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• We study the effect of emergency department crowding due to low severity patients. • We unpack welfare implications for high severity patients along their pathway in ED. • We show the slack in capacity by looking at the distribution of unplanned demand. • Emergency departments efficiently prioritise high severity patients. • Care rationing at very high levels of demand explains crowding effects on outcomes. Unexpected peaks in volumes of attendances at hospital emergency departments (EDs) have been found to affect waiting times, intensity of care and outcomes. We ask whether these effects of ED crowding on patients are caused by poor clinical prioritisation or a quality-quantity trade-off generated by a binding capacity constraint. We study the effects of crowding created by lower-severity patients on the outcomes of approximately 13 million higher-severity patients attending the 140 public EDs in England between April 2016 and March 2017. Our identification approach relies on high-dimensional fixed effects to account for planned capacity. Unexpected demand from low-severity patients has very limited effects on the care provided to higher-severity patients throughout their entire pathway in ED. Detrimental effects of crowding caused by low-severity patients materialise only at very high levels of unexpected demand, suggesting that binding resource constraints impact patient care only when demand greatly exceeds the ED's expectations. These effects are smaller than those caused by crowding induced by higher-severity patients, suggesting an efficient prioritisation of incoming patients in EDs. [ABSTRACT FROM AUTHOR]

Introduction: All the surgeries carry risks, which may lead to readmission at a later date. At present, there is limited Trauma and Orthopaedic (T&O) specific data in the literature. As a result, a prospective regional service evaluation aimed to discover the current complication and readmission rates across all T&O procedures and identify any factors associated with these outcomes.Methods: Data were collected at six sites across Yorkshire and Humber for all T&O procedures during October 2016. Patient demographics and procedure-specific data were collected. Post-operative complications and length of stay were recorded. All the patients were then followed up for 30 days post-discharge to determine if they experienced complications which resulted in readmission and further surgical intervention.Results: 1411 patients having a total of 64 operations were recorded with 1391 completing follow-up (98.5%). Overall in-patient complication rate was 8.4% with the readmission rate being 4.4%. An ASA grade of three or more was found to be associated with readmission. Procedure-related factors such as the use of VTE prophylaxis and prophylactic antibiotics, as well as the elective nature of certain operations were negatively associated with readmission. The largest subgroup of patients was those undergoing total hip (THR) or knee replacements (TKR). For these 234 patients, the readmission rate for TKR and THR being 3.77% and 3.13%, respectively.Conclusions: This large, multi-centre project describes readmission rates following trauma and orthopaedic surgery. In the presented study, the elective nature of the procedure was associated with a reduced risk of readmission. [ABSTRACT FROM AUTHOR]

Objective: To develop methods to model the relationship between cancer detection and recall rates to inform professional standards.Methods: Annual screening programme information for each of the 80 English NHSBSP units (totalling 11.3 million screening tests) for the seven screening years from 1 April 2009 to 31 March 2016 and some Dutch screening programme information were used to produce linear and non-linear models. The non-linear models estimated the modelled maximum values (MMV) for cancers detected at different grades and estimated how rapidly the MMV was reached (the modelled 'slope' (MS)). Main outcomes include the detection rate for combined invasive/micro-invasive and high-grade DCIS (IHG) detection rate and the low/intermediate grade DCIS (LIG) detection rate.Results: At prevalent screens for IHG cancers, 99% of the MMV was reached at a recall rate of 7.0%. The LIG detection rate had no discernible plateau, increasing linearly at a rate of 0.12 per 1000 for every 1% increase in recall rate. At incident screens, 99% of the MMV for IHG cancer detection was 4.0%. LIG DCIS increased linearly at a rate of 0.18 per 1000 per 1% increase in recall rate.Conclusions: Our models demonstrate the diminishing returns associated with increasing recall rates. The screening programme in England could use the models to set recall rate ranges, and other countries could explore similar methodology.Key Points: • Question: How can we determine optimum recall rates in breast cancer screening? • Findings: In this large observational study, we show that increases in recall rates above defined levels are almost exclusively associated with false positive recalls and a very small increase in low/intermediate grade DCIS. • Meaning: High recall rates are not associated with increases in detection of life-threatening cancers. The models developed in this paper can be used to help set recall rate ranges that maximise benefit and minimise harm. [ABSTRACT FROM AUTHOR]

BackgroundPsychiatric in-patients are at high risk of suicide. Recent reductions in bed numbers in many countries may have affected this risk but few studies have specifically investigated temporal trends. We aimed to explore trends in psychiatric in-patient suicide over time.MethodA prospective study of all patients admitted to National Health Service (NHS) in-patient psychiatric care in England (1997–2008). Suicide rates were determined using National Confidential Inquiry and Hospital Episode Statistics (HES) data.ResultsOver the study period there were 1942 psychiatric in-patient suicides. Between the first 2 years of the study (1997, 1998) and the last 2 years (2007, 2008) the rate of in-patient suicide fell by nearly one-third from 2.45 to 1.68 per 100 000 bed days. This fall in rate was observed for males and females, across ethnicities and diagnoses. It was most marked for patients aged 15–44 years. Rates also fell for the most common suicide methods, particularly suicide by hanging on the ward (a 59% reduction). Although the number of post-discharge suicides fell, the rate of post-discharge suicide may have increased by 19%. The number of suicide deaths in those under the care of crisis resolution/home treatment teams has increased in recent years to approximately 160 annually.ConclusionsThe rate of suicide among psychiatric in-patients in England has fallen considerably. Possible explanations include falling general population rates, changes in the at-risk population or improved in-patient safety. However, a transfer of risk to the period after discharge or other clinical settings such as crisis resolution teams cannot be ruled out. [ABSTRACT FROM PUBLISHER]

Background: Differences between women and men in treatment and outcome after admission with a ruptured abdominal aortic aneurysm (AAA) in England were studied. Methods: Routinely collected data in Hospital Episode Statistics, linked to death records, for emergency admissions for ruptured AAA in England were analysed. The percentage of patients who underwent surgical repair was calculated, together with 30-day case fatality rates and age-adjusted odds ratios (ORs), comparing women with men. Results: A total of 2463 women and 7615 men were admitted with a primary diagnosis of ruptured AAA (mean age 79.8 and 74.9 years respectively); 39.6 per cent of women and 66.4 per cent of men underwent surgical repair (OR 0.47 (95 per cent confidence interval 0.42 to 0.52)). Overall, 75.6 per cent of women and 61.7 per cent of men died within 30 days of admission (OR 1.36 (1.22 to 1.52)). The death rate for women and men who had surgery was similar (OR 1.01 (0.88 to 1.17)); when no operation was performed the mortality rate was higher in women, but not significantly so (OR 1.14 (0.91 to 1.42)). Conclusion: Women with a ruptured AAA were less likely to be treated surgically than men, and their overall mortality rate was higher. Lower rates of surgery in women than in men may contribute to the higher mortality in women, but other explanations are possible. [ABSTRACT FROM AUTHOR]

Background: Self-harm is a major healthcare problem in the United Kingdom, but monitoring of hospital presentations has largely been done separately in single centres. Multicentre monitoring of self-harm has been established as a result of the National Suicide Prevention Strategy for England.Method: Data on self-harm presentations to general hospitals in Oxford (one hospital), Manchester (three hospitals) and Leeds (two hospitals), collected through monitoring systems in each centre, were analysed for the 18-month period March 2000 to August 2001.Results: The findings were based on 7344 persons who presented following 10,498 episodes of self-harm. Gender and age patterns were similar in the three centres, 57.0% of patients being female and two-thirds (62.9%) under 35 years of age. The largest numbers by age groups were 15-19 year-old females and 20-24 year-old males. The female to male ratio decreased with age. Rates of self-harm were higher in Manchester than Oxford or Leeds, in keeping with local suicide rates. The proportion of patients receiving a specialist psychosocial assessment varied between centres and was strongly associated with admission to the general hospital. Approximately 80% of self-harm involved self-poisoning. Overdoses of paracetamol, the most frequent method, were more common in younger age groups, antidepressants in middle age groups, and benzodiazepines and sedatives in older age groups. Alcohol was involved in more than half (54.9%) of assessed episodes. The most common time of presentation to hospital was between 10 pm and 2 am.Conclusions: Multicentre monitoring of self-harm in England has demonstrated similar overall patterns of self-harm in Oxford, Manchester and Leeds, with some differences reflecting local suicide rates. Diurnal variation in time of presentation to hospital and the need for assessment of non-admitted patients have implications for service provision. [ABSTRACT FROM AUTHOR]

Background. This study investigates deliberate self-harm (DSH) presentations to Southern Derbyshire hospitals from 1990 to 1997. Methods . Retrospective evaluation of deliberate self-harm rates and socio-demographic variables associated with DSH in 9961 consecutive attendances at Derby's two district general hospitals. Results . A significant rise in the rates of DSH in Derbyshire was noted (82%). The gender ratio has changed, with rising numbers of DSH episodes in males. The ratio of DSH episodes to the total Accident & Emergency (A&E) attendances changed from 1.54 to 2.42, with a 36% (95% CI 32–40%) rise in DSH presentations. Overdose remains the most common method of DSH (F?=?85%, M?=?78%). Two-thirds of the DSH presentations were first DSH attempts. Conclusions . Overall DSH rates are increasing especially in men. In contrast, official suicide rates have reduced during the same period. The increase in DSH rates has implications for already overworked A&E Departments, as well as other emergency and psychiatric services. Service provision and organisation should be reviewed in light of this increasing demand. [ABSTRACT FROM AUTHOR]

Sand transport measurements of bedload and suspended load in the Sizewell-Dunwich Banks area, East Anglia have shown that the suspended mode is dominant The depth-integrated spring tidal residual is 5.66 g cm-1 sec-1 although the neap rate is only one of fifth of this. The calculated bedload transport rates also vary, from 0. 012 to 0.040 g cm-1 sec-1, correlating with changing meteorological conditions. In order to predict the bedload sediment circulation pattern from midwater current meter measurements, five sediment transport equations were calibrated, using fluorescent dyed sand Yalin's relationship gave the best estimates The bed shear stress was determined by extrapolating the velocity profile as a power law relationship, with an exponent equal to 0.1, from midwater down to 2 m and as a lognormal profile from 2 m to the sea-bed. Roughness length values appropriate to the substrate were used. Although bedload transport residuals are mainly to the south, the banks trend northwards from the coast and have also elongated in this direction. This is thought to be in response to the dominance of the suspended sediment transport it is suggested that a tidal residual eddy mechanism is responsible for the banks' maintenance, similar to the process operating in Start Bay, Devon. The well-documented westward movement of the banks is likely to be related to wave processes. [ABSTRACT FROM AUTHOR]