Clinical decision units: A new development for emergency medicine in the United Kingdom

Emergency medicine in the United Kingdom is in the midst of significant change and increasing demand. Admissions to the in-hospital bed base cause significant pressure on emergency departments (ED) which face increasing congestion. In Leeds, a city with a population of approximately 800 000, there has been a 15.9% increase in medical admissions over the past 10 years. This is in keeping with other developed countries whose emergency care systems are also being stretched to the limit.1,2 Recently, Government attention in the UK has been focused particularly on this increasing volume of unscheduled care. 'The National Health Service (NHS) Plan' and 'Reforming Emergency Care' both set standards for processes of care in ED. They suggest potential solutions to encourage the development of new schemes to try to control the increasing numbers of medical admissions.3,4 The problems are best seen as a failure in the overall system with inadequacies in the bed base (bed occupancy levels are frequently in excess of 95%), inefficiencies in the way patients are managed within the ED and difficulty in accessing safe discharge, contributing to the systems failure.5 Until now there have been few clearly defined strategies from within the ED to provide a system solution to help in some way in solving these problems.

A nurse-led outpatient service for patients with DVT

The traditional management of patients with suspected deep vein thrombosis required hospital admission for diagnostic investigation and anti-coagulation therapy. Since November 2001 all patients with suspected DVT at Tameside and Glossop Acute Services NHS Trust have been managed as outpatients via the vascular studies unit according to agreed protocols. Audit results have shown that the service has resulted in a reduction in bed occupancy for patients with a sole diagnosis of DVT, and a reduction in the cost of managing and treating patients with a suspected DVT.

Beds Simulator 1.0: a software for the modelisation of the number of beds required for a hospital department

The determination of the number of beds needed for a hospital department is a complex problem that try to take into account efficiency, forecasting of needs, appropriateness of stays. Health authority used methods based on ratios that do not take into account local specificities and use rather to support an economic decision. On the other side, the models developed are too specific to be applied to all type of hospital department. Moreover, all the solutions depend on the LoS (Length of Stay). We have developed a non parametric method to solve this problem. This modelisation was successfully tested in teaching and non teaching hospitals, for an Intensive Care Unit, two Internal Medicine and a surgical departments. A software easy to use was developed, working on Windows available on our website www.sante.univ-nantes.fr/med/stat/.

Delays in implementing admission orders for critical care patients associated with length of stay in emergency departments in six mid-Atlantic states

INTRODUCTION

Every day many admitted patients wait in emergency departments for available beds or for a receiving nurse to accomplish a transfer to an inpatient bed. The purpose of this study was to examine critical care patients' length of stay and time held in the emergency department once admitted to determine if (1) holding critical care patients in emergency departments after admission was related to skilled nursing shortages and/or limitations in available resources and (2) admission orders or tests may have been overlooked during this time. Little or no literature exists on this topic.

METHODS

A Likert scale survey designed to yield descriptive comparative correlational data was sent to directors of critical care and emergency service areas.

RESULTS

Received responses totaled 109. There is a positive correlation between increased length of stay and delays in implementation of admission orders while in emergency departments and tests missed or delayed upon arrival at the critical care unit. A majority of respondents indicated that ED nursing staff had responsibility for critical care admitted patients and other patients. Few indicated a formal process or committee was in place to address this issue specific to critical care patients. Limitations included a convenience sample and variations in operations related to size, location, and culture.

DISCUSSION

Further study is necessary to determine whether patients' length of stay in the hospital is increased because of delays in plans of care and if patient outcomes are ultimately affected.

Using a queueing model to help plan bed allocation in a department of geriatric medicine

By integrating queuing theory and compartmental models of flow we demonstrate how changing admission rates, length of stay and bed allocation influence bed occupancy, emptiness and rejection in departments of geriatric medicine. By extending the model to include waiting beds, we show how the provision of extra, emergency use, unstaffed, back up beds could improve performance while controlling costs. The model is applicable to all lengths of stay, admission rates and bed allocations. The results show why 10-15% bed emptiness is necessary to maintain service efficiency and demonstrate how unstaffed beds can serve to provide a more responsive and cost effective service. Further work is needed to test the validity and applicability of the model.

Bed blocking: fining councils is not the answer

A relative of mine has recently joined the much-maligned ranks of the so-called ‘bed blockers’. Three weeks after falling in her residential home and banging her head, she is still in hospital because the residential home cannot take her back (she has rapidly accelerating Alzheimer’s), and no nursing home place can be found. She cannot be cared for at home, because her home has been sold to pay for her care fees. There is allegedly a 6-month waiting list for the best nursing homes in the area, raising the prospect of a lengthy stay in hospital.

[Neonatal and pediatric intensive care in Rio de Janeiro: distribution of beds and analysis of equity]

OBJECTIVES

To identify the pediatric ICUs at Rio de Janeiro, number of beds, geographical distribution, public or private nature, type of hospital and assistance, studying population demand and to propose measures for improving equity.

METHODS

All ICUs of the State were visited from July 97 to June 98, identifying number of beds and average length of stay. With this information along with demographic data from IBGE, the necessity of beds were estimated, comparing availability and demand by region, and proposing improving equity strategies.

RESULTS

80 ICUs were identified (6 excluded), totaling 1080 beds; 60% intensive and 40% semi-intensive; 57% public and 43% private; 52% in exclusive neonatal ICUs; 14% in pediatric and 34% in mixed (65% neonatal beds), totaling 791 neonatal beds (73%). The majority of ICUs (75%) were part of general hospitals, 20% were in obstetric or obstetric-pediatric hospitals, and only 5% were part of university centers; the majority were in metropolitan area (89%), with 93% of beds for 74% of state children population, of whom, the majority were in Rio de Janeiro city (76%), with 73% of beds for 37% of population, contrasting with the inner of the State, with only 8 units (11%) and 79 beds (7%) for 26% of children.

CONCLUSIONS

There is no equity in the distribution and accessibility to the available beds, with lack in public and excess in private sectors, a great concentration in the metropolitan area and only 5% of ICUs at university hospitals, recommending a policy of redistribution and allocation of new beds in more needy areas, associated with the creation of an admission center along with an efficient reference and transportation system.

Striving towards efficiency in the Greek hospitals by reviewing case mix classifications

In order to verify the efficiency level of Greek public hospitals, this paper evaluates the most recent indicators. Relevant data were collected from the two following databases: (a) hospitals' utilisation data generally and per clinical speciality [Ministry of Health, Athens, (Data based) 1995]; (b) Patients' and hospitals' characteristics per diagnosis [National Statistical Office, Athens, (Data based) 1993]. As explanatory variables, the study examines supply and demand factors following case mix classifications. Firstly, average length of stay (ALOS) and secondly, cost per case were regressed as dependent variables. The study highlights the extent of variability across hospitals for different groups of patients with the same condition. The results specify the most important factors that affect ALOS and cost pertaining to efficiency. Per speciality analysis shows occupancy, size-type of the hospital, beds and doctors per speciality, access and use of outpatient services, and surgical operations, etc. as the most significant factors. Per disease-diagnosis analysis shows age of over 65 years, gender, residence, marital status, surgical operation and insurance as the most important factors. General cost analysis in all National Health Systems (NHS) hospitals shows that economies of scale appear in: (a) district and/or specialised hospitals of 250-400 beds; (b) regional and/or teaching hospitals of over but near to 400 beds. Consequently, the author determines the 'Greek' Diagnostic Related Groups (DRGs), based on the cost per clinical speciality in the nine basic specialities and on the cost per diagnosis of the top 15 diagnoses. Further to the scientific results, such studies will enhance much necessary discussions on the organisation of service delivery and financing, by following case mix classification.

[Evaluation of the efficiency of use of the bed fund of a central district hospital]

The paper deals with a complex sociohygienic study of the basic indices of resource provision of the public health system in the Tver Region and with an analysis of the scope of inpatient care to the population of the Torzhok District, Tver Region. Based on an in-depth examination, the efficiency of the use of the bed fund of the central district hospital (CDH) was evaluated and economic losses from inadequate use of beds and economic effects of work of daily CDH-based hospitals were calculated.

The impact of managed care penetration and hospital quality on efficiency in hospital staffing

The state of California has recently mandated minimum nurse-staffing ratios, raising concerns about possible affects on hospital efficiency. In this study, we examine how market factors and quality were related to staffing levels in California hospitals in 1995 (prior to implementation of the new law). We are particularly interested in the affect of managed care penetration on this aspect of hospital efficiency because the call to legislative action was predicated on fears that hospitals were reducing staffing below optimal levels in response to managed care pressures. We derive a unique measure of excess staffing in hospitals based on a data envelopment analysis (DEA) production function model, which explicitly includes ancillary care among the inputs and outputs. This careful specification of production is important because ancillary care use has risen relative to daily hospital services, with the spread of managed care and advances in medical technology. We find that market share (adjusted for size) and market concentration are the major determinants of excess staffing while managed care penetration is insignificant. We also find that poor quality (outcomes worse than expected) is associated with less efficient staffing. These findings suggest that the larger, more efficient urban hospitals will be penalized more heavily under binding staffing ratios than smaller, less-urban hospitals.

Assessing critical care unit performance: a global measure using graphical analysis

Outcome measurement in critical care is difficult because of the wide variety of patients treated and the diverse therapeutic options and pathways available. Individual outcome measures for critical care are available but are naturally limited to only a single aspect of performance. Most importantly, better performance in one aspect of care may compromise the standard of care in another. A global measure of performance would be helpful. For the year 1999-2000, the five hospitals in the East Anglian Critical Care Network provided data on capacity, workload and performance. The data was transformed and displayed graphically on a radar chart so that the area of the polygon within the radar chart was proportional to each unit's overall performance. The results from the five hospitals suggest that there is little overall difference in the units' global performance but the graphical representation highlighted some individual deficiencies. Graphical analysis of complex processes such as critical care delivery may facilitate performance assessment, providing that the measures chosen, weightings assigned and scales used are standardised with care.

Maternal morbidity and pregnancy outcome in a cohort of mothers transferred out of perinatal centres during a national census

OBJECTIVE

To record the maternal morbidity and pregnancy outcome in this cohort.

DESIGN

Retrospective data collection from a prospectively defined cohort.

SETTING

The 37 largest perinatal centres in the UK.

POPULATION

258 in utero transfers recorded during a three-month census (1/4/99-30/6/99).

METHODS

A questionnaire regarding the outcome of each mother was sent to the perinatal centre and receiving hospital.

RESULTS

Data were returned on 242/258 (94%) mothers. Fifty-eight percent were transferred out of their perinatal centre in preterm labour and 38% had coexisting disease necessitating early delivery. The median gestational age at transfer was 32 weeks (range 23-41). Sixty-one percent delivered at the receiving hospital; 12% were transferred on to a third hospital and 29% ultimately returned to deliver at the original perinatal centre. Fifty-two percent of mothers received postnatal care in hospitals other than those defined as a major perinatal centre. One mother delivered during transfer and a further nine within one hour of arrival. One mother received intensive care after delivery and later died, a further 7% required high dependency care postnatally. Data were available on 273/333 (82%) babies. The median gestational age at delivery was 34 weeks (range 24-41). Six infants were stillborn and 187/264 (71%) infants were admitted to a neonatal unit.

CONCLUSIONS

This study has documented the maternal morbidity, potential risks and pregnancy outcome of a cohort of mothers transferred out of the largest perinatal centres in the UK because of a shortage of neonatal cots. A national standard for the delivery of high risk perinatal services is needed to uphold good clinical practice guidelines in the care of high risk mothers and their infants.

Bed-blocking. Acute distress

A study of bed occupancy in 21 hospitals over the past two years showed an average of 29 per cent of patients no longer needed acute care. Two-thirds of this group had been in hospital for more than 28 days. About a fifth of this group were under 65. The main reasons for delayed discharges were waits for social services assessment or home-care packages.

An evaluation of bed management in a rural hospital adjacent to Indo-Nepal border in West Bengal

Bed management is one of the important activities for efficient hospital management. The present study on evaluation of bed management in a rural hospital revealed that the total bed capacity could not be utilised. The turnover rate, turnover interval, bed occupancy rate and average length of stay were closely corroborating.

The postanaesthesia care unit as a temporary admission location due to intensive care and ward overflow

BACKGROUND

With the increasing number of critically ill patients, and shortage of intensive care unit and ward beds, some postoperative patients stay for an unnecessarily long period in the postanaesthesia care unit (PACU), until a suitable bed is available.

METHODS

We prospectively studied this patient overflow admission to the PACU over 33 months. Four hundred patients with a mean age of 53.1 yr (range 0.2-94) were studied. Two hundred and eighty one (70.3%) patients were mechanically ventilated on admission to the PACU and 311 (77.8%) had invasive monitoring. Mean length of stay in the PACU was 12.9 (SD 10.6) h.

RESULTS

The busiest hours of admission were 01-11 am. Eighteen (4.5%) patients died in the PACU, while waiting for an intensive care unit bed. The main problems were insufficient medical and nursing coverage, and inadequate communication and visiting facilities for patient's families.

CONCLUSION

Patient overflow to the PACU is a common problem that requires attention. Guidelines for medical and nursing coverage, patient triage, and communication with relatives need to be outlined.

Use of acute hospital beds does not increase as the population ages: results from a seven year cohort study in Germany

OBJECTIVES

(1) To compare the number of hospital days used by survivors with those by persons in their last, second last, and third last year of life in relation to age; (2) to analyse lifelong hospital utilisation in relation to life expectancy.

DESIGN

Cohort study using a 10% sample (stratified by age and sex) of persons insured by one sickness fund.

SETTING

Germany, 1989-1995.

SUBJECTS

69,847 survivors (with a minimum of three more years to live), 1385 persons in last, 1368 in second last, and 1333 in third last year of life.

RESULTS

The number of days spent in hospital in the last year of life was lowest for the young (24.2 days under age 25) and the old (23.2 days at age 85+) and was greatest at ages 55-64 (40.6 days). The ratio of days to survivors was highest at age 35-44 (31.0) and fell continuously thereafter to 4.3 at age 85+. Similar patterns were seen for hospital days in the second and third year before death, except that peaks were at 35-44 years (22.5 and 13.7 days respectively). Calculated lifelong number of hospital days increased with age from 54.8 (death at age 20) to 201.0 (age 90). Numbers of hospital days per year of life, averaged over the entire lifespan, were stable at 2.0-2.2 for deaths between age 50 and 90 (and up to 2.7 at age 20).

CONCLUSIONS

Lifelong hospital utilisation for persons who die at 50 or later is directly proportional to the number of years lived. These data contradict results from cross sectional studies that suggest an exponential rise in health care costs as longevity increases. They have important implications for projections of future health care expenditure.

Strategies for more efficient performance through hospital merger

This article compares the operating performance of merged and non-merged local hospitals during the late 1980s and early 1990s, a period not unlike that being experienced in hospitals today. A matched case-control design is employed to create "synthetically" merged hospitals--to represent them as if they had effected a merger--and compares their performance to a group of similar hospitals that did merge.