On healthcare self-organisation: a complexity approach to exploring patient journeys and outcomes
File(s)
Author(s)
Boncea, Estera
Type
Thesis
Abstract
Background: The movement of patients within and between hospitals has been difficult to quantify and evaluate, yet thousands of transfers occur daily. They pose social challenges, as healthcare staff coordinate and communicate across individual specialities, and structural challenges, as hospitals continue to face unprecedented demand for limited bed spaces. Using a complex systems lens, this thesis aimed to understand the complexity of patient movement and its effect on patient outcomes.
Methods and Results: A multi-method approach was taken, comprising five original studies in the United Kingdom's (UK) National Health Service (NHS). Study one uses electronic health record (EHR) data from patient spells spanning three years to understand the impact of transfers on hospital-acquired infection (HAI), reporting that each additional transfer increased the odds of developing a HAI increase by 9%. Building on this, Study two uses a mixed-methods approach to differentiate transfers, defining regular, site and atypical transfers, and understand their impacts. Each atypical transfer resulted in an estimated increase in average length of stay of 2.8 days (95% CI: 2.6-3.1), while regular transfers had an effect size of 1.9 days (95% CI: 1.8-2.0). Qualitative findings indicated that atypical transfers are driven by a mixture of co-occurring patient conditions, a lack of bed capacity, and requirements for specialist equipment. Study three reports a further thematic analysis of the focus group findings, detailing four interconnected themes implicated in underlying global patterns of patient movement: communication and information flow, creating capacity, system interactions and Covid-19.
Taking a broader perspective, Study four and five explored two potential avenues for hospital reorganisation. Study four used network analysis to identify unexpected communities of wards, suggesting an alternative configuration of a hospital which would reduce the number of atypical transfers, as well as transfers across different buildings. Lastly, Study 5 leveraged the conditions created by the Covid-19 pandemic to explore the potential impacts of virtual care on information flow, as an increasing number of services look to expand telemedicine capacity.
Conclusion: Collectively, these findings provide healthcare professionals and decision-makers with a greater understanding of the impact of patient movement, and the interconnected and complex elements which must be considered when organising hospital care.
Methods and Results: A multi-method approach was taken, comprising five original studies in the United Kingdom's (UK) National Health Service (NHS). Study one uses electronic health record (EHR) data from patient spells spanning three years to understand the impact of transfers on hospital-acquired infection (HAI), reporting that each additional transfer increased the odds of developing a HAI increase by 9%. Building on this, Study two uses a mixed-methods approach to differentiate transfers, defining regular, site and atypical transfers, and understand their impacts. Each atypical transfer resulted in an estimated increase in average length of stay of 2.8 days (95% CI: 2.6-3.1), while regular transfers had an effect size of 1.9 days (95% CI: 1.8-2.0). Qualitative findings indicated that atypical transfers are driven by a mixture of co-occurring patient conditions, a lack of bed capacity, and requirements for specialist equipment. Study three reports a further thematic analysis of the focus group findings, detailing four interconnected themes implicated in underlying global patterns of patient movement: communication and information flow, creating capacity, system interactions and Covid-19.
Taking a broader perspective, Study four and five explored two potential avenues for hospital reorganisation. Study four used network analysis to identify unexpected communities of wards, suggesting an alternative configuration of a hospital which would reduce the number of atypical transfers, as well as transfers across different buildings. Lastly, Study 5 leveraged the conditions created by the Covid-19 pandemic to explore the potential impacts of virtual care on information flow, as an increasing number of services look to expand telemedicine capacity.
Conclusion: Collectively, these findings provide healthcare professionals and decision-makers with a greater understanding of the impact of patient movement, and the interconnected and complex elements which must be considered when organising hospital care.
Version
Open Access
Date Issued
2023-07-06
Date Awarded
2024-02-01
Copyright Statement
Creative Commons Attribution NonCommercial Licence
License URL
Advisor
Costelloe, Ceire
Expert, Paul
Sponsor
London Interdisciplinary Social Science Doctoral Training Partnership
Economic and Social Research Council (Great Britain)
Grant Number
ES/P000703/1
Publisher Department
School of Public Health
Publisher Institution
Imperial College London
Qualification Level
Doctoral
Qualification Name
Doctor of Philosophy (PhD)