deaths within 48h – adverse events after general surgical procedures. The
Surgeon. Article in press.
Arenal, J. J. (2003). Mortality associated with emergency abdominal surgery in the elderly.
Canadian Journal of Surgery, 46(2): 111-6
NCEPOD (2010). Op. cit.
ASGBI (2010) Emergency Surgery Survey Association of Surgeons of Great Britain and Ireland
Newsletter Number 31; September 2010.
45
Adequate provision of emergency theatre lists during the day should mean the
majority of emergency surgery is undertaken on a list that operates extended hours
during the daytime and possibly into the evening. Only surgery to save ‘life and limb’
should be undertaken at night.72 However any hospital admitting emergency general
surgical patients must have the capacity to open up an emergency theatre, with its
associated team in the middle of the night if needed.73 74
6.4.
Best practice in the operating theatre
6.4.1.
Seniority and supervision of surgeon performing the operation
NCEPOD linked poor outcomes with unsupervised non-consultants performing major
surgery on emergency patients, stating that the level of supervision was ‘inadequate’
in a third of cases 75. In addition, 72.3% of surgeons surveyed in 2010 felt that the
mandatory presence of a consultant surgeon (and anaesthetist) in theatre would
‘significantly improve care’76. Emergency situations themselves present a unique set
of conditions, where the timely recognition of complications and effective management
once complications occur reduces mortality.77 A more experienced surgeon is more
likely to identify and mitigate complications and provide expert input and leadership. 78
The grade and experience of the surgeon conducting the operation should match the
complexity of the case. The consultant should be involved in the decision making
process and undertake the procedure themselves if there is any doubt about the
competence of junior staff, or the severity of the condition. The Royal College of
Surgeons state that ‘high risk’ patients should have their operation carried out under
the direct supervision of a consultant and anaesthetist79.
Figure 25: Average number of hours of consultant surgical presence on week
days and weekends. Source: 2011 Survey of London acute trusts.
72
73
74
75
75
76
77
78
79
NCEPOD (1990) Report of the National Confidential Enquiry into Perioperative Deaths
National Confidential Enquiry into Patient Outcome and Death. (2003). Who Operates When?
NCEPOD
Royal College of Surgeons (2011). Op. cit
NCEPOD (2007). Op. cit.
NCEPOD (2010). Op. cit.
ASGBI (2010) Emergency Surgery Survey Association of Surgeons of Great Britain and Ireland
Newsletter Number 31; September 2010
Ghaferi et al (2009) Variation in hospital mortality associated with inpatient surgery. The New
England Journal of Medicine. 2009 (361) 14 p1368
NCEPOD (2010). Op. cit.
Royal College of Surgeons (2011). Op. cit.
46
Average number of hours on site
12
9.6
10
8
6
4
3.9
2
0
Saturday - Sunday
Monday - Friday
The data above illustrates that the number of hours that consultants are available
varies between weekends and weekdays. London is not therefore offering patients a
consistent emergency surgical service at all times.
Key message
The provision of emergency general surgery during the week and at weekends
in London is inequitable. Consultant general surgeons are onsite for
significantly fewer hours at weekends than they are in the week meaning
patients are not receiving a consistent service 7 days a week.
6.4.2.
Seniority and supervision of the anaesthetist supporting the operation
The grade and experience of the anaesthetist supporting the operation is vital to
patient outcomes. The presence of an appropriately trained and experienced
anaesthetist is the main determinant of patient safety during anaesthesia 80 and The
RCS recommend that all emergency theatres should have a consultant anaesthetist
present81.
NCEPOD82 found that trainee anaesthetists carried out 60-70% of their emergency
work out of hours, whereas consultants did 75% of their emergency work during office
hours (see figure below). Involvement of a senior anaesthetist continues to be a theme
nearly a decade on in the most recent NCEPOD publication83.
Figure 26: Proportion of anaesthetist work done out-of-hours versus in-hours,
broken down into grade of anaesthetist. Adapted from source: NCEPOD 2003
Who Operates When?
80
81
82
83
RCA (2009) Guidelines for the provision of anaesthetic services. Royal College of Anaesthetists.
RCS (2004). Op. cit.
NCEPOD (2003). Op. cit.
NCEPOD (2010). Op. cit.
47
The level of supervision given to anaesthetic trainees is also important. Evidence has
found that 22% of anaesthesia related surgical mortality involved the grade of the
anaesthetist being too junior84. The Royal College of Anaesthetists state that the
anaesthetic service for surgical emergencies must be provided by anaesthetists who
are either consultants or, if non-consultants, must have access to consultants.85
In London, not all patients have access to consultant anaesthetists, especially at
weekends. The graph below illustrates the variation in consultant anaesthetist
presence on week days versus weekends; currently there is marked variation across
London in consultants’ presence between weekdays and weekends.
Figure 27: Average variation in consultant anaesthetist presence at week days
versus weekends. Source: 2011 survey of London acute trusts.
84
85
McFarlane (2009) The Scottish Audit of Surgical Mortality: a review of areas of concern related to
anaesthesia over 10 years. Anaesthesia 2009, 64, 1324-1331
RCA (2009) Guidelines for the provision of anaesthetic services. Royal College of Anaesthetists
48
Monday - Friday
Saturday - Sunday
Weekday London average
Weekend London average
12
10
8
6
4
2
C&W
GSTT-ST
NUH
NMUH
BCF-CF
WMUH
SGH
BLT-RL
ESH-SH
EH
KH
London sites
LHT
CHS
NWL-NPH
KCH
RFH
BHRT-KG
BHRT-QH
ICH-HH
BCF-BH
ICH-CXH
WXH
WH
HUH
ICH-SM
SLH-QEW
UCLH
SLH-PRUH
THH
0
Key message
A consultant anaesthetist’s direct involvement in emergency operations is
associated with better outcomes for patients. In London, consultant
anaesthetists’ availability varies across hospital site, and even more so at
weekends.
6.4.3.
Speciality of the surgeon performing the operation
An emergency general surgeon on the emergency rota will typically undertake all
types of emergency general surgery that present. However there are emerging studies
which suggest that where the elective speciality of a surgeon matches the specialty of
the emergency condition, this can lead to better outcomes for patients, in terms of
decreased mortality, fewer complications and a shorter length of stay.86 However, a
2005 study of a UK hospital found that 30% of general surgery operations were
conducted by a surgeon where the operation did not match their subspecialty87.
The survey of London Trusts showed that while many sites had a range of
subspecialist surgeons on their emergency rotas, Trusts would not be able to ensure
that all patients are treated by a surgeon whose subspecialty matches the illness of
the patient. Several Trusts had specialist breast and vascular surgeons on their rotas
86
Biondo et al (2010) Impact of surgical specialization on emergency colorectal surgery outcomes.
Archives Surgery 2010; 145(1): 79-86
87 Garner, J. P. et al (2005) Sub-specialization in general surgery: the problem of providing a safe
emergency general surgical service. Colorectal Disease. 8, 273-277
49
– meaning that the only abdominal surgery these surgeons undertake will be on an
emergency basis. This is not appropriate to achieve best outcomes for patients.
6.5.
Emergency general surgery in London
6.5.1.
Activity in London
Figure 28: Number of emergency general surgical procedures in London
hospitals in 2009/10. Source: HES 09/10
Abcess drainge
Appendicetomy
Hernia repair
Cholecystectomy
Colorectal
Upper GI
1200
1000
800
600
400
200
0
London sites
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts
emergency admissions.
*The following Trusts have more than one site which accept emergency admissions within their data:
ICH, NWL, BCF, UCLH, RBH, ESH
*Where volumes of activity were less than five for a particular site/Trust, the activity level has been
shown on the graph as the number two
6.5.2.
Surgical techniques
Operations are performed by two methods, traditional open surgery or laparoscopic
surgery. Laparoscopic surgery is minimally invasive ‘key-hole’ surgery and is
associated with a shorter hospital stay and fewer complications than conventional
open surgery88. These outcomes have been demonstrated in studies on
appendicectomies89, 90, cholecystectomies91 and colorectal surgery92.
It is not clinically appropriate that all operations should be done laparoscopically.
However, all modern emergency surgical services should be able to offer this service
88
Ingraham et al (2010) Comparison of 30-day outcomes after emergency general surgery procedures:
potential for targeted improvement. Surgery. Volume 148; 2. (2010)
89 Gilliam, A. D. et al (2007) Day case emergency laparoscopic appendectomy. Surgical Endoscopy
22:483-486
90 Cochrane Review (2002) Laparoscopic surgery for appendicitis. The Cochrane database of
systematic review (ISSN 1464-780X)
91 David et al (2007) Management of acute gallbladder disease in England. British Journal of Surgery
2008; 95: 472-476
92 Law et al (2007) Impact of laparoscopic resection for colorectal cancer on operative outcomes and
survival. Annals of surgery. Vol 245: 1; 2007
50
to all patients where it is suitable. The figure below shows the proportion of surgeons,
on the emergency rota, able to undertake laparoscopic surgery.
Figure 29: Proportion of surgeons on the general emergency surgical rota who
offer laparoscopic surgery.
100
90
80
70
60
50
40
30
20
10
0
London site
The survey of Trusts demonstrated that access to ’key hole’ surgery was variable and
that more than half the Trusts that responded did not have all the surgeons on their
rota able to conduct laparoscopic surgery. In several Trusts, less than half the
surgeons are trained to offer this procedure. This situation must change to ensure
patients receive the benefits of modern surgery and access to this technique
improves.
Key message
All emergency general surgical services should be able to offer laparoscopic
surgery. However, half the hospitals in London do not have all emergency
general surgeons on their rota trained and able to offer this modern surgery.
6.5.3.
Appendicectomy
Removal of the appendix, or an appendicectomy, is the most common emergency
general surgery operation. Performing a laparoscopic appendicectomy has significant,
well documented advantages over open appendicectomy, with respect to length of
hospital stay, rate of routine discharge, and postoperative in-hospital morbidity 93, 94.
Although not all patients are suitable for a laparoscopic appendicectomy, patients that
are suitable should at least have the option of that surgical approach.
93
Cochrane Review (2002) Laparoscopic surgery for appendicitis. The Cochrane database of
systematic review (ISSN 1464-780X)
94 Hellberg, A. et al (1999) Prospective randomised multicentre study of laparoscopic versus open
appendicectomy. British Journal of Surgery. 86 (48-53)
51
Figure 31 shows that this is not currently the situation in London. There is clear
variation across London (from 67% down to 9%) in the proportion of appendicectomies
that were performed laparoscopically. These proportions are directly linked to the
proportion of emergency general surgeons at each hospital who are able to undertake
laparoscopic surgery (see figure 30). Figure 31 also shows variation in the proportion
of procedures that had to be converted from laparoscopic to open. The data shows
that with this level of variation in approaches London is providing an inequitable
service and some patients are not receiving the benefits of modern surgery.
Figure 30: Proportion of appendicectomy operations that were performed either
laparoscopically, converted from a laparoscopic to an open or performed as an
open operation. Source: HES 2009-2010
Laparoscopic
Converted to Open
Open
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
6.5.4.
London sites
Cholecystectomy
Clinical management strategies for patients with acute gallbladder disease need to
change. Mounting evidence indicates that patients with this condition should largely
be operated on laparoscopically95, and that surgery should be undertaken during the
same admission as the initial presentation96, 97,. In a recent analysis of UK hospital
admission data98 showed that only 14.7% of patients, admitted as an emergency for
acute gallbladder disease had surgery within the same admission. Those that did not
have their surgery during their first admission went on to have high re-admission rates
(some patients had as many as 10 re-admissions before elective surgery), and a
second length of stay in hospital associated with their elective surgery. This is not the
best use of scarce resources and offers a poor service to patients.
95
96
97
98
Peng, W. K., Sheikh, Z., Nixon, S. J. & Paterson-Brown, S. (2005). Role of laparoscopic
Cholecystectomy in the early management of acute gallbladder disease. British Journal of Surgery,
92: 586-591
Gurusamy, K. S. & Samraj, K. (2006). Early versus delayed laparoscopic cholecystectomy for acute
cholecystitis. Cochrane Database Systematic Reviews, 4
Cameron, I. C., Chadwick, C., Phillips, J. & Johnson, A. G. (2004). Management of acute
cholecystitis in UK hospitals: time for a change. Postgraduate Medicine Journal, 80: 292-294
David, G. G., Al-Sarira, A. A. Willmott, S., Deakin, M., Corless, D. J. & Slavin, J. P. (2008).
Management of acute gallbladder disease in England. British Journal of Surgery 2008; 95: 472-476
52
Figure 32 below shows the proportion of cholecystectomies performed in the first
emergency admission compared to proportion of cholecystectomies performed as an
elective admission, following an emergency admission for acute cholecystitis in 20092010. There is clear variation in practice across London.
Figure 31: Proportion of cholecystectomies performed in the first emergency
admission compared to proportion of cholecystectomies performed as an
elective admission, following an emergency admission for acute cholecystitis.
Source: HES 2009/2010
Elective readmission (following emergency admission for cholecystitis)
Emergency admission cholecystectomy
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
London site
This variation in service models needs to be addressed if London is to offer all patients
an equitable high quality service. Trusts in London have been slow to take up the new
management practices for patients requiring emergency gall bladder surgery.
Key message
Best practice is for cholecystectomy to be undertaken during the first admission
for the majority of patients with acute cholecystitis, and is associated with
reduced length of stay and fewer unplanned re-admissions for patients. In the
majority of London hospitals patients are not offered this service.
6.5.5.
Emergency day case surgery
There are now clear indications for emergency day case surgery as a core component
of an emergency surgical service99. Day case surgery has mutual benefits for the
patient and hospital; by eliminating the need for an overnight stay, the hospital’s bed
capacity is used more efficiently and the patient is able to return home sooner without
the discomfort and inconvenience involved in a prolonged stay. There are now clear
99
NHS Institute for Innovation and Improvement (2010). Directory of Ambulatory Emergency Care for
Adults. Version 2 – March 2010.
53
guidelines regarding which patient groups are suitable to be treated with emergency
day case surgery100 yet only 57% of sites currently offer this service in London101.
Figure 33 shows the wide gap between actual and potential practice of emergency
day case surgery in London. The dotted line represents the minimum proportion of
cases that could be suitable for emergency day case surgery and the purple bars
indicate the proportion currently being treated as an emergency day case. The
orange bar shows the large proportion of cases that currently have a length of stay of
1 or 2 nights, suggesting that there is a large proportion of abscess drainage surgery
incurring unnecessary overnight stays in hospital.
Figure 32: Percentage of abscess procedures that were treated as day case and
with a length of stay between 1-2 days. The dotted lines indicate where the
proportion of cases that could be suitable for day case surgery could sits (as
described in the Directory of Ambulatory Care, v2)
London sites
London should be providing more day case emergency surgery, as there are clear
benefits to both patients and hospitals. A quality service would have day case surgical
rates in the region of 60% - the best performing Trust in London at present is operating
at about 40%. The potential savings in shifting to more day case surgery in London
are huge.
Key message
Emergency day case surgery provides a high quality service at lower cost, yet is
not widely practised in London.
6.5.6.
Hernias
100
NHS Institute for Innovation and Improvement (2010). Directory of Ambulatory Emergency Care for
Adults. Version 2 – March 2010.
101 Loftus, I. M. and Watkin, D. F. L. (1997) Provision of a day case abscess service. Annals of the
Royal College of Surgeons of England 1997; 97: 289-290
54
If a patient presents as an emergency with a hernia, the presence of a senior,
experienced surgeon is crucial to diagnose any signs of strangulation or bowel
obstruction both of which would necessitates undertaking the operation more rapidly.
If the surgical decision maker is certain that neither of these conditions are present,
then the patient can usually be offered day case surgery. The current provision of this
service in London is unclear.
6.5.7.
Procedures on the colon
Another main component of emergency general surgery is colorectal surgery. A
colectomy consists of the surgical resection of any part of the large intestine and is a
highly specialised operation, often related to cancer102. Emergency colorectal surgery
has a high mortality rate, with one recent UK study stating that 16.9% of patients died
within 30 days following an emergency laparotomy103.
In London, HES data demonstrates the significant variation in 30 day readmission
rates following this complex surgery.
Figure 33. Emergency readmission rate (30 days) for colorectal surgery. Trusts
listed in ascending order. Source: HES 2009-2010
Emergency readmission rate (30 days)
London average
25.0%
20.0%
15.0%
10.0%
5.0%
LHT
CHS
NWL
KCH
NUH
BLT
BCFH
THH
SGH
ESH
GSTT
ICH
WXH
WH
KH
London sites
BHRT-KG
HUH
RFH
SLH-QMS
C&W
BHRT-QH
SLH-PRUH
WMUH
UCLH
SLH-QEW
NMUH
EH
0.0%
For patients admitted to some hospitals, they have a one in five (20%) chance of
returning to hospital within 30 days. In order to improve, London needs to move
towards best practice in this area.
102
103
Garner, J. P. et al (2005) Sub-specialization in general surgery: the problem of providing a safe
emergency general surgical service. Colorectal Disease. 8, 273-277
Clarke, A. (2011) Mortality and postoperative care after emergency laparotomy. European Journal
of Anaesthesiology. 2011 Jan; 28 (1): 7-9
55
6.6.
Population and volume demands on an emergency general surgery
service
The Royal College of Surgeons state that emergency services require a critical
population mass in order to provide efficient and effective services. The preferred
catchment population size for an acute general hospital providing the full range of
facilities, specialist staff and expertise for both elective and emergency medical and
surgical cases would be 450,000 – 500,000104 .
There is a large cohort of literature that supports the view that surgeons who perform a
high volume of procedures tend to have better outcomes. Whilst some studies have
focused on hospital volume and outcomes and found no correlation105, a large UK
review found a correlation between overall hospital activity volume and better
outcomes of mortality, length of stay and reduced complications. More significantly
the study also found that the correlation between positive outcomes became even
stronger when they were associated with a specific surgeon, and even more if the
surgeon was a specialist106. Experience in surgical specialities are developed in
elective work, as well as emergency work. The graph below shows the large variation
in volume of elective and emergency colorectal surgery procedures across London
trusts in 2009-2010.
Figure 34: Number of emergency and elective colorectal surgery procedures
2009-2010. Trusts are listed in order of the total volume of procedures. Source:
HES 2009-2010
London sites
104
105
106
RCS (2006) Delivering high-quality surgical services for the future. The Royal College of Surgeons
of England.
Kwan, T. et al (2008) Population-based information on emergency colorectal surgery
Chowdhury et al (2007) A systematic review of the impact of volume of surgery and specialization on
patient outcome. British Journal of Surgery 2007; 94: 145-161
56
It is clear that certain levels of activity volume are needed to maintain and improve the
skills of clinicians107. With 70% of complex general surgical emergencies being
colorectal, and an aging population that form the typical patient for a colorectal
emergency, it is likely that the major problem lies with maintaining the skills of the
upper gastrointestinal surgeons for complex colorectal emergency operations108.
Key message
Higher surgeon and hospital volumes of cases are associated with better patient
outcomes for many complex operations.
107
Institute of Public Policy and Research (2007) The future hospital. The progressive case for change.
Institute of Public Policy Research
108 Garner, J. P. et al (2005) Sub-specialization in general surgery: the problem of providing a safe
emergency general surgical service. Colorectal Disease. 8, 273-277
57
7. Hospital infrastructure
Many patients admitted as emergencies do not just require input from the medical and
surgical team. There are a range of other services and specialist input that many
patients will require during their stay that will be addressed in this section.
7.1.
Access to mental health services
Patients admitted with mental health problems often have lengthier assessments, and
staff report that arriving at a diagnosis and subsequent management plan can be
difficult. The input of mental health services is vital to deliver a modern, responsive
and integrated acute service. Patients should have the same access to a consultant
psychiatrist as they would have from a consultant specialising in physical health.109
Deliberate self-harm is one of the most common reasons for an emergency admission
to hospital, with over 170,000 admissions per year in the UK.110 A recent survey of this
patient group rated staff poorly in terms of both their attitude and understanding of the
condition, as well as highlighting serious gaps in the training.111 For some patients, this
can lead to non-engagement with services and possibly further self-harm episodes.
Poor provision of mental health services, particularly out-of-hours, contributes
significantly to delayed discharges and blocks patient pathways. An efficient pathway
is therefore dependant on access to quality mental health services. The response to
the London survey demonstrates access out of hours to mental health services is
poor. Out of hours, about half the Trusts don’t have access to psychiatric liaison
services on site.
Figure 35: Access to psychiatric liaison services (Source 2011 survey of acute
trusts)
109
110
111
Academy of Medical Royal Colleges. (2008). Managing urgent mental health needs in the acute
trust: a guide by practitioners, for managers and commissioners in England and Wales
NICE. (2004). Self-harm: The short-term physical and psychological management and secondary
prevention of self-harm in primary and secondary care. CG16
Strevens, P., Blackwell, H., Palmer, L. & Hartwell, E. (2008). Better services for people who selfharm. Aggregated report, wave 3 baseline data. Royal College of Psychiatrists. Also available at:
http://www.rcpsych.ac.uk/pdf/Aggregated%20W3%20Baseline%20Report.pdf
58
Monday Friday
Visiting
Overnight
Visiting
Saturday Sunday
Visiting
Onsite
Yes
Onsite
No
Onsite
0%
20%
40%
60%
80%
Number of hosptial sites
The range of need, both social and clinical, means the first response to a patient with
mental health problems is best provided by a liaison psychiatry team with access to
local crisis services. Across London, not only is there significant variation in access to
services, but also prompt access, particularly out of hours is poor.
7.1.1.
Liaison services for dementia
NICE112 have released guidance on dementia care and recommend that acute trusts
should provide services that address the specific personal and social care needs and
the mental and physical health needs of people with dementia hospital facilities for any
reason. The quality standard states that people with suspected dementia have access
to a liaison service that specialises in the diagnosis and management of dementia. At
present in London, access to these services are inequitable.
Key message
National recommendations state that hospitals should provide patients admitted
as an emergency with prompt access to mental health services. In London,
especially at weekends, this recommendation is not being achieved.
7.2.
Alcohol misuse
The number of hospital admissions due to alcohol misuse was 1.1 million in 2009/10,
a 100% increase since 2002/03. If this rise continues, by the end of the current
Parliament 1.5 million people will be admitted to hospital annually as a result of
drinking113. The Department of Health has set out a standards around the provision of
alcohol services114. The important messages include:
112
National Institute for Public Health and Clinical Excellence. (2011). Clinical guideline 42. Dementia:
supporting people with dementia and their carers in health and social care
113 Alcohol Concern. (2010). Making alcohol a health priority. Opportunities to reduce alcohol harms and
rising costs.
114 Department of Health. (2009). Signs for improvement – commissioning interventions to reduce
alcohol-related harm. Also available at:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_104854.pdf
59

Appointing Alcohol Nurse Specialists in ED departments and acute hospital
clinics working with non-dependent drinkers, and giving clinical advice to
improve standards of care for alcohol dependent patients

Appointing alcohol health workers in acute hospitals targeting dependent
drinkers

Improving the effectiveness and capacity of specialist treatment to ensure that
at least 15% of estimated dependent drinkers in the area receive treatment the
directed enhanced service for all newly registered patients
Investment in alcohol services should be prioritised as an “invest to save” measure.
Across London the increasing burden of acute admissions, resulting from alcohol
related issues needs to be given the attention it demands.
7.3.
Older people
In London, over a third of emergency admissions are for patients aged over 70 (see
figure 37). A significant proportion of older people presenting with an emergency
admission will be frail, have several co-morbidities and have complex social care
needs which differ substantially from the needs of younger patients.
Figure 36: Percentage of adult emergency admissions in London hospital trusts
in 2009/10 by age group. Source HES 2009/10
13%
25%
16-39
40-54
55-69
25%
18%
70-84
85+
19%
It is recommended that those who present with geriatric syndromes (e.g. falls,
confusion, delirium, dementia and reduced mobility) are best cared for in a service that
offers a comprehensive geriatric assessment. Prompt screening of all older acute
medical inpatients by a specialist multidisciplinary team, including senior nurse, allied
health professional with a geriatrician improves clinical effectiveness and general
60
hospital performance.115 The London survey demonstrated that this was not currently
happening routinely across London.
Figure 37: Is there a dedicated older people's on-take service?
Saturday - Sunday
No
Yes
Monday - Friday
0%
20%
40%
60%
80%
This early input means that patients get to the right place first time and leads to
improved quality of life; reduced hospital stay, re-admission rates and
institutionalisation. The service should also be available seven days a week116 and
occur within 24 hours of admission. This has been shown to reduce mortality,
discharge into care homes and prevent future re-admission to hospital.117 London
needs to improve its acute services to elderly and frail patients to ensure they receive
the services they need.
7.3.1.
Falls service
A comprehensive falls prevention service is another indicator of high quality care
across the hospital and community interface. A high proportion of acute admissions
result from falls. NICE have released guidance around how to deliver a quality falls
prevention service118. This includes a recommendation that following an injurious fall,
older people should be offered a multidisciplinary assessment to identify and address
future risk and promote independence and physical function. Both The American and
British Geriatric Societies119 recommend that all older people should be screened for
falls risk and offered an assessment if they have sustained two or more falls in the last
12 months or present with an acute fall or have difficulty with walking and balance.
115
116
Harari, D., Martin, F. C., Buttery, A., O’Neill, S. & Hopper, A. (2007). The older person’ assessment
and liaison team “OPAL”: avaluation of comprehensive geriatric assessment in acute medical
inpatients. Age and Ageing, 36: 670-675
Conroy, S. & Cooper, N. (2010). Acute medical care of elderly people. British Geriatrics Society.
Also available at:
http://www.bgs.org.uk/index.php?option=com_content&view=article&id=44:gpgacutecare&catid=12:goodp
ractice&Itemid=106
117
118
NHS Institute for Innovation and Improvement. (2009). Delivering on quality and value. Focus on:
frail older people
National Institute for Public Health and Clinical Excellence. (2004). Falls: The assessment and
prevention of falls in older people. Clinical Guideline 21. Also available at:
http://www.nice.org.uk/nicemedia/pdf/CG021NICEguideline.pdf
119
American Geriatrics Society & British Geriatrics Society. (2010). Clinical practice guideline:
prevention of falls in older persons
61
Key message
Nearly 40% of emergency admissions in London are for patients aged over 70
years but over half of London hospitals do not have a dedicated on-take service
for older people.
7.4.
Critical and intensive care services
Comprehensive critical care is the complete process of care for the critically ill which
focuses on the level of care that patients need. This encompasses the needs of those
at risk of critical illness, those who have recovered from critical illness and the needs
of those during critical illness.120 The current provision of critical care in London is
characterised by considerable variation in delivery, quality and effectiveness.
7.4.1 Poor recognition of deteriorating patients and escalation protocols
Clinical deterioration can occur at any time in a patient’s illness but is more common
following an emergency admission. Failure to recognise deterioration and act
appropriately can impact significantly on outcomes. One study showed that 4%of
unexpected deaths on a ward were potentially avoidable if appropriate action had
been taken when deterioration was first observed.121
Patients with obvious clinical indicators of acute deterioration are frequently
overlooked or poorly managed on a ward122 and patients often have prolonged periods
of physiological instability prior to admission to an intensive care unit (ICU).123 It is
therefore imperative that patients exhibiting physiological abnormalities receive prompt
and appropriate interventions and early input from senior doctors.
7.4.2 Early warning systems
Early warning systems are used to identify patients are at risk of serious deterioration
in their physical condition. Early recognition of deterioration relies on the correct
observations being performed at appropriate intervals. The role of nursing staff is key
in this area. NCEPOD found that although many nurses performed observations, in
only 5% of cases were instructions given to nursing staff on parameters that should
trigger an alert to medical staff for further patient review.124
These systems need to be linked to a response team that is appropriately skilled to
assess and manage the clinical problems. There are several early warning systems in
operation across the different hospital sites in London. A proportion of these are not
validated and this is an area where standardisation could improve patient care.
120
121
122
123
124
Comprehensive Critical Care, A Review of Adult Critical Care Services (2000): Department of Health
McQuillan P, Pilkington S, Allan A et al (1998): Confidential inquiry into quality of care before
admission to intensive care BMJ; 346: 1853-1858
Hillman KM, Bristow PJ, Chey T, Daffum K, Jacques T, Norman SL, Bishop GF, Simmons G (2002):
Duration of life-threatening antecedents prior to intensive care, Intensive Care Med; 28(11):1629-34
NCEPOD (2005). Op. cit.
NCEPOD (2005). Op. cit.
62
Key message
Patients requiring intensive care need to be identified at the earliest opportunity
and appropriate escalation followed to improve outcomes.
7.4.3 Referral process
Critically ill patients have little physiological reserve and need prompt therapy. Best
practice is for consultants to be involved in the referral of all patients. NCEPOD found
in their audit that only 27% of referrals were made by consultants. Eight per cent of
referrals were also deemed inappropriate due to the very poor predicted patient
outcome and the likelihood that ICU would not be of benefit.125
In addition, all referrals should be assessed by the intensive care team prior to
admission. In 18% of cases NCEPOD found that this was not the case, this review
rate was not influenced by the time of day.
7.4.4 Admission process
A consultant intensivist should review all patients admitted to ICU within 12 hours of
admission.126 NCEPOD found that 27% of patients were admitted to ICU without
consultant intensivist involvement, increasing to 37% overnight. Once admitted 24%
of patients were not reviewed by a consultant intensivist within 12 hours, falling short
of the published standard.
Additionally, a British survey found that weekend admission to the surgical intensive
care unit (ICU) was associated with an increased mortality rate.127
Key message
Consultant involvement in critical care referrals and admission falls short of
published best practice standards leading to inappropriate admissions and
extended ICU stays.
7.5.
Hospital at night
The Hospital at Night (H@N) concept proposes that the way to achieve effective
clinical care, out of hours, is to have one or more multi-professional teams who,
between them, have the full range of skills and competences to meet patients'
immediate needs. The approach provides the potential to provide best possible care
for patients given the changes in permitted working hours for doctors in training.
At present, adoption of the H@N concept varies by hospital trust across London, with
implementation across just 17 sites. There is variation in structured handovers to the
H@N team across London hospitals and less than half (46%) have full attendance
from both medical and surgical specialities. Additionally, across H@N as a whole,
there is often a lack of a robust system that meets patient demand both for new
admissions and coverage of a hospital’s inpatient bed base.
125
126
127
Ibid.
Good Medical Practice for Physicians (2004): Federation of Royal College of Physicians of the UK
Ensminger SA, Morales IJ, Peters SG, Keegan MT et al. The hospital mortality of patients admitted
to the ICU on weekends. Chest 2004;126:1292–98.
63
8. Patient experience
The experiences of patients are important markers for the quality of any service. This
is no different for patients admitted to hospital on an unplanned basis. The patient
panel have highlighted that with the vast majority of emergency admissions there is
little time to exercise choice in provider and patients therefore attend their nearest
hospital. This means that it is even more important to ensure that services are not only
equitable, but also of a consistently high standard across London.
Over recent years, patient surveys have given good indications as to the areas where
efforts might be profitably focussed to improve the service offered to patients including
poor communication and a lack of information and an environment where they feel
they can raise their concerns freely and have their feedback incorporated into services
to make improvements for future patients.
There are in excess of 500,000 unplanned/emergency hospital admissions each year
in London and so where poor care affects even small proportions of patients, this
actually has an impact on large numbers of people.
8.1.
Communication and information
Communication and the listening skills of staff continue to be an issue, and some of
the national surveys have shown that patients believe this situation is getting worse 128.
In practical terms, this means patients felt they were not given enough information
about their condition or the treatment they were receiving. This is especially pertinent
for patients admitted as an emergency where uncertainty and worry are even more
acutely present. There is currently a lack of clinical guidelines for many common acute
conditions with corresponding patient information leaflets.
The recent Healthcare Ombudsman report129 into the care of elderly patients also
highlighted a theme of poor communication between patients, their families and NHS
staff. Not only are the consequences of this distressing for patients, but it can also
mean that the specific needs of the patient are not met, whether it be in terms of a lack
of pain relief or poorly planned discharged arrangements. Working closely with
patients and their families who have recently been through an emergency admission is
key to improving this situation.
It is not just communication with patients that matters. Better partnership working and
communication between external agencies such as community health, social services
and voluntary sector organisations could reduce lengths of stay and unplanned readmissions. This is particularly relevant for those that have a long term condition,
dementia or other mental health related issues. Where an unplanned admission
occurs the hospital staff also need better access to information relating to the package
of care the patient was receiving in the community. These links between services
reduce patient anxiety, improves understanding of the problems and the condition of
the patient and aids recovery and timely discharge.
128
Garratt, E. (2008). The key findings report for the 2008 inpatient survey. The Picker Institute Europe.
Also available at:
http://www.nhssurveys.org/Filestore//documents/Key_Findings_report_for_the_2008__Inpatient_Survey.p
df
129
Health Service Ombudsman. (2011). Care and compassion? Report of the Health Service
Ombudsman on ten investigations in NHS care of older people.
64
8.2.
Raising concerns about care and complaints procedures
The patient panel have spoken about a fear not just of complaining, but also of raising
concerns about the quality of care with staff. This is reiterated in the 2010 Care Quality
Commission inpatient services survey where it was found that the majority of patients
– 88% - were not asked to give their views on the quality of their care while in hospital
and and 58% did not see posters while in hospital explaining how to complain about
the care they received.130 It is important to create a working culture where carers and
patients feel comfortable about raising concerns, without them being dismissed. Staff
need to show cultural awareness and sensitivity to issues to ensure that patients are
comfortable with how a concern is being dealt with.
Every NHS organisation has a complaints procedure in place, and The NHS
Constitution131 sets out the rights of patients in this area. It is not simply a matter of
admitting that errors have taken place, but explaining how they will be prevented in the
future in a sustainable way. Staff training is key to achieving this permanent change.
Patients should be encouraged to complain, without fear that the care of their loved
ones will be adversely affected. The role of the hospital Patient Advice and Liaison
Service (PALS) and the Complaints Review board will be key to achieving this.
Detailed “real” responses can be enlightening and constructive and can be more
helpful than some of the results of national surveys to address problems.
Key message
Poor communication, listening skills and the provision of accessible
information has a marked impact on the experience of patients and their families
130
131
Inpatient services survey 2010, The Picker Institute Europe
Department of Health. (2010). The NHS Constitution. Also available at:
http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/nhs-constitutioninteractive-version-march-2010.pdf
65
9. Workforce and training
9.1.
Impact of reduced number of medical and surgical trainees
There has been a reduction in the number of core trainees across London. In order to
maintain the current rotas, trusts will either have to fund non-training, non-consultant
grades to take up the posts or to look to new models of care.
There are two main issues with maintaining current rotas with doctors in non-training
posts (e.g. staff grades, trust fellows or speciality doctors). Firstly, there are not a
large number of doctors that exist to take up these posts. Secondly, having a large
proportion of staff grades on a rota would mean that there were a disproportionate
number of posts which weren’t subject to the same scrutiny as a training or consultant
post. It can be more difficult to engage such doctors in continuing professional
development since their posts are not subject to the scrutiny of deanery inspections in
the same way as training grade posts.
9.2.
The impact of surgical specialisation on the on-call rota
Increasingly training is becoming speciality focused and this is making the staffing of
an emergency general surgical service more challenging. As more surgeons
undertake sub-specialities, where once there was a pool of general surgeons to recruit
from, there are now two or three smaller pools of subspecialties. To ensure a clear
and balanced rota, surgeons must be recruited across specialities but the number in
each pool is smaller. This can have a significant impact when staffing emergency
general surgery rotas.
Additionally, specialities that would have traditionally been included on an emergency
general surgery rota now have their own speciality rotas; vascular surgeons now run a
rota separate to the general surgery rota. Breast surgeons increasingly feel deskilled
at contributing to the general surgery rota. This means that the pool of eligible
surgeons from which an emergency general surgical rota can be drawn is reduced.
This adds to the pressure of ensuring that an emergency general surgical rota is
adequately staffed to ensure a safely delivered service.
Key message
Due to the development of sub-specialties in general surgery, hospitals in
London will find it increasingly difficult to appropriately staff the consultant
emergency general surgery rota.
9.3.
Impact of the European Working Time Directive
9.3.1.
Impact on all rotas
The European Working Time Directive that limits a working week to a legal maximum
to 48 hours has been in place in hospitals since 2009. Whilst it is possible to ‘opt out’
of this maximum, rotas are not able to be planned around this basis. This means that
in order to deliver the same service that existed prior to EWTD more doctors have to
be recruited to ensure that the rotas are fully staffed and compliant with the EWTD, or
the reduction of the service has to be considered or new models of care created.
66
The RCP survey of April 2010132 showed that junior doctors were covering an average
of 61 patients overnight, but one junior doctor was covering 400 patients. Consultant
physicians are already working more than the 48-hour limit set by the European
Working Time Directive (EWTD), therefore job plans must change in order to reflect
different working patterns and must include arrangements to ensure that there are
adequate rest periods.
9.3.2.
Impact on training
A major factor in training of surgeons of the future is the balance between training time
and service time; all trainees will inevitably provide some service. The effect of EWTD
on training has been to dramatically condense the number of hours in which training
was traditionally delivered. Training does take additional time in supervision and
assessment which will be affected by the seniority of the trainee, the number of
trainees and non-training grades and the consultant’s time to train.
Trainees are frequently used to cover gaps on rotas, at the expense of elective
training opportunities. Onerous night-time and weekend rotas reduce supervised
training opportunities which mean that trainees are not receiving the supervised
experiences they should. Shorter sessions of work have led to complex rotas,
frequent handovers with difficulties in maintaining continuity of care with implications
for patient safety133. There are clear recommendations from the Temple Report that
training needs to take place in a consultant delivered service 134.
Key message
Implementation of the European Working Time Directive means that medical and
surgical trainees have less time to undertake their training. Trainees should not
be used to cover gaps in the emergency rota as this affects their training by
further reducing the hours available for training.
9.4.
Developing sustainable services
There are clear messages that a lot of current services are running on the goodwill of
consultants and other staff to be contacted out of hours, even when not on call. This
is endemic across all services: medical, surgical and diagnostic.
The emergency theatre provides excellent training for junior surgeons when
supervised by senior staff135 and is an important training ground136 and needs to be
recognised as such. London is the most popular training school in the country for
surgery (competition ratios 6:1). Recruitment to surgery training posts in London is not
a problem as very large numbers of trainees apply at all levels. Because of the
capacity in London, the quality and its immense popularity amongst trainees means
there is a very strong argument that there should be more, not less, trainees in
London. This case needs to be made.
132
RCP (2010). Op. cit.
Canter, R. (2010) Impact of reduced working time on surgical training in the United Kingdom and
Ireland. The Surgeon. Article in Press.
134 Temple (2010) Time for training? A Review of the impact of the European Working Time Directive
on the quality of training
135 RCS (2007). Op. cit.
136 NCEPOD (2007). Op. cit.
133
67
10.
Conclusion
This document serves as a joint statement between London’s current commissioners
and the clinical community. The acute medicine and emergency general surgery
service that is provided for London patients today needs to change. Maintaining the
current standards of service provision is not an option, and there is a duty to change
the way that services are currently provided.
Standards of care at weekends and out-of-hours need particular attention. There is
now clear clinical evidence suggesting that the chance of death significantly increases
if a patient is admitted out-of-hours compared to in hours – in London alone if mortality
rates were the same at the weekend as during the week 520 lives could be saved
every year. When this information is considered in the context of the London survey
results, it highlights that service provision is considerably worse at weekends than it is
on a weekday. This large variation in standards at different times of the week cannot
continue and this message is supported by the Royal College of Physicians and
Surgeons.
There are two important messages from the survey of London’s NHS trusts that
provide acute medicine and emergency general surgery. Firstly, there is stark variation
in provision across London. Variation exists between sites and within individual sites
huge variation exists between week days compared to that at weekends. This means
the NHS in London is providing an inequitable service to Londoners and that the day
of the week or the hospital at which a patient happens to present with their illness are
the determining factors as to of the quality of service they will receive. This is not
acceptable. Patients have little choice over when and where they are treated in an
emergency; therefore all hospitals need to be providing a consistently high quality
service, 7 days a week. Secondly, most London hospitals are not meeting Royal
College guidance and NCEPOD recommendations around the provision of their
services. Where service recommendations and evidence around best practice exist,
commissioners should ensure that hospitals provide care to these standards.
London needs to realise the challenges that it faces in relation to workforce. With
increasing sub-specialisation there are fewer general surgeons to cover the on-call
emergency rota, fewer trainees than in previous years and working hours are
constrained by the EWTD. Therefore, there is a need to think innovatively about how
to address these shortfalls both in terms of staffing levels and the provision of
services.
The proposed model of care standards will be published in Autumn 2011 and will
address the issues raised in the case for change. It will propose how services should
be delivered in future and how commissioners and providers can act to improve the
quality of care and treatment for patients.
68
11.
Glossary of terms
Acute medical unit (AMU): A dedicated hospital facility that acts as the focus for
acute medical care for patients that have presented as emergencies to hospital, or
who have developed an acute medical illness whilst in hospital.
Acute medicine: That part of general (internal) medicine concerned with the
immediate and early specialist management of adult patients suffering from a wide
range of medical conditions who present to, or from within, hospitals, requiring urgent
or emergency care.
Acute surgical unit (ASU): A dedicated hospital facility that ensures that the
assessment and treatment of acute surgical patients are concentrated in one area,
allowing rapid transfer from the emergency department, or other wards and areas of
the hospital, where they can be quickly prioritised by experienced staff.
Allied health professionals: Clinical healthcare professions distinct from medicine,
dentistry, and nursing who work in healthcare teams to make the healthcare system
function by providing a range of diagnostic, technical, therapeutic and direct patient
care and support services.
Ambulatory care: Clinical care which may include diagnosis, observation, treatment
and rehabilitation, not provided within the traditional hospital bed base or within the
traditional outpatient services.
Ambulatory emergency care: Care whereby emergency patients are managed
without an overnight hospital stay.
Anastomotic leaks: failure of a seam where two pieces of bowel have been joined
together
Appendicitis: Inflammation of the appendix.
Appendicectomy: Surgical removal of the appendix.
Association of Surgeons of Great Britain and Ireland (ASGBI): an association
representing general surgery and all its related specialities throughout the United
Kingdom and Ireland.
British Society for Gastroenterology: A body which exists to maintain and promote
high standards of patient care in gastroenterology and to enhance the capacity of its
members to discover and apply new knowledge to benefit patients with digestive
disorders.
Critical care: A branch of medicine concerned with life support for critically ill patients.
Colorectal: Pertaining to the colon and rectum.
Computed tomography (CT): A medical imaging method employing tomography,
undertaken in sections through the use of wave of energy, created by computer
processing.
Cholecystitus: Acute gallbladder disease.
69
Cholecystectomy: The surgical removal of the gallbladder.
Department of Health: The government department responsible for public health
issues and which exists to improve the health and wellbeing of people in England.
Directed enhanced service: Special services or activities provided by GP practices
that have been negotiated nationally. Practices can choose whether or not to provide
these services.
Diverticulitis: Swelling of an abnormal pouch (diverticulum) in the intestinal wall.
Early warning system: Systems and process, and values and behaviours which
make up a system for the early detection and prevention of serious failures, such as a
deteriorating patient.
Emergency admission: An admission that is unpredictable and at short notice
because of clinical need.
Emergency general surgery: Unplanned/non-elective/emergency general surgical
procedures for example, surgery for abdominal disease, and includes patients who are
already in the hospital and develop a need for surgery.
Endoscopy: Typically refers to looking inside the body for medical reasons using an
endoscope.
European Working Time Directive (EWTD): A collection of regulations concerning
hours of work, designed to protect the health and safety of workers.
Genomic: Pertaining to genes and the non-coding sequences of DNA.
Geriatric syndromes: Groups of specific signs and symptoms that occur more often
in the elderly and can impact patient morbidity and mortality.
Hospital at Night: A concept which aims to redefine how medical cover is provided in
hospitals during the out-of-hours period. It proposes that effective clinical care can be
achieved by ensuring that one or more multi-professional teams who, between them,
have the full range of skills and competences to meet patients' immediate needs are
onsite in hospitals during the night.
Immunocompromised: A person who has an immunodeficiency of any kind and may
be particularly vulnerable to opportunistic infections, in addition to normal infections
that could affect everyone.
Intensive care unit (ICU): a designated area offering facilities for the prevention,
diagnosis and treatment of multiple organ failure.
Intensivist: physician who specializes in the care of critically ill patients, usually in an
intensive care unit (ICU).
70
Interventional radiology: A subspecialty of radiology in which minimally invasive
procedures are performed using image guidance. Some of these procedures are done
for purely diagnostic purposes, while others are done for treatment purposes
Laparotomy: A surgical procedure involving a large incision through the abdominal
wall to gain access into the abdominal cavity.
Laparoscopic surgery: A modern surgical technique in which operations in the
abdomen are performed through small incisions, also called minimally invasive
surgery, bandaid surgery and keyhole surgery.
Magnetic resonance imaging: A medical imaging technique most commonly used in
radiology to visualise the internal structure and function of the body.
Molecular testing: Examination of specific genes to detect abnormalities.
Multidisciplinary team: A group of expert doctors, nurses and other healthcare
professionals with a special interest in the diagnosis, treatment and management of
people with cancer.
National Confidential Enquiry into Patient Outcome and Death (NCEPOD): A
national organisation whose purpose is to assist in maintaining and improving
standards of medical and surgical care for the benefit of the public by reviewing the
management of patients, by undertaking confidential surveys and research, and by
maintaining and improving the quality of patient care and by publishing and generally
making available the results of such activities.
NHS Institute for Innovation and Improvement: An arm’s length body that assists
the NHS in transforming healthcare for patients by developing and spreading new
work practices, technology and improved leadership.
Pancreatitis: Inflammation of the pancreas.
Pathology: The study and diagnosis of disease
Peri-operative: The period around the time of a surgical operation.
Peritonitis: An inflammation of the peritoneum, the serous membrane that lines part
of the abdominal cavity.
Quality, Innovation, Productivity and Prevention (QIPP) programme: A
programme that works at national, regional and local levels to support clinical teams
and NHS organisations to improve the quality of care they deliver while making
efficiency savings that can be reinvested in the service to deliver year on year quality
improvements.
Royal College of Physicians (RCP): An independent membership organisation
which supports and represents physicians and engages in physician development and
raising standards in patient care.
Royal College of Surgeons (RCS): An independent membership organisation which
provides support and training to enable surgeons to achieve and maintain the highest
standards of patient care.
71
Society for Acute Medicine: The national representative body for staff caring for
medical patients in the acute hospital setting.
Stoma: An opening, either natural or surgically created, which connects a portion of
the body cavity to the outside environment.
Systemic sepsis: A condition characterised by a whole-body inflammatory state
(called a systemic inflammatory response syndrome or SIRS) and the presence of a
known or suspected infection.
Therapeutic endoscopy: The medical term for an endoscopic procedure during
which treatment is carried out via the endoscope.
72
12.
Appendices
Appendix 1 – Membership of clinical expert panels and project board
Membership of project board
Derek Bell
Shaun Danielli
Daniel Elkeles
Hannah Farrar
Celia Ingham Clark
Andy Mitchell
Simon Robbins
Julie Screaton
Matt Thompson
Denise Bavin
Clinical lead: acute
medicine
Project manager
Sector director of
strategy
NHS London
Clinical lead:
emergency surgery
Executive clinical
sponsor
Senior responsible
officer
People and
organisational
development
Overall clinical
director
GP representative
Professor of Emergency Medicine,
Imperial College London
Assistant Director, Acute and
Specialist Care, London Health
Programmes
Director of strategy, NHS North
West London
Director of Strategy and
Commissioning Development,
NHS London
Medical Director, The Whittington
Hospital NHS Trust
Medical Director, NHS London
Chief Executive, South East
London Sector
Director Workforce Transformation,
NHS London
Professor of Vascular Surgery, St
Georges Healthcare NHS Trust
Camden
Acute Medicine Clinical Expert Panel
Louise Briggs
Acute rehabilitation of the older St Georges Healthcare NHS
person (medicine)
Trust
Peter Brodrick
Consultant Anaesthetist
Richard GrocottMason
Cardiology and General
(internal) Medicine
Rachel Landau
Emergency Medicine
Linda McQuaid
Community services
Nadeem Nayeem
Emergency Medicine
Kevin O'Kane
Acute Physician
Royal College of
Anaesthetics
The Hillingdon Hospital NHS
Trust & The Royal Brompton
and Harefield NHS Trust
Whittington Hospital NHS
Trust
Sutton & Merton Community
Services
University Hospital Lewisham
Representing the College of
Emergency Medicine
Guy's and St Thomas' NHS
Foundation Trust
73
Steven Reid
Liaison Psychiatry
Magda Smith
Gastroenterology
General Medicine
Divisional Director Medicine
St Mary’s Hospital, London /
Central and Northwest
London NHS Foundation
Trust
Barking, Havering and
Redbridge Hospitals NHS
Trust, Romford Essex
Neil Thomson
Pre-hospital Emergency
Medicine
London Ambulance Service
NHS Trust
David Ward
Consultant in Acute Medicine
South London Healthcare
NHS Trust - Queen Elizabeth
Hospital, Greenwich
Emergency General Surgery Clinical Expert Panel
Cleave Gass
Anaesthesia
St George's Hospital
Jane Linsell
General and Colorectal Surgery
Adrian Marcus
Consultant Radiologist
Marilyn Plant
GP
Lewisham Healthcare NHS
Trust
Barnet and Chase Farm NHS
Trust
NHS Richmond
Jonathan Ramsay General and Emergency
Urological Surgery
Imperial College Healthcare
NHS Trust
Tom Smith
Whipps Cross University
Hospital Trust
Imperial College Healthcare
NHS Trust
Chelsea and Westminster
Hospital NHS Foundation
Trust
London Ambulance Service
NHS Trust
Barts and the London NHS
Trust
London Ambulance Service
NHS Trust
Nigel Standfield
Anaesthesia and Intensive
Care
Consultant Vascular Surgeon
Jeremy
Thompson
General Surgery – Upper GI
Fenella Wrigley
Deputy Medical Director
London Ambulance Service
Consultant in Emergency
Medicine
Medical Director
Fionna Moore
74
Out of London experts
Both are members of the clinical expert panels.
Philip Dyer
Jane McCue
Consultant Physician - Acute
Medicine
President for the Society of Acute
Medicine
Consultant Colorectal Surgeon
Heartlands Hospital
Society of Acute
Medicine
East and North
Hertfordshire NHS Trust
Project Team
Jessamy Hayes
Project Officer
London Health Programmes
Katie Horrell
Project Officer
London Health Programmes
Patrice Donnelly
QIPP Strategy Manager
NHS London
Paul Harris
Administrator
London Health Programmes
Mark Hindmarsh
Senior Project Officer
London Health Programmes
75
Appendix 2 – Membership of patient panel
Trevor Begg
Belinda Blanchard
Audrey Brightwell
Martin Dadswell
Julian Maw
Donald McLeish
Mohammed Qureshi
John Ryan
Verite Reilly-Collins
Martin Saunders
Deanna Sidley
Jim Wong
Tera Younger
Appendix 3 – Acute medicine data, length of stay
On all charts, the orange line represents the London average figure.
Figure 38: The average length of stay for patients admitted as an emergency with a
diagnosis of respiratory disease admitted to London hospitals in 2009/10. Source: HES
09/10
7.0
6.0
5.0
4.0
3.0
2.0
1.0
SLH-QMS
RBH
SLH-QEW
KH
CHS
BHRT-QH
WXH
KCH
NMUH
ICH
HUH
WMUH
SLH-PRUH
LHT
RFH
ESH
UCLH
WH
SGH
NUH
NWL
GSTT
EH
BLT
C&W
BCF
BHRT-KG
THH
0.0
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
Figure 39: The average length of stay for patients admitted as an emergency with a
diagnosis of diseases of the digestive system and intestines admitted to London
hospitals in 2009/10. Source: HES 09/10
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
NUH
LHT
WH
BCF
BLT
EH
C&W
GSTT
NWL
SGH
THH
CHS
ICH
KCH
WXH
BHRT-KG
ESH
HUH
KH
RFH
SLH-PRUH
UCLH
WMUH
SLH-QMS
RBH
BHRT-QH
SLH-QEW
NMUH
0.0
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
77
Figure 40: The average length of stay for patients admitted as an emergency with a
diagnosis of heart failure and ischaemic heart disease admitted to London hospitals in
2009/10. Source: HES 09/10
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
THH
ESH
RBH
BHRT-KG
BLT
C&W
KCH
RFH
SLH-QEW
LHT
UCLH
ICH
WH
WXH
BCF
GSTT
KH
NUH
SLH-PRUH
SGH
WMUH
CHS
NMUH
NWL
BHRT-QH
SLH-QMS
EH
HUH
0.0
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
Figure 41: The average length of stay for patients admitted as an emergency with a
diagnosis of diseases of the urinary system admitted to London hospitals in 2009/10.
Source: HES 09/10
18.0
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
RBH
GSTT
BLT
NWL
UCLH
EH
WH
C&W
KCH
RFH
THH
LHT
BHRT-KG
BCF
ESH
NUH
ICH
BHRT-QH
SLH-PRUH
HUH
SGH
NMUH
WMUH
WXH
SLH-QEW
CHS
KH
SLH-QMS
0.0
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
78
Figure 42: The average length of stay for patients admitted as an emergency with a
diagnosis of influenza and pneumonia admitted to London hospitals in 2009/10.
Source: HES 09/10
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
LHT
NWL
RBH
THH
UCLH
BHRT-KG
GSTT
KCH
NUH
SLH-PRUH
BLT
RFH
SLH-QEW
SGH
WH
BHRT-QH
ESH
HUH
WXH
C&W
CHS
BCF
EH
WMUH
KH
SLH-QMS
ICH
NMUH
0.0
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
Figure 43: The average length of stay for patients admitted as an emergency with a
diagnosis of infections of the skin admitted to London hospitals in 2009/10. Source:
HES 09/10
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
BHRT-KG
CHS
BHRT-QH
ICH
SLH-QMS
WXH
SLH-QEW
BCF
SLH-PRUH
WMUH
SGH
RFH
NMUH
KCH
HUH
LHT
THH
ESH
EH
NWL
UCLH
GSTT
BLT
KH
WH
NUH
C&W
RBH
0.0
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
79
Appendix 4 – Acute medicine data, 30 day re-admission rates
On all charts, the orange line represents the London average figure.
Figure 44. 30-day re-admission rates for patients admitted as an emergency with a
diagnosis respiratory disease in London hospitals. Source HES inpatients 09/10
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
KH
NMUH
SLH-QEW
WMUH
BHRT-KG
KCH
BHRT-QH
CHS
BCF
C&W
NUH
HUH
NWL
WXH
SLH-PRUH
RFH
ICH
WH
GSTT
EH
ESH
SGH
UCLH
BLT
THH
LHT
RBH
SLH-QMS
0.0%
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
Figure 45. 30-day re-admission rates for patients admitted as an emergency with a
diagnosis of diseases of the digestive system and intestines in London hospitals.
Source HES inpatients 09/10
RBH
WMUH
NMUH
CHS
SLH-QEW
C&W
NUH
RFH
WH
UCLH
BHRT-QH
BHRT-KG
EH
SLH-PRUH
ESH
KH
KCH
THH
WXH
GSTT
ICH
HUH
BCF
BLT
NWL
SGH
LHT
SLH-QMS
20.00%
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
80
Figure 46. 30-day re-admission rates for patients admitted as an emergency with a
diagnosis of heart failure and ischaemic heart disease in London hospitals. Source
HES inpatients 09/10
45.0%
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
KH
NMUH
SLH-QEW
WMUH
RBH
SLH-PRUH
KCH
CHS
HUH
RFH
BCF
NWL
GSTT
BHRT-QH
WXH
WH
C&W
BHRT-KG
BLT
ICH
SGH
UCLH
EH
ESH
NUH
LHT
THH
SLH-QMS
0.0%
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
Figure 47. 30-day re-admission rates for patients admitted as an emergency with a
diagnosis of diseases of the urinary system in London hospitals. Source HES
inpatients 09/10
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
RBH
NMUH
KH
RFH
SLH-QEW
HUH
NUH
BHRT-QH
GSTT
CHS
BHRT-KG
BCF
NWL
SLH-PRUH
WH
KCH
WMUH
WXH
ESH
C&W
ICH
UCLH
EH
SGH
LHT
BLT
THH
SLH-QMS
0.0%
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
81
Figure 48. 30-day re-admission rates for patients admitted as an emergency with a
diagnosis of diagnosis of influenza and pneumonia in London hospitals. Source HES
inpatients 09/10
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
KH
BHRT-KG
HUH
WMUH
UCLH
NUH
NMUH
BHRT-QH
BCF
RFH
WXH
KCH
ESH
SLH-PRUH
WH
CHS
ICH
SLH-QEW
C&W
GSTT
NWL
EH
SGH
LHT
BLT
THH
RBH
SLH-QMS
0.0%
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
Figure 49. 30-day re-admission rates for patients admitted as an emergency with a
diagnosis of infections of the skin in London hospitals. Source HES inpatients 09/10
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
RBH
NMUH
BHRT-KG
HUH
RFH
CHS
BHRT-QH
SLH-PRUH
WMUH
SLH-QEW
GSTT
C&W
KCH
ICH
WXH
SGH
BCF
NUH
WH
UCLH
NWL
EH
ESH
BLT
THH
LHT
KH
SLH-QMS
0.0%
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
82
Appendix 5 – Emergency general surgery data, length of stay
Figure 50 Average (median) length of stay for appendicectomies. The line represents
the London average length of stay. Source: HES 2009-2010
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
Figure 51 Average length of stay for an emergency Cholecystectomy in London.
Source: HES 2009-2010
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
83
Figure 52 Average LOS following emergency surgery for hernia repair. Source HES
2009/2010.
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
Figure 53 Average LOS for emergency admissions for colorectal surgery. Trusts
listed in ascending order for longer lengths of stay. Source: HES 2009-2010
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
84
Appendix 6 – Emergency general surgery data, 30 day re-admission rates
Figure 54: Emergency readmission (30 days) of appendicectomies. The line
represents the London average. Source: HES 2009-2010
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
Figure 55: Emergency readmission rate following an emergency Cholecystectomy
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
85
Figure 56: Rate of emergency readmission rates following emergency abscess
surgery. Source HES: 2009/2010
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
Figure 57: Emergency readmission (30 days) rate following emergency surgery for
hernia repair. Source: HES 2009-2010
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
86
Figure 58: Emergency readmission rate (30 days) for colorectal surgery. Trusts listed
in ascending order. Source: HES 2009-2010
*As of November 2010, Queen Mary’s Hospital, (South London Healthcare Trust) no longer accepts emergency
admissions.
*The following Trusts have more than one site which accept emergency admissions within their data: ICH, NWL,
BCF, UCLH, RBH, ESH
87
Appendix 7 – Disclaimers
Hospital Episode Statistics
Queen Mary’s Hospital, Sidcup
As of November 2010, Queen Mary’s Hospital, Sidcup no longer takes emergency
admissions but is included on the graphs for as there was activity recorded for this site in
2009/10.
Trusts and sites on the HES activity graphs
Where possible, data has been included on a site by site basis. Where data is shown by
trust, rather than by site, this reflects how coding is recorded at the trust and that it was not
possible to divide the trust activity by site. The following Trusts have more than one site
which accept emergency admissions within their data:

Barnet and Chase Farm Hospitals NHS Trust

Epsom and St Helier University Hospitals NHS Trust

Imperial College Healthcare NHS Trust

North West London Hospitals NHS Trust

Royal Brompton & Harefield NHS Foundation Trust

University College London Hospital NHS Foundation Trust
Where volumes of activity reported was less than five
Where volumes of activity recorded were less than five, for the purpose of this paper we have
used the number two to represent activity that has taken place. Where the volume of activity
is recorded as two on each graph, it should be noted that this could represent any number
between one and five.
Emergency re-admissions
As 2010/11 data is not available re-admissions within 30 days can only be calculated where
the first admission has a discharge date of 01/03/2010 or earlier. As such the rates here
reflect emergency re-admission rates based on 11 months worth of data. Re-admission rates
are for all emergency re-admissions regardless of reason of re-admission.
Quality and accuracy in HES data
It is acknowledged that HES data can include inaccuracies. However, it is data that is
entered by trusts and remains the best way of understanding the levels of hospital activity.
Risk and case mix adjustment
None of the charts relating to length of stay or re-admission rates have been adjusted in any
way for case mix or risk.
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Codes used to represent trusts and hospital sites in graphs.
BCFH-BH
Barnet Hospital
BCFH-CF
Chase Farm Hospital
BHRT
Barking, Havering and Redbridge Hospitals NHS Trust
BHRT-KG
King George Hospital
BHRT-QH
Queen’s Hospital
BLT
Bart’s and The London NHS Trust
BLT-SB
St Bartholomew’s Hospital
BLT-RL
The Royal London Hospital
C&W
Chelsea & Westminster Hospital
CHS
Croydon University Hospital
EH
Ealing Hospital
ESH
Epsom and St Helier University Hospitals NHS Trust
ESH-EH
Epsom Hospital
ESH-SH
St Helier Hospital
GOSH
Great Ormond Street Hospital for Children NHS Trust
GSTT
Guy's and St Thomas' NHS Foundation Trust
GSTT-GH
Guy’s Hospital
GSTT-ST
St Thomas’ Hospital
HUH
Homerton University Hospital
ICH
Imperial College Healthcare NHS Trust
ICH-CXH
Charing Cross Hospital
ICH-HH
Hammersmith Hospital
ICH-SM
St Mary’s Hospital
KCH
King's College Hospital
KH
Kingston Hospital
LHT
University Hospital Lewisham
NMUH
North Middlesex University Hospital NHS Trust
89
i
ii
NUH
Newham University Hospital
NWLH
North West London Hospitals NHS Trust
NWL-NPH
Northwick Park Hospital
NWL-CMH
Central Middlesex Hospital
RBH
Royal Brompton & Harefield NHS Foundation Trust
RFH
The Royal Free Hospital
RMH
The Royal Marsden NHS Foundation Trust
RNOH
Royal National Orthopaedic Hospital NHS Trust
SGH
St George's Hospital
SLH
South London Healthcare NHS Trust
SLH-PRUH
Princess Royal University Hospital
SLH-QEH
Queen Elizabeth Hospital
SLH-QMS
Queen Mary’s Hospital
THH
The Hillingdon Hospital
UCLH
University College London Hospital
WXH
Whipps Cross University Hospital
WH
The Whittington Hospital
WMUH
West Middlesex University Hospital
Bell, M. D., Redelmeier, D. A. (2001). Mortality among patients admitted to hospitals on weekends compared with
weekdays The New England Journal of Medicine 345: 9
Bell, M. D., Redelmeier, D. A. (2001). Mortality among patients admitted to hospitals on weekends compared with
weekdays The New England Journal of Medicine 345: 9
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