[Patient referral and patient volume in a regional hospital]

BACKGROUND

A general trend in health care is the increasing discrepancy between resources available and the volume of patients treated. Few studies have looked at a reduction in patient referral as a possible explanation for this situation.

MATERIAL AND METHODS

The volume of hospital admissions and outpatient care 1996 through 2000 at a large regional hospital was related to the number of referrals over the same period.

RESULTS

There was an overall increase in patient admissions as well as in outpatient care during the study period. However, while the number of new referrals seen as outpatients dropped by 1.2%, the number of patients in for controls increased by 27.1%. While some departments had an increase in both admissions and new outpatients, other departments had a dramatic decrease in new patient contacts but total patient volume was maintained by a comparable increase in control consultations. At the same time, there was a 15.1% overall drop in new patient referrals (new referrals for admissions down 44.4%, new referrals for outpatient care down 11.4%), in some departments even more.

INTERPRETATION

The study shows that patient demand for hospital care is not unlimited and should also be considered when more resources allocated to hospitals do not result in increased patient volume.

Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation

BACKGROUND

UK recommendations suggest that large neonatal intensive-care units (NICUs) have better outcomes than small units, although this suggestion remains unproven. We assessed whether patient volume, staffing levels, and workload are associated with risk-adjusted outcomes, and with costs or staff wellbeing.

METHODS

186 UK NICUs were stratified according to volume of patients, nursing provision, and neonatal consultant provision. Primary outcomes were hospital mortality, mortality or cerebral damage, and nosocomial bacteraemia. We studied 13515 infants of all birthweights consecutively admitted to 54 randomly selected NICUs. Multiple logistic regression analyses were done with every primary outcome as the dependent variable. Staff wellbeing and stress were assessed by anonymous mental health index (MHI)-5 questionnaires.

FINDINGS

Data were available for 13334 (99%) infants. High-volume NICUs treated the sickest infants and had highest crude mortality. Risk-adjusted mortality and mortality or cerebral damage were unrelated to patient volume or staffing provision; however, nosocomial bacteraemia was less frequent in NICUs with low neonatal consultant provision (odds ratio 0.65, 95% CI 0.43-0.98). Mortality was raised with increasing workload in all types of NICUs. Infants admitted at full capacity versus half capacity were about 50% more likely to die, but there was wide uncertainty around this estimate. Most staff had MHI-5 scores that suggested good mental health.

INTERPRETATION

The implications of this report for staffing policy, medicolegal risk management, and ethical practice remain to be tested. Centralisation of only the sickest infants could improve efficiency, provided that this does not create excessive workload for staff. Assessment of increased staffing levels that are closer to those in adult intensive care might be appropriate.

Seasonal variation in admission rates to intensive care units

Intensive care physicians perceive that there is seasonal variation in the number of admissions to critical care services. There is, however, little published evidence to support this belief. Data were therefore collected from five adjacent critical care units in the eastern region over a period of 8 years, in order to quantify any seasonal variation that may exist. Data on 16 355 critically ill patients were obtained between 1992 and 2000. Analysis showed clear winter peaks; December had a 30% higher admission rate than the quietest month, February. There was a small, but increasing, summer peak. The admission rate also exhibits an increasing linear trend, equivalent to a 6.6% annual increase in admissions per critical care bed. We conclude that there is significant seasonal variation in critical care activity, and that this is important to consider when planning services.

Organisational implications of concentration orthopaedic services

The re-organisation of the acute health services in 1999 is causing many acute trusts to consider the practical implications of concentrating services. This may be in terms of the complete merger of departments at different units or a less radical policy of the alternation of the responsibility for emergency receiving between units. The benefits may include the opportunity to improve the quality of care by providing more specialist services, more attractive working conditions with a larger pool of specialists providing the on-call rota and enhanced opportunity for training. Economic theory indicates that concentration should lead to economies of scale by greater sharing of fixed overhead costs, whilst statistical theory specifies that concentration should produce a relative decline in the variability of demand. This paper examines the effects of concentration on emergency admissions in an orthopaedic department by means of a series of simulation experiments. It examines the potential economies of scale for theatre utilisation and bed usage associated with increasing the volume of non-elective patients. As the volume of patients increases so the relative variability of demand decreases and the relative demand for emergency operating theatre time declines. Concentration could offer savings on theatre time allocated to trauma patients, but the impact on wards is less significant with concentration having a limited effect on the demand for beds.

Marital status and bed occupancy in health and social care facilities in the United Kingdom

The purpose of the study was to test the hypothesis that marriage and physical health are positively related.A secondary analysis was performed of census data on all individuals aged 15 y and over occupying beds in general health and social care facilities (excluding mental health) in England and Wales, Scotland, and Northern Ireland in 1971, 1981 and 1991. Using bed occupancy in health and social care facilities as a proxy for ill health, this paper investigates the relationship between marital status and physical health in the United Kingdom. The findings, expressed as the proportion of individuals (excluding staff and visitors) aged 15 y and over within these facilities, suggest that: a) Whether considered separately or together, married men and women are healthier than non-married men and women, as reflected in their much lower use of health and social care beds; b) This positive relationship between marriage and health has increased steadily since the 1970s; c) Within the non-married population, whereas the single are most at risk among men, the widowed are most at risk among women; d) In contrast to the married and widowed, there are some consistent age-specific gender differences among the divorced and single, with men of working age at much higher risk than women of working age. This study confirms research findings elsewhere that marriage and physical health are positively related. Throughout the United Kingdom, not only are married people healthier than non-married people, as reflected in their much lower use of health and social care beds, but this relationship holds irrespective of gender.

Appropriateness of bed usage for inpatients admitted as emergencies to internal medicine services

OBJECTIVE

To establish the appropriateness of bed usage for acute care within the medical directorates of two district general hospitals using a validated assessment tool, the Emergency Admission Review (EAR). This tool assesses the appropriateness of day of care against strict criteria and allows classification of care as either acute or non-acute.

DESIGN

Prospectively, 200 medical emergency admissions, 100 in each of the hospitals, were selected. Following identification patients were assessed every two days during the first fortnight of admission or until discharge. Those patients staying longer than two weeks were then assessed weekly until conclusion of the audit period or discharge whichever was reached first.

SETTING

The medical directorates of two District General Hospitals within one acute NHS trust.

SUBJECTS

All patients admitted as medical emergencies, who were 14 years or older and had a length of stay of 24 hours or more.

RESULTS

A total of 787 acute in-patient bed days were analysed in Hospital A of which 363 (46%) were deemed inappropriate for acute care. In Hospital B 810 bed days were analysed and 44% (363) were deemed inappropriate. In Hospital A the most common reason for bed-days not meeting the acute care criteria was short-term waiting, accounting for 60% (217 days) of the total bed days deemed non-acute. In Hospital B the most common reason for patients receiving non-acute care was that they were having active rehabilitation. This accounted for 29% (105 days) of the total number of non-acute care days. In Hospital B three patients accounted for 28% of the total occupied bed days.

CONCLUSIONS

The use of the EAR is a systematic and objective approach to the assessment of appropriateness of acute care. It applies strict criteria to determine the reason for a patient's continued hospital stay. From the results it is clear that a significant proportion of medical emergency admissions in both Hospital A and B remain in hospital for care that is deemed non-acute and therefore in theory could be performed in another setting. This information has significant potential in identifying the opportunities for streamlining services within hospitals to reduce short-term delays and also to inform the development of intermediate care services both within and outwith the acute hospital setting.

Audit of orthopaedic bed utilisation

Blockage of beds on an orthopaedic ward causes multiple problems; it can result in cancellation of patients or elective surgery, longer waiting lists and a crisis with emergency admissions. This often necessitates 'boarding out' of patients, which is not ideal for optimal patient care. Not all patients on an orthopaedic ward need continuing orthopaedic medical or nursing care and it may be more appropriate for these patients to be managed in a rehabilitation environment. From 1/09/98-30/11/98 data were collected on all patients admitted to an adult orthopaedic ward. Information recorded included the reason for admission, age, diagnosis, surgical procedure, family and social circumstances. In addition, the date when discharge was deemed appropriate was recorded as well as the actual date of discharge. We defined the length of overstay as the time spent in an orthopaedic bed after discharge had been deemed appropriate. There were 621 patients admitted for a total of 3159 bed days. There were 253 elective admissions and 368 emergency admissions. A total of 255 bed days were blocked by 46 patients (41 emergency and 5 elective) accounting for eight per cent of the total bed days. Of these 236 (93%) were due to emergency admissions and 19 (7%) were due to elective admissions, most blocked beds were due to patients who required rehabilitation in either a unit for the young disabled or a geriatric rehabilitation ward.

Elderly patients must not be victims of shortages

The Government has announced that it intends to end hospital ‘bed-blocking’ by 2004. It aims to achieve this goal through a £300m agreement with councils and the independent sector that they will place older people in residential and nursing care homes, and provide intensive home care and intermediate care. The initial target is that by 2002 no more than 10% of older people will be occupying an acute hospital bed.

Changes in the profile of paediatric intensive care associated with centralisation

OBJECTIVES

To compare intensive care admissions from a defined population of children in 1991 and 1999, during a period of organisational change and centralisation of paediatric intensive care.

DESIGN

Two 12-month population-based audits were compared. Data were collected from hospitals in Birmingham and the surrounding districts. Denominator data were obtained from the Office for National Statistics. The place and rate of intensive care admission, the use of mechanical ventilation at admission, mortality and length of stay were compared.

SETTING

Hospitals in the West Midlands.

PARTICIPANTS

All children (<15 yrs) living in Birmingham who received intensive care during the study periods.

MEASUREMENTS AND RESULTS

The number of Birmingham resident children admitted for intensive care increased from 277 to 510 (p<0.0001) i.e. from 1.3 to 2.3 admissions per 1,000 children per year. The proportion of admissions to the principal paediatric intensive care unit increased from 60% to 90% (p<0.0001) in association with its expansion from 6 to 18 beds. Length of ICU stay decreased from 103 to 74 h (difference 29 h, 95%CI, 4.78-54.2 h, p=0.0117). Child mortality fell over this period by 34 deaths per 100,000 children (95%CI 16-51, p<0.0001). The proportion of children requiring mechanical ventilation at admission to intensive care was unchanged.

CONCLUSIONS

Centralisation by expansion of the lead centre was associated with a large increase in the numbers of children receiving intensive care consistent with an unmet need for paediatric intensive care in 1991, which may still exist. Centralisation of paediatric intensive care may have contributed to the fall in child mortality over this time period.

Home care and the reshaping of acute hospitals in England. An overview of problems and possibilities

A changing boundary between hospital and home-care services over two decades has taken place enabling people to live in their own homes wherever possible, enabling "choice of independence". Against this background, five principal issues are raised regarding how hospital services have been reshaped over that time and how the pattern of service developments outside the hospital has altered over the same period.

Changing patterns of hospital admission for asthma, 1981-97

BACKGROUND

Hospital admission rates for asthma have stopped rising in several countries. The aim of this study was to use linked hospital admission data to explore recent trends in asthma admissions in Scotland.

METHODS

Linked Scottish Morbidity Records (SMR1) for asthma (ICD-9 493 and ICD-10 J45-6) from 1981 to 1997 were used to describe rates of first admissions and readmissions by age and sex. As a measure of resource use, annual trends in bed days used were also explored by age and sex.

RESULTS

There were 160 039 hospital admissions for asthma by 82 421 individuals in Scotland during the study period. The overall hospital admission rate increased by 122% (from 106.7 to 236.7 per 100 000 population) but this varied by sex, age, and admission type. First admissions rose by 70% from 73.2 per 100 000 in 1986 to 124.8 per 100 000 in 1997 while readmissions fell. Children (<15 years) experienced a decline in overall admissions after 1992 due to falls in both new admissions and readmissions. By 1997 the ratio of female to male admissions was 0.57 in children, but 1.50 above 14 years of age. Mean lengths of stay fell from 10.7 days to 3.7 days between 1981 and 1997 and bed days used showed little change except for a decline after 1992 in children.

CONCLUSIONS

After a period of increasing hospitalisation for asthma in Scotland, rates of admission among children have begun to fall but among adults admissions continue to rise.

Recent trends in hospital use by children in England

BACKGROUND

Routine hospital statistics for England appear to overestimate use of children's wards and include numbers of well newborn babies staying with their mothers after delivery ("well babies").

AIM

To review trends in use of children's wards excluding data on newborn babies.

METHODS

We reviewed routine, published, and age stratified data requested from the Department of Health to identify separately "well babies" and babies receiving neonatal specialist care from admissions (surgical and paediatric) to children's wards.

RESULTS

Routine reports for paediatric activity contain large numbers of "well babies", (almost half the total) as well as babies receiving specialist neonatal care. After excluding these, paediatric admissions represent 9.9% of the child population aged under 5 years each year (an additional 2.5% are admitted for surgical care). Between 1989 and 1997 paediatric admissions rose by 19% and surgical admissions fell by 25% with a plateau reached in overall child admissions. There are now fewer beds in which children stay for a shorter time and there is more day case surgery. Neonatal specialist care work has risen despite a fall in births.

CONCLUSION

Categories should be established for reporting paediatric episodes on children's wards separately from those on neonatal units, with better identification of "well babies". When monitoring use of children's inpatient facilities or planning new units, care must be taken to separate paediatric data on neonatal units from work on children's wards. Children's surgical episodes should also be taken into account.

Prospective evaluation of patients refused admission to an intensive care unit: triage, futility and outcome

OBJECTIVES

To evaluate factors associated with decisions to refuse ICU admission and to assess the outcome of refused patients.

DESIGN AND SETTING

Prospective, descriptive evaluation in a multi-disciplinary intensive care unit, university referral hospital.

PATIENTS AND PARTICIPANTS

All adult emergency referrals over a 7-month period.

INTERVENTIONS

The number of beds available at the time of referral, the patient's age, gender, diagnosis, mortality probability model score and hospital survival were documented. The outcome of the referral and the reason for refusal were recorded.

MEASUREMENTS AND RESULTS

Of 624 patients 388 were admitted and 236 (38%) refused. Reasons for refusal were triage (n=104), futility (n=82) and inappropriate referral (too well; n=50). The standardised mortality ratio (SMR) for refused and admitted groups was 1.24 (95% CI 1.05-1.46) and 0.93 (0.78-1.09) respectively. The SMR ratio (refused SMR/admitted SMR) was highest in the middle range of illness (1.95, 1.19-3.20). Inappropriate referrals had a better than expected outcome despite refusal, with a SMR ratio of 0.39 (0.11-0.99). Excluding inappropriate referrals, multivariate analysis demonstrated that refusal was associated with older age, diagnostic group and severity of illness. Triage decisions were associated with a diagnosis of sepsis, and futility decisions with greater severity of illness and recent cardiac arrest.

CONCLUSIONS

Refusal of admission to our ICU is common. Excess mortality of patients refused is most marked in the middle range of severity of illness. Age, diagnostic group, and severity of illness are important in decision making. Strategies should be developed to create admission criteria that would identify patients in the middle range of severity of illness who should benefit most from ICU care.

Does investor ownership of nursing homes compromise the quality of care?

OBJECTIVES

Two thirds of nursing homes are investor owned. This study examined whether investor ownership affects quality.

METHODS

We analyzed 1998 data from state inspections of 13,693 nursing facilities. We used a multivariate model and controlled for case mix, facility characteristics, and location.

RESULTS

Investor-owned facilities averaged 5.89 deficiencies per home, 46.5% higher than nonprofit facilities and 43.0% higher than public facilities. In multivariate analysis, investor ownership predicted 0.679 additional deficiencies per home; chain ownership predicted an additional 0.633 deficiencies. Nurse staffing was lower at investor-owned nursing homes.

CONCLUSIONS

Investor-owned nursing homes provide worse care and less nursing care than do not-for-profit or public homes.

Hospital-at-home

Hospital-at-home schemes are becoming an increasingly popular way of delivering health care world-wide. Schemes differ in the type of patients they cater for and in the intensity and complexity of treatment they provide. Although they have been in existence since 1961, there have been few randomized controlled studies to determine their effectiveness as an alternative to standard hospital care. Furthermore, some studies have produced conflicting results. Although there is accumulating evidence that they produce satisfactory patient outcomes and are acceptable to patients and carers, their cost-effectiveness is still uncertain. Further randomized controlled studies incorporating prospective cost analyses are needed. This paper discusses the evidence to support hospital-at-home as an alternative and complementary model of health care particularly for older people.

Strategies for cutting hospital beds: the impact on patient service

OBJECTIVE

To develop insights on the impact of size, average length of stay, variability, and organization of clinical services on the relationship between occupancy rates and delays for beds.

DATA SOURCES

The primary data source was Beth Israel Deaconess Medical Center in Boston. Secondary data were obtained from the United Hospital Fund of New York reflecting data from about 150 hospitals.

STUDY DESIGN

Data from Beth Israel Deaconess on discharges and length of stay were analyzed and fit into appropriate queueing models to generate tables and graphs illustrating the relationship between the variables mentioned above and the relationship between occupancy levels and delays. In addition, specific issues of current concern to hospital administrators were analyzed, including the impact of consolidation of clinical services and utilizing hospital beds uniformly across seven days a week rather than five.

PRINCIPAL FINDINGS

Using target occupancy levels as the primary determinant of bed capacity is inadequate and may lead to excessive delays for beds. Also, attempts to reduce hospital beds by consolidation of different clinical services into single nursing units may be counterproductive.

CONCLUSIONS

More sophisticated methodologies are needed to support decisions that involve bed capacity and organization in order to understand the impact on patient service.

Managing health care variability to achieve quality care

While much has been written about variation and health care, one area that has received little attention is variation within hospitals related to the operations management--which can lead to wasted money and human resources. Two Boston researchers who have been studying this area say that addressing these variations--and using techniques found in other major industries across the country--could give hospitals a new tool in addressing patient safety issues, nursing shortages, cost containment, and overall better quality of care.