Health system collapse 45 days after the detection of COVID-19 in Ceará, Northeast Brazil: a preliminary analysis

INTRODUCTION

COVID-19 emerged in late 2019 and quickly became a serious public health problem worldwide. This study aim to describe the epidemiological course of cases and deaths due to COVID-19 and their impact on hospital bed occupancy rates in the first 45 days of the epidemic in the state of Ceará, Northeastern Brazil.

METHODS

The study used an ecological design with data gathered from multiple government and health care sources. Data were analyzed using Epi Info software.

RESULTS

The first cases were confirmed on March 15, 2020. After 45 days, 37,268 cases reported in 85.9% of Ceará's municipalities, with 1,019 deaths. Laboratory test positivity reached 84.8% at the end of April, a period in which more than 700 daily tests were processed. The average age of cases was 67 (<1 - 101) years, most occurred in a hospital environment (91.9%), and 58% required hospitalization in an ICU bed. The average time between the onset of symptoms and death was 18 (1 - 56) days. Patients who died in the hospital had spent an average of six (0 - 40) days hospitalized. Across Ceará, the bed occupancy rate reached 71.3% in the wards and 80.5% in the ICU.

CONCLUSIONS

The first 45 days of the COVID-19 epidemic in Ceará revealed a large number of cases and deaths, spreading initially among the population with a high socioeconomic status. Despite the efforts by the health services and social isolation measures the health system still collapsed.

Determinants of Boarding of Patients with Severe Mental Illness in Hospital Emergency Departments

BACKGROUND

Boarding of patients in hospital emergency departments (EDs) occurs routinely across the U.S. ED patients with behavioral health conditions are more likely to be boarded than other patients. However, the existing literature on ED boarding of psychiatric patients remains largely descriptive and has not empirically related mental health system capacity to psychiatric boarding. Nor does it show how the mental health system could better address the needs of populations at the highest risk of ED boarding.

AIMS OF THE STUDY

We examined extent and determinants of "boarding" of patients with severe mental illness (SMI) in hospital emergency departments (ED) and tested whether greater mental health system capacity may mitigate the degree of ED boarding.

METHODS

We linked Oregon's ED Information Exchange, hospital discharge, and Medicaid data to analyze encounters in Oregon hospital EDs from October 2014 through September 2015 by 7,103 persons aged 15 to 64 with SMI (N = 34,207). We additionally utilized Medicaid claims for years 2010-2015 to identify Medicaid beneficiaries with SMI. Boarding was defined as an ED stay over six hours. We estimated a recursive simultaneous-equation model to test the pathway that mental health system capacity affects ED boarding via psychiatric visits.

RESULTS

Psychiatric visits were more likely to be boarded than non-psychiatric visits (30.2% vs. 7.4%). Severe psychiatric visits were 1.4 times more likely to be boarded than non-severe psychiatric visits. Thirty-four percent of psychiatric visits by children were boarded compared to 29.6% for adults. Statistical analysis found that psychiatric visit, substance abuse, younger age, black race and urban residence corresponded with an elevated risk of boarding. Discharge destinations such as psychiatric facility and acute care hospitals also corresponded with a higher probability of ED boarding. Greater supply of mental health resources in a county, both inpatient and intensive community-based, corresponded with a reduced risk of ED boarding via fewer psychiatric ED visits.

DISCUSSION

Psychiatric visit, severity of psychiatric diagnosis, substance abuse, and discharge destinations are among important predictors of psychiatric ED boarding by persons with SMI. A greater capacity of inpatient and intensive community mental health systems may lead to a reduction in psychiatric ED visits by persons with SMI and thereby decrease the extent of psychiatric ED boarding.

IMPLICATIONS FOR HEALTH POLICIES

Continued investment in mental health system resources may reduce psychiatric ED visits and mitigate the psychiatric ED boarding problem.

Guess Who's Coming to Dinner: COVID-19 in a COVID-free Unit

Objective

To assess the impact of the pandemic on surgical activity and the occurrence and features of Covid-19 in a Covid-free urologic unit in a regional hospital in Northern Italy.

Materials and Methods

Our Department is the only urologic service in the Trento Province, near Lombardy, the epicenter of Covid-19 in our Country. We reviewed the surgical and ward activities during the 4 weeks following the national lockdown (March 9 to April 5, 2020). The following outcomes were investigated: surgical load, rate of admissions and bed occupation, and the rate and characteristics of unrecognized Covid-positive patients. Data were compared with that of the same period of 2019 (March 11 to April 7).

Results and Conclusion

About 63%, 70%, 64%, and 71%, decline in surgery, endoscopy, bed occupation, and admission, respectively, occurred during the 4 weeks after the lockdown, as compared to 2019. Urgent procedures also declined by 32%. Three (8%) of 39 admissions regarded unrecognized Covid-19 overlapping or misinterpreted with urgent urologic conditions such as fever-associated urinary stones or hematuria. In spite of a significant reduction of activity, a non-negligible portion of admissions to our Covid-free unit regarded unrecognized Covid-19. In order to preserve its integrity, we propose an enhanced triage prior to the admission to a Covid-free unit including not only routine questions on fever and respiratory symptoms but also nonrespiratory symptoms, history of exposure, and a survey about the social and geographic origin of the patient.

Associations between hospital occupancy, intensive care unit transfer delay and hospital mortality

PURPOSE

Hospital occupancy (HospOcc) pressures often lead to longer intensive care unit (ICU) stay after physician recognition of discharge readiness. We evaluated the relationships between HospOcc, extended ICU stay, and patient outcomes.

MATERIALS AND METHODS

7-year retrospective cohort study of 8500 alive discharge encounters from 4 adult ICUs of a tertiary hospital. We estimated associations between i) HospOcc and ICU transfer delay; and ii) ICU transfer delay and hospital mortality.

RESULTS

Median (IQR) ICU transfer delay was 4.8 h (1.6-11.7), 1.4% (119) suffered in-hospital death, and 4% (341) were readmitted. HospOcc was non-linearly related with ICU transfer delay, with a spline knot at 80% (mean transfer delay 8.8 h [95% CI: 8.24, 9.38]). Higher HospOcc level above 80% was associated with longer transfer delays, (mean increase 5.4% per % HospOcc increase; 95% CI, 4.7 to 6.1; P < .001). Longer ICU transfer delay was associated with increasing odds of in-hospital death or ICU readmission (odds ratio 1.01 per hour; 95% CI 1.00 to 1.01; P = .04) but not with ICU readmission alone (OR 1.01 per hour; 95% CI 1.00 to 1.01, P = .14).

CONCLUSIONS

ICU transfer delay exponentially increased above a threshold hospital occupancy and may be associated with increased hospital mortality.

Impact of shortened length of stay for delivery on the required bed capacity in maternity services: results from forecast analysis on administrative data

BACKGROUND

We examine the implications of reducing the average length of stay (ALOS) for a delivery on the required capacity in terms of service volume and maternity beds in Belgium, using administrative data covering all inpatient stays in Belgian general hospitals over the period 2003-2014.

METHODS

A projection model generates forecasts of all inpatient and day-care services with a time horizon of 2025. It adjusts the observed hospital use in 2014 to the combined effect of three evolutions: the change in population size and composition, the time trend evolution of ALOS, and the time trend evolution of the admission rates. In addition, we develop an alternative scenario to evaluate the impact of an accelerated reduction of ALOS.

RESULTS

Between 2014 and 2025, we expect the number of deliveries to increase by 4.41%, and the number of stays in maternity services by 3.38%. At the same time, a reduction in ALOS is projected for all types of deliveries. The required capacity for maternity beds will decrease by 17%. In case of an accelerated reduction of the ALOS to reach international standards, this required capacity for maternity beds will decrease by more than 30%.

CONCLUSIONS

Despite an expected increase in the number of deliveries, future hospital capacity in terms of maternity beds can be considerably reduced in Belgium, due to the continuing reduction of ALOS.

A Prospective Audit of Inappropriately Occupied Hospital Beds in Patients with Newly Acquired Traumatic Spinal Cord Injury

Aim To quantify the inappropriate bed occupancy amongst patients with traumatic spinal cord injury (TSCI) awaiting transfer of care from the acute to community. Methods A prospective audit was carried out, of all newly acquired cases of TSCI in 2017, who progressed through acute care and specialist rehabilitation. Results Forty-four patients who were audited spent a total of 3915 days occupying a hospital bed, inappropriate for their phase of care, 78 awaiting admission to specialist acute care, 3126 awaiting admission to rehabilitation and 711 awaiting discharge from rehabilitation. Conclusion Valuable health-care resources are being wasted because TSCI patients cannot move seamlessly from one phase of care to the next. This impacts negatively on the quality of care being delivered to this patient cohort.

Do hospital pressures change following rotavirus vaccine introduction? A retrospective database analysis in a large paediatric hospital in the UK

OBJECTIVE

Hospitals in the UK are under increasing clinical and financial pressures. Following introduction of childhood rotavirus vaccination in the UK in 2013, rotavirus gastroenteritis (RVGE) hospitalisations reduced significantly. We evaluated changes in 'hospital pressures' (demand on healthcare resources and staff) following rotavirus vaccine introduction in a paediatric setting in the UK.

DESIGN

Retrospective hospital database analysis between July 2007 and June 2015.

SETTING

A large paediatric hospital providing primary, secondary and tertiary care in Merseyside, UK.

PARTICIPANTS

Hospital admissions aged <15 years. Outcomes were calculated for four different patient groups identified through diagnosis coding (International Classification of Disease, 10th edition) and/or laboratory confirmation: all admissions; any infection, acute gastroenteritis and RVGE.

METHODS

Hospital pressures were compared before and after rotavirus vaccine introduction: these included bed occupancy, hospital-acquired infection rate, unplanned readmission rate and outlier rate (medical patients admitted to surgical wards due to lack of medical beds). Interrupted time-series analysis was used to evaluate changes in bed occupancy.

RESULTS

There were 116 871 admissions during the study period. Lower bed occupancy in the rotavirus season in the postvaccination period was observed for RVGE (-89%, 95% CI 73% to 95%), acute gastroenteritis (-63%, 95% CI 39% to 78%) and any infection (-23%, 95% CI 15% to 31%). No significant overall reduction in bed occupancy was observed (-4%, 95% CI -1% to 9%). No changes were observed for the other outcomes.

CONCLUSIONS

Rotavirus vaccine introduction was not associated with reduced hospital pressures. A reduction in RVGE hospitalisation without change in overall bed occupancy suggests that beds available were used for a different patient population, possibly reflecting a previously unmet need.

TRIALS REGISTRATION NUMBER

NCT03271593.

Does hospital competition improve efficiency? The effect of the patient choice reform in England

We use the 2006 relaxation of constraints on patient choice of hospital in the English NHS to investigate the effect of hospital competition on dimensions of efficiency including indicators of resource management (admissions per bed, bed occupancy rate, proportion of day cases, and cancelled elective operations) and costs (reference cost index for overall and elective activity, cleaning services costs, laundry and linen costs). We employ a quasi differences-in-differences approach and estimate seemingly unrelated regressions and unconditional quantile regressions with data on hospital trusts from 2002/2003 to 2010/2011. Our findings suggest that increased competition had mixed effects on efficiency. An additional equivalent rival increased admissions per bed by 1.1%, admissions per doctor by 0.9% and the proportion of day cases by 0.38 percentage points, but it also increased the number of cancelled elective operations by 2.5%.

Assessment of the operating room efficiency by the real time of room occupancy

BACKGROUND

The operating room is the most cost consuming area of hospitals. However, it still suffers from a non-optimized organization.

AIM

To evaluate the performance of our operating rooms by the real room occupancy time (RROT), to identify the main causes of its alteration and to analyze the problem of deprogramming.

METHODS

This is an observational and descriptive study conducted in two operating rooms in Sahloul teaching Hospital during August 2016. For the two studied rooms, a pre-established data sheet was filled during the days of scheduled activity. Collected parameters were  total RROT,  different periods of RROT, room occupancy rate, room overflow rate, incidence and causes of non-compliance with the surgical program and causes of RROT alteration.

RESULTS

  The mean start time of the activity was 41.93 min/day. The mean overflow time was 11.51 min/day. The RROT was 246.56 min/day, corresponding to an average occupancy rate of 68.49%. On average 1.86 acts were performed per room and per morning with a total of 86 interventions. The deprogramming problem was noted in 38 cases. Its main causes were the overshoot of the vacation time offered to surgeons (36.84%), the emergencies (18.42%) and the non-respect of the anesthesia instructions (15.78%).

CONCLUSION

The occupancy rate in our structures is relatively acceptable but should not hide the need to optimize the use of available resources. Corrective actions focusing primarily on delayed start-up and periodic reassessments are essential.

Management decision of hospital surge: assessing seasonal upsurge in inpatient medical bed occupancy rate among public acute hospitals in Hong Kong

BACKGROUND

There were recurrent upsurges in demand for public hospital services in Hong Kong. An understanding of the contribution of some possible factors for the rise in health care burden would help to inform hospital management strategies.

AIM

To evaluate the utilization patterns of hospitalizations in medical wards among public acute hospitals in Hong Kong during surge periods.

DESIGN

Retrospective study.

METHODS

By extracting the information in press releases between 2014 and 2018, descriptive statistics about medical ward occupancy situation during six surge periods were generated. A time series model was constructed to estimate the occupancy rate at each hospital and assess its relationship with the intensity of seasonal influenza activity, extreme weather, day of week and long holidays.

RESULTS

There was a significant increase in the number of admissions to medical wards in all six surge periods. A significant variation in occupancy rate between weekdays and geographic regions was observed. The occupancy rate in 10, out of 15, hospitals was significantly associated with the influenza activity, while there was limited effect of weather on the occupancy rate. A significant holiday effect was observed during Christmas and Chinese New Year, resulting in a lower bed occupancy rate.

CONCLUSIONS

A differential burden in public hospitals during surge periods was reported. Contingency bed and staff management shall be tailored to individual hospitals, given their differences in the determinants for inpatient bed occupancy.

First four years of operation of a municipal acute bed unit in rural Norway

OBJECTIVE

To evaluate the use of a small municipality acute bed unit (MAU) in rural Norway resulting from the Coordination reform regarding occupancy-rate, patient characteristics and healthcare provided during the first four years of operation. Further, to investigate whether implementation of the new municipal service avoided acute hospital admissions.

DESIGN

Observational study.

SETTING

A two-bed municipal acute bed unit.

SUBJECTS

All patients admitted to the unit between 2013 and 2016.

MAIN OUTCOME MEASURES

Demographics, comorbidity, main diagnoses and level of municipal care on admission and discharge, diagnostic and therapeutic initiatives, MAU occupancy rate, and acute hospital admission rate.

RESULTS

Altogether, 389 admissions occurred, 215 first-time admissions and 174 readmissions. The mean MAU bed occupancy rate doubled from of 0.26 in 2013 to 0.50 in 2016, while acute hospital admission rates declined. The patients (median age 84.0 years, 48.9% women at first time admission) were most commonly admitted for infections (28.0%), observation (22.1%) or musculoskeletal symptoms (16.2%). Some 52.7% of the patients admitted from home were discharged to a higher care level; musculoskeletal problems as admission diagnosis predicted this (RR =1.43, 95% CI 1.20-1.71, adjusted for age and sex).

CONCLUSION

Admission rates to MAU increased during the first years of operation. In the same period, there was a reduction in acute hospital admissions. Patient selection was largely in accordance with national and local criteria, including observational stays. Half the patients admitted from home were discharged to nursing home, suggesting that the unit was used as pathway to a higher municipal care level. Key Points Evaluation of the first four years of operation of a municipality acute bed unit (MAU) in rural Norway revealed: • Admission rates to MAU increased, timely coinciding with decreased acute admission rates to hospital medical wards. • Most patients were old and had complex health problems. • Only half the patients were discharged back home; musculoskeletal symptoms were associated with discharge to a higher care level.

The Association of Inpatient Occupancy with Hospital-Acquired Clostridium difficile Infection

Few studies have evaluated the relationship between high hospital occupancy and hospital-acquired complications. We evaluated the association between inpatient occupancy and hospital-acquired Clostridium difficile infection (CDI) using a novel measure of hospital occupancy. We analyzed administrative data from California hospitals from 2008-2012 for Medicare recipients aged 65 years with a discharge diagnosis of acute myocardial infarction, heart failure, or pneumonia. Using daily census data, we constructed patient-level measures of occupancy on admission day and average occupancy during hospitalization (range: 0-1), which were split into 4 groups. We used logistic regression with cluster standard errors to estimate the adjusted and unadjusted relationship of occupancy with hospital-acquired CDI. Across 327 hospitals, 558,344 discharges met our inclusion criteria. Higher admission day occupancy was associated with significantly lower adjusted likelihood of CDI. Compared to the 0-0.25 occupancy group, patients admitted on a day of 0.51-0.75 occupancy had 0.86 odds of CDI (95% CI 0.75-0.98). The 0.76-1.00 admission occupancy group had 0.87 odds of CDI (95% CI 0.75-1.01). With regard to average occupancy, intermediate levels of occupancy 0.26-0.50 (odds ratio [OR] = 3.04, 95% CI 2.33-3.96) and 0.51-0.75 (OR = 3.28, 95% CI 2.51-4.28) had over 3-fold increased adjusted odds of CDI relative to the low occupancy group; the high occupancy group did not have signifcantly different odds of CDI compared to the low occupancy group (OR = 0.96, 95% CI 0.70-1.31). These findings should prompt exploration of how hospitals react to occupancy changes and how those care processes translate into hospital-acquired complications in order to inform best practices.

Communication and bed reservation: Decreasing the length of stay for emergency department trauma patients

BACKGROUND

Prolonged emergency department (ED) length of stay (LOS) is associated with poorer clinical outcomes and patient experience. At our community hospital, trauma patients were experiencing extended ED LOS incommensurate with their clinical status. Our objective was to determine if operational modifications to patient flow would reduce the LOS for trauma patients.

METHOD

We conducted a retrospective chart review of admitted trauma patients from January 1, 2015 to June 30, 2016 to study two interventions. First, a communication intervention [INT1], which required the ED provider to directly notify the trauma service, was studied. Second, a bed intervention [INT2], which reserved two temporary beds for trauma patients, was added. The primary outcome was the average ED LOS change across three time periods: (1) Baseline data [BASE] collected from January 1, 2015 to June 30, 2015, (2) INT1 data collected from July 1, 2015 to October 18, 2015, and (3) INT2 data collected from October 19, 2015 to June 30, 2016. Data was analyzed using descriptive statistics, two-sample t-tests, and multivariate linear regression.

RESULTS

A total of 777 trauma patients were reviewed, with 151, 150 and 476 reviewed during BASE, INT1, and INT2 time periods, respectively. BASE LOS for trauma patients was 389 min. After INT1, LOS decreased by 74.35 min (±31.92; p < 0.0001). After INT2 was also implemented, LOS decreased by 164.56 min (±22.97; p < 0.0001) from BASE LOS.

CONCLUSION

Direct communication with the trauma service by the ED provider and reservation of two temporary beds significantly decreased the LOS for trauma patients.

Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients

OBJECTIVES

ICU admission delays can negatively affect patient outcomes, but emergency department volume and boarding times may also affect these decisions and associated patient outcomes. We sought to investigate the effect of emergency department and ICU capacity strain on ICU admission decisions and to examine the effect of emergency department boarding time of critically ill patients on in-hospital mortality.

DESIGN

A retrospective cohort study.

SETTING

Single academic tertiary care hospital.

PATIENTS

Adult critically ill emergency department patients for whom a consult for medical ICU admission was requested, over a 21-month period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patient data, including severity of illness (Mortality Probability Model III on Admission), outcomes of mortality and persistent organ dysfunction, and hourly census reports for the emergency department, for all ICUs and all adult wards were compiled. A total of 854 emergency department requests for ICU admission were logged, with 455 (53.3%) as "accept" and 399 (46.7%) as "deny" cases, with median emergency department boarding times 4.2 hours (interquartile range, 2.8-6.3 hr) and 11.7 hours (3.2-20.3 hr) and similar rates of persistent organ dysfunction and/or death 41.5% and 44.6%, respectively. Those accepted were younger (mean ± SD, 61 ± 17 vs 65 ± 18 yr) and more severely ill (median Mortality Probability Model III on Admission score, 15.3% [7.0-29.5%] vs 13.4% [6.3-25.2%]) than those denied admission. In the multivariable model, a full medical ICU was the only hospital-level factor significantly associated with a lower probability of ICU acceptance (odds ratio, 0.55 [95% CI, 0.37-0.81]). Using propensity score analysis to account for imbalances in baseline characteristics between those accepted or denied for ICU admission, longer emergency department boarding time after consult was associated with higher odds of mortality and persistent organ dysfunction (odds ratio, 1.77 [1.07-2.95]/log10 hour increase).

CONCLUSIONS

ICU admission decisions for critically ill emergency department patients are affected by medical ICU bed availability, though higher emergency department volume and other ICU occupancy did not play a role. Prolonged emergency department boarding times were associated with worse patient outcomes, suggesting a need for improved throughput and targeted care for patients awaiting ICU admission.

Do Community Hospitals Reduce the Use of District General Hospital Inpatient beds?

Community hospitals have been supported by the general public and by professionals as one means of increasing choice between local, low technology, care and high technology care at the district general hospital. However, there is no information on the impact of community hospitals on district general hospital use subsequent to NHS and community care reforms.

Examination of routinely gathered activity data in the Bath Health District revealed that availability of community hospital beds was associated with reduced use of central inpatient services in the city of Bath. The reduction was most apparent for medical and geriatric beds. Decrease in the use of surgical beds was small. However, total inpatient bed use (including central and community hospital beds) was higher in the population with access to community hospital beds.

We conclude that community hospitals offer one option for accessible health care and, as such, merit systematic evaluation of costs and benefits. This study presents some evidence that savings could be achieved through improved efficiency.

Peripherally Inserted Central Catheters (PICCs) and Potential Cost Savings and Shortened Bed Stays In an Acute Hospital Setting

Peripheral inserted central catheters (PICCs) have increasingly become the mainstay of patients requiring prolonged treatment with antibiotics, transfusions, oncologic IV therapy and total parental nutrition. They may also be used in delivering a number of other medications to patients. In recent years, bed occupancy rates have become hugely pressurized in many hospitals and any potential solutions to free up beds is welcome. Recent introductions of doctor or nurse led intravenous (IV) outpatient based treatment teams has been having a direct effect on early discharge of patients and in some cases avoiding admission completely. The ability to deliver outpatient intravenous treatment is facilitated by the placement of PICCs allowing safe and targeted treatment of patients over a prolonged period of time. We carried out a retrospective study of 2,404 patients referred for PICCs from 2009 to 2015 in a university teaching hospital. There was an exponential increase in the number of PICCs requested from 2011 to 2015 with a 64% increase from 2012 to 2013. The clear increase in demand for PICCs in our institution is directly linked to the advent of outpatient intravenous antibiotic services. In this paper, we assess the impact that the use of PICCs combined with intravenous outpatient treatment may have on cost and hospital bed demand. We advocate that a more widespread implementation of this service throughout Ireland may result in significant cost savings as well as decreasing the number of patients on hospital trollies.

Major trends of the last decade in the number of icu beds, the number of icu patients, and the rates of icu mortality in Ukraine

OBJECTIVE

Introduction: At present, the world faces an extremely heterogeneous situation in providing population with access to intensive care. In healthcare systems of different countries, there are significant differences in the number of available ICU beds per 10 thousand population. Even in the united Europe, the indicator is extremely variable and ranges from 0.42 ICU beds per 10.000 population in Portugal to 2.92 ICU beds per 10.000 population in Germany (a difference of almost 7 times), amounting to an average of 1.15 ICU beds per 10 thousand population The aim: To identify major trends in the number of ICU beds, the number of ICU patients and the rates of ICU mortality in Ukraine over the period of time from 2007 to 2015 based on the analysis of available data on the national intensive care service.

PATIENTS AND METHODS

Materials and methods: The data from the 2007 nationwide audit of the domestic intensive care service and the summarized 2015 annual reports from the regional intensive care services, encompassing all the healthcare facilities that provide intensive care to population (819 hospitals in total) and represent 22 out of 26 administrative territories (regions) of the country, have been used to carry out comparative, 2015 vs. 2007, analysis and establish major trends in the indicators of interest.

RESULTS

Results: The negligible increase in the number of ICU beds on referential territories in absolute (from 4.765 to 5.049) and relative (from 1.4 to 1.5 per 10 thousand population) figures have been found within the period of time from 2007 to 2015. In contrast, more prominent increase in the number of ICU patients (from 385.068 to 462.395 in absolute figures and from 111.6 to 138.2 per 10 thousand population) and in ICU mortality rates (from 8.4% to 8.7%) have been established. The average Ukrainian figure of the number of ICU beds per 10 thousand population for the year 2015 (1.5) seems to be roughly comparable with the corresponding European one for the year 2012 (1.15).

CONCLUSION

Conclusions: The inclining trends in the number of ICU patients and ICU mortality rates, against the background of negligible growth in the bed capacity of the national intensive care service, indicate the need in the increase in the number of ICU beds in Ukraine.

Physicians and Advanced Practitioners Specializing in Nursing Home Care, 2012-2015

This study characterizes trends in the use by nursing homes of nursing home specialists (defined as generalist physicians, nurse practitioners, and physician assistants) who billed at least 90% of their clinical episodes from nursing home settings between 2012 ans 2015.

Caring for critically ill patients outside intensive care units due to full units: a cohort study

OBJECTIVES

This study sought to analyze the clinical and epidemiologic characteristics of critically ill patients who were denied intensive care unit admission due to the unavailability of beds and to estimate the direct costs of treatment.

METHODS

A prospective cohort study was performed with critically ill patients treated in a university hospital. All consecutive patients denied intensive care unit beds due to a full unit from February 2012 to February 2013 were included. The data collected included clinical data, calculation of costs, prognostic scores, and outcomes. The patients were followed for data collection until intensive care unit admission or cancellation of the request for the intensive care unit bed. Vital status at hospital discharge was noted, and patients were classified as survivors or non-survivors considering this endpoint.

RESULTS

Four hundred and fifty-four patients were analyzed. Patients were predominantly male (54.6%), and the median age was 62 (interquartile range (ITQ): 47 - 73) years. The median APACHE II score was 22.5 (ITQ: 16 - 29). Invasive mechanical ventilation was used in 298 patients (65.6%), and vasoactive drugs were used in 44.9% of patients. The median time of follow-up was 3 days (ITQ: 2 - 6); after this time, 204 patients were admitted to the intensive care unit and 250 had the intensive care unit bed request canceled. The median total cost per patient was US$ 5,945.98.

CONCLUSIONS

Patients presented a high severity in terms of disease scores, had multiple organ dysfunction and needed multiple invasive therapeutic interventions. The study patients received intensive care with specialized consultation during their stay in the hospital wards and presented high costs of treatment.

The impact of the improvement in internal medicine consultation process on ED length of stay

INTRODUCTION

Although consultations are essential for delivering safe, high-quality care to patients in emergency departments, they contribute to emergency department patient flow problems and overcrowding which is associated with several adverse outcomes, such as increases in patient mortality and poor quality care. This study aimed to investigate how time flow metrics including emergency department length of stay is influenced by changes to the internal medicine consultation policy.

METHOD

This study is a pre- and post-controlled interventional study. We attempted to improve the internal medicine consultation process to be more concise. After the intervention, only attending emergency physicians consult internal medicine chief residents, clinical fellows, or junior staff of each internal medicine subspecialty who were on duty when patients required special care or an admission to internal medicine.

RESULTS

Emergency department length of stay of patients admitted to the department of internal medicine prior to and after the intervention decreased from 996.94min to 706.62min. The times from consultation order to admission order and admission order to emergency department departure prior to and after the intervention were decreased from 359.59min to 180.38min and from 481.89min to 362.37min, respectively. The inpatient mortality rates and Inpatient bed occupancy rates prior to and after the intervention were similar.

CONCLUSION

The improvements in the internal medicine consultation process affected the flow time metrics. Therefore, more comprehensive and cooperative strategies need to be developed to reduce the time cycle metrics and overcrowding of all patients in the emergency department.

Do hospitals respond to rivals' quality and efficiency? A spatial panel econometric analysis

We investigate whether hospitals in the English National Health Service change their quality or efficiency in response to changes in quality or efficiency of neighbouring hospitals. We first provide a theoretical model that predicts that a hospital will not respond to changes in the efficiency of its rivals but may change its quality or efficiency in response to changes in the quality of rivals, though the direction of the response is ambiguous. We use data on eight quality measures (including mortality, emergency readmissions, patient reported outcome, and patient satisfaction) and six efficiency measures (including bed occupancy, cancelled operations, and costs) for public hospitals between 2010/11 and 2013/14 to estimate both spatial cross-sectional and spatial fixed- and random-effects panel data models. We find that although quality and efficiency measures are unconditionally spatially correlated, the spatial regression models suggest that a hospital's quality or efficiency does not respond to its rivals' quality or efficiency, except for a hospital's overall mortality that is positively associated with that of its rivals. The results are robust to allowing for spatially correlated covariates and errors and to instrumenting rivals' quality and efficiency.

Patient trajectories in a Norwegian unit of municipal emergency beds

OBJECTIVE

The Coordination reform was implemented in Norway from 2012, aiming at seamless patient trajectories. All municipalities are required to establish emergency care beds (MEBs) to avoid unnecessary hospital admissions. We aimed to examine occupancy rate, patient characteristics, diagnoses and discharge level of municipal care in a small MEB unit.

DESIGN

Cross-sectional, observational study.

SETTING

A two-bed emergency care unit.

SUBJECTS

All patients admitted to the unit during one year.

MAIN OUTCOME MEASURES

Patients' age and gender, comorbidity, main diagnoses and municipal care level on admission and discharge, diagnostic and therapeutic initiatives, occupancy rate.

RESULTS

Sixty admissions were registered, with total bed occupancy 194 days, and an occupancy rate of 0.27. The patients (median age 83 years, 57% women) had mostly infections, musculoskeletal symptoms or undefined conditions. Some 48% of the stays exceeded three days and 43% of the patients were subsequently transferred to nursing homes or hospitals.

CONCLUSION

Occupancy rate was low. Patient selection was not according to national standards, and stays were longer. Many patients were transferred to nursing homes, indicating that the unit was an intermediate pathway or a short cut to institutional care. It is unclear whether the unit avoided hospital admissions.

Analysis of patient falls among hospitalised patients in Makkah region

OBJECTIVE

To assess the frequency and its correlation of patient fall with preventing or precipitating factors among inpatients.

METHODS

The observational study was conducted in Makkah Region, Saudi Arabia from October 15 2012 to November 4, 2013. Data was collected using a questionnaire from 16 hospitals in four districts of Makkah province. The material was sampled through systematic randomisation from inpatient files and data was collected for those who had fallen inside the hospital. The questionnaire, validated through a pilot study run under the Directorate of Quality and Patient Safety in Makkah, was used to see whether the hospitals had adopted and applied international standards for assessment of adult and paediatric patients for falls as well as effectiveness of these applications.

RESULTS

Of 4,799 beds, occupancy rates ranged from 1680(35%) to 4,799(100%). Out of 291 falls in all, 144(49.48%) were in Jeddah. Besides, 116(40%) of the falls occurred in the last quarter of the Islamic calendar. Statistically significant difference was found in fall episodes in different months (p=0.007). Statistical analysis indicated that the factors that significantly raised the number of patient falls were increase in hospital beds and their occupancy rate (Spearman's correlation: 0.621 and 0.579 respectively).

CONCLUSIONS

The frequency of falls varied from hospital to hospital and factors like higher number of bed capacity and occupancy rate increased the falls.

Potential of Earlier Detection and Treatment of Disease-Related Malnutrition with Oral Nutrition Supplements to Release Acute Care Bed Capacity

A recent systematic review and meta-analysis shows that appropriate use of oral nutrition supplements (ONS) in community patients is associated with a significant reduction in hospitalisations. Given higher use of acute care resource by malnourished versus normally nourished patients, this paper examines the potential to reduce bed utilisation by applying these results to Irish inpatient and malnutrition prevalence data. In 2013, adults admitted to hospital with medium or high malnutrition risk scores used an estimated 36% of adult acute inpatient bed days. Targeted use of ONS in community patients might reduce hospitalisation by 168,438 adult bed days per year, equivalent to 460 beds per day. This is particularly important, given high bed occupancy rates and twelve month daily averages of 254 patients on trolleys. Relevant stakeholders should consider strategies to ensure effective ONS use with a view to improving outcomes and reducing pressure on the acute care system.