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Discussion
In this preintervention and postintervention comparative study using SUS data, the findings indicate that introduction of the Bradford Command Centre may have improved patient safety. However, given improvements in mortality have also been observed in the CHH (control site) during the same period, improvements seen in the BRI hospital data may not be entirely due to the command centre. In addition, there was no significant difference between preintervention and postintervention periods linked to only the technological components of the command centre system.
Hospital command centres are expected to improve the management of patient flow by making use of real-time monitoring of patients. It is hypothesised that this improved patient flow is beneficial for patient safety. However, in our related work,21 we found that measures of patient flow did not indicate improvements at the BRI site during the study period. This suggests that patient flow may not be primarily responsible for the improvements. Given also that similar improvements were seen at our control site, it could be that the changes observed by our measures of patient safety were due to nationwide responses to the COVID-19 pandemic or some other within-hospital factors that we did not measure. The impact of command centres on patient safety in complex multiple department hospitals is rarely reported in the literature, mainly due to the novelty of this type of initiative in acute care. A recent report from Saudi National Health Command Centre (NHCC) indicated that emergency admissions mortality was below 2%.6 The mortality rate reported by the authors agrees with our findings of this study. What must be noted though is that the NHCC is a hub at a national level and its report appears to have compared pre-COVID-19 and post-COVID-19 pandemic data. On the other hand, the Bradford command centre is a single trust hospital and our study has compared preintervention period data against the multistage postintervention data, which included the prepandemic and postpandemic period.
Our study has certain limitations. First, health service delivery was significantly affected by the COVID-19 pandemic resulting in rapid systemwide effects, which may have impacted on the population of patients and capacity management in both hospitals. Cancellation and postponement of surgical operations were common due to reallocation of resources during the peaks of the pandemic. Although we attempted to control for the effects of the pandemic in our time series models, the proximity of the activation of the command centre with the onset of the pandemic surge makes it difficult to isolate the effect of the intervention or control for the pandemic without masking potential variation.
Second, apart from the command centre, it has been assumed that the intervention site (BRI hospital) and control site (CHH) are equivalent in other factors, which may not necessarily be the case. The control site showed considerably higher initial mortality which might have led to subsequent reduction in mortality rates or local interventions to reduce mortality, acting as a confounding factor in attempts to isolate the effect of the command centre intervention. Readmission rates additionally showed widely different trends between the study and control site.
Another potential limitation of the study concerns the focus of this quantitative evaluation on a small number of outcome indicators for what was a system-wide initiative designed to impact many areas. Although informing our intervention models using qualitative research at the study site is a strength in our design, qualitative investigation additionally revealed the complexity of this type of intervention and the challenges of implementation within a pressured acute care environment. This may have influenced the study outcome in a number of ways. Staff recall of the historical implementation timeline was variable (especially for piloting and roll-in of intervention components, including organisational in addition to technological elements). There were suggestions that colocation of staff in the command centre room preceded the roll-in and activation phase for command centre displays, so the team may have already been established and coordinating functions sooner than the intervention timeline suggests, leading to under specification of our model. When considering the challenges observed in implementing the technological aspects of the intervention, including data quality, there may have been significant time lag between activation of components and any impact on patient safety outcomes. Given the complexity in our intervention model, we did not seek to control for lagged effects of intervention implementation (the time it takes for an intervention to start to influence detectable outcomes). Rather, we presumed that the effects of the intervention components were instantaneous.
Finally, due to data access limitations, we were not able to explore all outcomes identified for analysis in our study protocol. Hence, evaluation is needed, across multiple healthcare systems and command centre models, to understand how this type of intervention impacts downstream patient safety outcomes.
Nonetheless, the strengths of the study are threefold. First, we have used a large sample size for the analyses: a total of inpatient 203 807 inpatient visits and 34 625 surgical operations. Second, the use of electronic health record data minimises the inherent biases and errors in other types of observational data. Third, we employed a robust quasi-experimental design using repeated time series measurement.
In conclusion, the results of the study indicate that a digital hospital command centre package that includes both technological (data display) elements and organisational components may have a marginal positive impact on some patient safety outcomes. However, patient safety improvements in the control site hospital suggest that it may not entirely be due to the introduction of the command centre. In addition, when the technology alone was considered as the intervention (command centre display roll-in and command centre activation), it does not appear to have a significant impact on patient safety outcomes. Thus, further research using data from other hospital organisations that use command centres is warranted.
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