OUtLiers

In statistical terms, an outlier is someone or thing that stands-out from the anticipated range of data or results.

Existing beyond the constraints of a normal distribution for the individual can be awkward – for scientists it can be the basis of a career.

Luria, in his 1967 book, The Mind of the Mnemonist, A.R.Luria described the experiences of S, a man who was unable to forget.

Big or small, fast or slow, aberrations fill the world of natural history making museums, films and narratives interesting.

In the more mundane reality of 21^st Century hospital care, an outlier is someone who is unwell enough to be in hospital but not adequately sick – (or fortunate) to be treated or cared-for in the ward or department of the relevant specialty. These people by and large, exist as second-class citizens, frequently receiving sub-optimal care, treatment and attention; I will elaborate shortly; first an illustrative example:

Muhammad, 91 is admitted to hospital with shortness of breath. He receives the best assessment, investigation and treatment available to Medicine; blood tests, x-rays, the appropriate antibiotics are prescribed for his pneumonia and he is seen within five hours of arriving in hospital by a specialist. Everything is hunky-dory.

Three days later Muhammad is significantly better – no longer dependent on high-flow oxygen; his nebulisers continue and, antibiotics have been switched from intravenous to tablet.

Three in the morning and the hospital runs-out of beds. There is a crisis. Depending on the system or organisation this be – a red, purple or black alert …too many patients are seeking admission for the numbers of beds. (Think ‘the ship cannae take it captain!’ In Star-Trekian).

The norm is for the majority of these additional patients to be both older and experiencing medical causes of ill health – that is, infection, falls, confusion, clots and non-specific pain (although not in the tummy as the surgeons get that).

The pressure builds, beds are needed, and those patients no longer deemed ‘sick’ are stepped-down to non-medical beds; the precious resources of a respiratory ward are required. Muhammad is transferred from chest ward to elective surgery – these are beds that are kept aside to bring-in patients schedule for cancer or other operations.

Muhammad, in the morning wakes and finds that the people surrounding him are no longer ‘medical’ – but, ‘surgical’ – more often attached to drips, drains and other systems of bodily measurement; the ward-rounds are swifter and the nurses more focused.

Mo (let’s call him that), is now a medical outlier – a medical patient on a surgical ward; an unintentional interloper. Not one of us, the body-language says.

Often, such patients are highlighted in a different colour – ‘Mr M A – medical outlier’ – not gall bladder, appendix or spleen; other. The nurses are familiar with the treatment, but the interaction is somehow different – Mo’s measurements are medical not surgical, his pathway not along lines established by mister, but, doctor.

And Dr A, the enthusiastic consultant, after completing his ward round of base ward patients i.e. medical patients on a medical ward will trudge over to surgery to see the outliers. Those additional to surplus, representatives of a failed system, and perhaps just before lunchtime say hello to Mo; tired, the consultant is perhaps a little less attentive – Mo is his 30^th patient of the day, after all. And fin.

Medical patients on outlying surgical or orthopaedic wards experience prolonged lengths of stay, they are exposed to greater risk and have a higher chance of deterioration than those supported on medical wards. _{1, 2,3 & 4}

The solution?

Different places have created different solutions.

In the NHS, the answer would be funding more physicians – ideally geriatricians like me, for the population of the olders is growing at a faster rate than any other. But, no, this isn’t the planning. We stumble-on, slow iterations taking us from here to there.

My mum was once a medical outlier on a surgical ward. It didn’t work for her.

What do you do if you or your mum, dad, sister or brother find themselves outliers, outsiders, strangers in a strange – strange land?

I guess in part, this blog might help – awareness of the problem is part of the solution; realisation that extra care and attention is needed to avoid a secondary experience; beyond this, find those hospitals that invest in quality improvement and innovation, organisations that heed the warning-signs and seek to do better, differently.

Look for a hospital that is person-centred – one where you, or Mo are seen as people not numbers, statistics or disease-codes. And, if you find yourself in a situation where those providing the treatment or care are less informed, perhaps call them out, ask them why, what, how, who; explore their values and motivations.

And get home as fast as you can.

1. Alameda, César, and Carmen Suárez. “Clinical outcomes in medical outliers admitted to hospital with heart failure.” European journal of internal medicine 20.8 (2009): 764-767.
2. Santamaria, John D., et al. “Do outlier inpatients experience more emergency calls in hospital? An observational cohort study.” Med J Aust 200.1 (2014): 45-8.
3. Serafini, Francesco, et al. “Outlier admissions of medical patients: prognostic implications of outlying patients. The experience of the Hospital of Mestre.” Italian Journal of Medicine 9.3 (2015): 299-302.
4. Stylianou N, Fackrell R, Vasilakis C Are medical outliers associated with worse patient outcomes? A retrospective study within a regional NHS hospital using routine data BMJ Open 2017;7:e015676. doi: 10.1136/bmjopen-2016-015676