The quality and safety of healthcare provided to hospital inpatients who are placed on clinically inappropriate wards

Background: Almost all NHS hospitals regularly place patients on wards that are not clinically appropriate if there are no beds available on the correct specialty ward. Such patients are commonly called outliers. Approximately one in ten NHS inpatients experience an adverse event that causes them harm as a direct result of the care they receive while in hospital. It was hypothesised that placement on a ward that is not clinically appropriate for patients’ needs could act as an underlying (latent) condition which may increase patients’ susceptibility to adverse events.

Methods: A descriptive quantitative study of the outliers and other inpatients in a single large NHS Foundation Trust was conducted using routinely available data. The aims were to investigate: the trend of outliers over the course of one year, age, gender, specialty, internal transfers between wards, length of stay in hospital and mortality. Two separate qualitative interview studies were conducted at the Trust to ascertain NHS staff members’ and patients’ perceptions and experiences of the quality and safety of care received by outlying patients.

Results: Medical and elderly outliers increased over the winter months. Outliers were transferred between wards a significantly greater number of times than other inpatients. Multivariate analyses demonstrated no differences in age, gender, or mortality; however, outliers stayed in hospital significantly longer than other inpatients and outliers were significantly more likely to come from medicine than from any other specialty. Both staff and patients identified a number of factors which may contribute to healthcare errors experienced by outlying patients. Placement of patients on clinically inappropriate wards creates competing demands on staff members’ time and consequently results in delays, poses a number of communication barriers, compromises input from knowledgeable staff, may provide an unsuitable ward environment, and can be inappropriate for individual patients’ needs.

Conclusions: The placement of patients on clinically inappropriate wards is a specific patient safety concern and constitutes a latent condition which may expose patients to a number of contributory factors that underlie adverse events. The quality of care may be compromised as outliers are often prioritised beneath other inpatients.