APPROPRIATENESS OF ACUTE MEDICAL ADMISSIONS AND LENGTH OF STAY

Objective: To use the Appropriateness Evaluation Protocol (AEP) to ass ess the extent of inappropriate utilisation of hospital beds by acute medical patients. To determine whether clinicians viewed the AEP decis ions as valid. Design: Retrospective review of the medical records of a 10% random sample of 8,210 patients admitted as medical emergencies. An objective independent review instrument (AEP) was used to assess t he medical necessity for hospitalisation at admission and on each subs equent day. To test the validity of the screening instrument, a subsam ple of the reviewed records was further assessed by a panel of physici ans. Setting: A district general hospital in the West Midlands region of England. Subjects: Eight hundred and twenty-one adult patients admi tted to general medicine during one calendar year. Main outcome measur es: Proportions of admissions and days of care for which inpatient med ical care was judged appropriate. Reasons for inappropriate utilisatio n and potential bed-days that could be saved by the development and us e of alternative services were also considered. Validity of the AEP wa s tested by assessing agreement between the majority decision of an ex pert panel and the criterion-based AEP decision. Results: AEP identifi ed 51/821 (6%) admissions and 2,195/4,885 (45%) days of care as inappr opriate. Over half the patients had a hospital stay in which at least half the days were judged inappropriate. The commonest reason for inap propriate days was remaining in hospital after the medical purpose for admission had been accomplished. This accounted for 38% of inappropri ate days reviewed. In validity testing there was a high level of agree ment between the physicians and the AEP, with kappa values greater tha n 0.80 for admissions and days of care. Conclusions: The AEP is a vali d and useful instrument for assessing the utilisation of acute medical beds in a NHS hospital. In this study acute medical admissions were l argely appropriate at the time of admission but a substantial proporti on of subsequent days of care was considered inappropriate by AEP crit eria. Most inappropriate utilisation was due to organisational issues within the hospital. As a result of this study, several service and po licy developments were identified that should improve the efficiency o f bed utilisation at the hospital.