Measuring appropriate use of acute beds. A systematic review of methods and results

Reallocation of Shafa Hospital Beds in Kerman Using Goal Programming Model

INTRODUCTION

In order to improve health, hospital sources such as beds and staffing should be properly allocated and used. The aim of this study is reallocation of Shafa hospital beds in Kerman using a goal-programming model.

METHODS

This study was an applied cross-sectional study, which used the goal programming model and software WinQSB to optimize bed allocation. By review of the literature and interviews with experts, the constraints in beds allocation were identified, and using the collected data the desired model was designed.

RESULTS

Hospital beds were redistributed based on the constraints of the goal-programming model and objectives. The results showed that there was a shortage of beds in departments such as burns, GICU, HICU, cardiac surgery, emergency, and orthopedics, and excess of beds in the ear, nose, and throat (ENT), ophthalmology, and neurology departments.

CONCLUSION

It is anticipated that the optimal allocation of hospital beds, regarding hospital activity indicators, can lead to greater justice in the provision of services and a better distribution of resources.

Impact of continuous Medical Aid utilisation on healthcare utilisation: unique insight using the 2008-2012 Korean Welfare Panel Study (KOWEPS)

OBJECTIVES

Although there has been considerable discussion about the social safety net, few studies related to effect of duration of continuous receipt of Medical Aid on healthcare utilisation have been conducted. Therefore, we investigate whether the duration of receiving Medical Aid affected medical care utilisation.

SETTING

Data were collected from the Korean Welfare Panel Study conducted from 2008 to 2012.

PARTICIPANTS

We included 11,783 samples.

INTERVENTIONS

Estimating changes in their healthcare utilisation during specific time intervals (1, 2 and ≥3 years) after they switched from National Health Insurance to Medical Aid.

PRIMARY AND SECONDARY OUTCOME MEASURES

Number of outpatient visits.

RESULTS

The number of outpatient visits per year was 0.0.051-fold higher (p value: 0.434) among those who were Medical Aid beneficiaries for a continuous period of 1 year, 0.0.267-fold higher (p value: 0.000) among those who were beneficiaries for a continuous period of 2 years, and 0.0.562-fold higher (p value:<0.0001) among those who were beneficiaries for a continuous period of 3 years than it was among those who were beneficiaries of National Health Insurance.

CONCLUSIONS

Our results reflect an association between the number of consecutive years of receiving Medical Aid and number of outpatient visits. Since duration of dependence is correlated with reduced exit rates, limits on length of benefits should be considered to strengthen the incentive to return to work.

Discharge planning from hospital

BACKGROUND

Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co-ordination of services following discharge from hospital.This is the third update of the original review.

OBJECTIVES

To assess the effectiveness of planning the discharge of individual patients moving from hospital.

SEARCH METHODS

We updated the review using the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 9), MEDLINE, EMBASE, CINAHL, the Social Science Citation Index (last searched in October 2015), and the US National Institutes of Health trial register (ClinicalTrials.gov).

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to individual participants. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies according to patient groups (elderly medical patients, patients recovering from surgery, and those with a mix of conditions) and by outcome. We performed our statistical analysis according to the intention-to-treat principle, calculating risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible because of differences in the reporting of outcomes, we summarised the reported data in the text.

MAIN RESULTS

We included 30 trials (11,964 participants), including six identified in this update. Twenty-one trials recruited older participants with a medical condition, five recruited participants with a mix of medical and surgical conditions, one recruited participants from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials recruited participants admitted to hospital following a fall. Hospital length of stay and readmissions to hospital were reduced for participants admitted to hospital with a medical diagnosis and who were allocated to discharge planning (length of stay MD - 0.73, 95% CI - 1.33 to - 0.12, 12 trials, moderate certainty evidence; readmission rates RR 0.87, 95% CI 0.79 to 0.97, 15 trials, moderate certainty evidence). It is uncertain whether discharge planning reduces readmission rates for patients admitted to hospital following a fall (RR 1.36, 95% CI 0.46 to 4.01, 2 trials, very low certainty evidence). For elderly patients with a medical condition, there was little or no difference between groups for mortality (RR 0.99, 95% CI 0.79 to 1.24, moderate certainty). There was also little evidence regarding mortality for participants recovering from surgery or who had a mix of medical and surgical conditions. Discharge planning may lead to increased satisfaction for patients and healthcare professionals (low certainty evidence, six trials). It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition (very low certainty evidence, five trials).

AUTHORS' CONCLUSIONS

A discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and reduces the risk of readmission to hospital at three months follow-up for older people with a medical condition. Discharge planning may lead to increased satisfaction with healthcare for patients and professionals. There is little evidence that discharge planning reduces costs to the health service.

How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals

Background

Hospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown.

Aims

To investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners.

Methods

The project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources.

Findings

Patients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity.

Conclusions

This research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions.

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Artificial Neural Networks and risk stratification models in Emergency Departments: The policy maker's perspective

The primary goal of Emergency Department (ED) physicians is to discriminate between individuals at low risk, who can be safely discharged, and patients at high risk, who require prompt hospitalization. The problem of correctly classifying patients is an issue involving not only clinical but also managerial aspects, since reducing the rate of admission of patients to EDs could dramatically cut costs. Nevertheless, a trade-off might arise due to the need to find a balance between economic interests and the health conditions of patients. This work considers patients in EDs after a syncope event and presents a comparative analysis between two models: a multivariate logistic regression model, as proposed by the scientific community to stratify the expected risk of severe outcomes in the short and long run, and Artificial Neural Networks (ANNs), an innovative model. The analysis highlights differences in correct classification of severe outcomes at 10 days (98.30% vs. 94.07%) and 1 year (97.67% vs. 96.40%), pointing to the superiority of Neural Networks. According to the results, there is also a significant superiority of ANNs in terms of false negatives both at 10 days (3.70% vs. 5.93%) and at 1 year (2.33% vs. 10.07%). However, considering the false positives, the adoption of ANNs would cause an increase in hospital costs, highlighting the potential trade-off which policy makers might face.

Perception of quality of care of patients with potentially severe diseases evaluated at a distinct quick diagnostic delivery model: a cross-sectional study

BACKGROUND

Although hospital-based outpatient quick diagnosis units (QDU) are an increasingly recognized cost-effective alternative to hospitalization for the diagnosis of potentially serious diseases, patient perception of their quality of care has not been evaluated well enough. This cross-sectional study analyzed the perceived quality of care of a QDU of a public third-level university hospital in Barcelona.

METHODS

One hundred sixty-two consecutive patients aged ≥ 18 years attending the QDU over a 9-month period were invited to participate. A validated questionnaire distributed by the QDU attending physician and completed at the end of the first and last QDU visit evaluated perceived quality of care using six subscales.

RESULTS

Response rate was 98 %. Perceived care in all subscales was high. Waiting times were rated as 'short'/'very short' or 'better'/'much better' than expected by 69-89 % of respondents and physical environment as 'better'/'much better' than expected by 94-96 %. As to accessibility, only 3 % reported not finding the Unit easily and 7 % said that frequent travels to hospital for visits and investigations were uncomfortable. Perception of patient-physician encounter was high, with 90-94 % choosing the positive extreme ends of the clinical information and personal interaction subscales items. Mean score of willingness to recommend the Unit using an analogue scale where 0 was 'never' and 10 'without a doubt' was 9.5 (0.70). On multivariate linear regression, age >65 years was an independent predictor of clinical information, personal interaction, and recommendation, while age 18-44 years was associated with lower scores in these subscales. No schooling predicted higher clinical information and recommendation scores, while university education had remarkable negative influence on them. Having ≥4 QDU visits was associated with lower time to diagnosis and recommendation scores and malignancy was a negative predictor of time to diagnosis, clinical information, and recommendation.

DISCUSSION

It is worthy of note that the questionnaire evaluated patient perception and opinions of healthcare quality including recommendation rather than simply satisfaction. It has been argued that perception of quality of care is a more valuable approach than satisfaction. In addition to embracing an affective dimension, satisfaction appears more dependent on patient expectations than is perception of quality.

CONCLUSIONS

While appreciating that completing the questionnaire immediately after the visit and its distribution by the QDU physician may have affected the results, scores of perceived quality of care including recommendation were high. There were, however, significant differences in several subscales associated with age, education, number of QDU visits, and diagnosis of malignant vs. benign condition.

Establishing and implementing best practice to reduce unplanned admissions in those aged 85 years and over through system change [Establishing System Change for Admissions of People 85+ (ESCAPE 85+)]: a mixed-methods case study approach

Background

In England, between 2007/8 and 2009/10, the rate of unplanned hospital admissions of people aged 85 years and above rose from 48 to 52 per 100. There was substantial variation, with some areas showing a much faster rate of increase and others showing a decline.

Objectives

To identify system characteristics associated with higher and lower increases in unplanned admission rates in those aged 85 years and over; to develop recommendations to inform providers and commissioners; and to investigate the challenges of starting to implement these recommendations.

Design

Mixed-methods study using routinely collected data, in-depth interviews and focus groups. Data were analysed using the framework approach, with themes following McKinsey’s 7S model. Recommendations derived from our findings were refined and prioritised through respondent validation and consultation with the project steering group. The process of beginning to implement these recommendations was examined in one ‘implementation site’.

Participants

Six study sites were selected based on admission data for patients aged 85 years and above from primary care trusts: three where rates of increase were among the most rapid and three where they had slowed down or declined. Each ‘improving’ or ‘deteriorating’ site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services, and adult social care. At each site, representatives from these organisations at strategic and operational levels, as well as representatives of patient groups, were interviewed to understand how policies had been developed and implemented. A total of 142 respondents were interviewed.

Results

Between 2007/8 and 2009/10, average admission rates for people aged 85 years and over rose by 5.5% annually in deteriorating sites and fell by 1% annually in improving sites. During the period under examination, the population aged 85 years and over in deteriorating sites increased by 3.4%, compared with 1.3% in improving sites. In deteriorating sites, there were problems with general practitioner access, pressures on emergency departments and a lack of community-based alternatives to admission. However, the most striking difference between improving and deteriorating sites was not the presence or absence of specific services, but the extent to which integration within and between types of service had been achieved. There were also overwhelming differences in leadership, culture and strategic development at the system level. The final list of recommendations emphasises the importance of issues such as maximising integration of services, strategic leadership and adopting a system-wide approach to reconfiguration.

Conclusions

Rising admission rates for older people were seen in places where several parts of the system were under strain. Places which had stemmed the rising tide of admissions had done so through strong, stable leadership, a shared vision and strategy, and common values across the system.

Future work

Research on individual components of care for older people needs to take account of their impact on the system as a whole. Areas where more evidence is needed include the impact of improving access and continuity in primary care, the optimal capacity for intermediate care and how the frail elderly can best be managed in emergency departments.

Study registration

UK Clinical Reasearch Network 12960.

Funding details

The National Institute for Health Research Health Services and Delivery Research programme.

Impact of socio-economic status on hospital length of stay following injury: a multicenter cohort study

BACKGROUND

Injury is second only to cardiovascular disease in terms of acute care costs in North America. One key to improving injury care efficiency is to generate knowledge on the determinants of resource use. Socio-economic status (SES) is a documented risk factor for injury severity and mortality but its impact on length of stay (LOS) for injury admissions is unknown. This study aimed to examine the relationship between SES and LOS following injury. This multicenter retrospective cohort study was based on adults discharged alive from any trauma center (2007-2012; 57 hospitals; 65,486 patients) in a Canadian integrated provincial trauma system. SES was determined using ecological indices of material and social deprivation. Mean differences in LOS adjusted for age, gender, comorbidities, and injury severity were generated using multivariate linear regression.

RESULTS

Mean LOS was 13.5 days. Patients in the highest quintile of material/social deprivation had a mean LOS 0.5 days (95 % CI 0.1-0.9)/1.4 days (1.1-1.8) longer than those in the lowest quintile. Patients in the highest quintiles of both social and material deprivation had a mean LOS 2.6 days (1.8-3.5) longer than those in the lowest quintiles.

CONCLUSIONS

Results suggest that patients admitted for traumatic injury who suffer from high social and/or material deprivation have longer acute care LOS in a universal-access health care system. The reasons behind observed differences need to be further explored but may indicate that discharge planning should take patient SES into consideration.

Identifying alternatives to old age psychiatry inpatient admission: an application of the balance of care approach to health and social care planning

Background

Mental health problems in older people are common and costly, posing multiple challenges for commissioners. Against this backdrop, a series of initiatives have sought to shift resources from institutional to community care in the belief that this will save money and concurs with user preferences. However, most of this work has focused on the use of care home beds and general hospital admissions, and relatively little attention has been given to reducing the use of mental health inpatient beds, despite their very high cost.

Methods

The study employed a ‘Balance of Care approach’ in three areas of North-West England. This long-standing strategic planning framework identifies people whose needs can be met in more than one setting, and compares the costs and consequences of the possible alternatives in a simulation modelling exercise. Information was collected about a six-month cohort of admissions in 2010/11 (n = 216). The sample was divided into groups of people with similar needs for care, and vignettes were formulated to represent the most prevalent groups. A range of key staff judged the appropriateness of these admissions and suggested alternative care for those considered least appropriate for hospital. A public sector costing approach was used to compare the estimated costs of the recommended care with that people currently receive.

Results

The findings suggest that more than a sixth of old age psychiatry inpatient admissions could be more appropriately supported in other settings if enhanced community services were available. Such restructuring could involve the provision of intensive support from Care Home Outreach and Community Mental Health Teams, rather than the development of crisis intervention and home treatment teams as currently advocated. Estimated savings were considerable, suggesting local agencies might release up to £1,300,000 per annum. No obvious trade-off between health and social care costs was predicted.

Conclusions

There is considerable potential to change the mix of institutional and community services provided for older people with mental health problems. The conclusions would be strengthened by further studies and the incorporation of evidence about relative outcomes. However, the utility of the approach in challenging established patterns of resource allocation and building local ownership for change is apparent.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0913-1) contains supplementary material, which is available to authorized users.

French Multicenter Evaluation of the Appropriateness of Admission to the Emergency Department of the Over-80s

BACKGROUND

Persons over 80 represents 40% of patients in French emergency services. We assessed the appropriateness of these admissions and sought to identify risk factors for inappropriate hospital stays.

METHODS

The appropriateness of admission was assessed in a prospective, cross-sectional, multicenter study in eight hospitals in France by means of the Appropriateness Evaluation Protocol (French version, AEPf) during two non-consecutive periods of four weeks in 2010. We analyzed admission of patients aged 80 and over who were admitted to the hospital after a stay in the emergency department of the same hospital. Demographics and morbidity factors were recorded as were administrative hospitalization data to identify risk factors associated with inappropriate admissions. We also evaluated the economic impact of inappropriate admissions. For cost analysis, all variables were obtained from anonymized hospital reports of a diagnosis-related group system used for funding of the hospitals by health insurance.

RESULTS

During two different periods, 1577 patients were included. 139 (8.8%) hospital admissions were inappropriate according to explicit criteria of the AEPf, but 18 of these (1.1%) were in fact considered appropriate by the physician responsible for the admission, leading to 121 (7.7%) inappropriate admissions. Multivariate logistic regression showed that patients with heart disease were less often subject to inappropriate admission (odds ratio OR= 0.36 [0.23; 0.56], p < 0.001), as also were patients who usually lived in a nursing home (OR = 0.53 [0.30; 0.87], p = 0.018) and patients with higher Acute Physiology Scores (OR = 0.97 [0.95; 0.99], p < 0.001). Inappropriate admission increased when patients had a syndrome as the main diagnosis (OR = 1.81 [1.81; 2.83], p = 0.010). By contrast, cognitive functions, gait and balance disturbance or falls, behavioral disorders and method of transport to the emergency department did not change the probability of inappropriateness. The median cost of the hospital stay of an older patient was 3 606.5 [2 498.1; 4 994.2] euros for inappropriate admissions.

CONCLUSION

Inappropriate emergency admissions of older patients were infrequent. None of the geriatric syndromes were linked with the phenomenon and principle causes were severity of illness, mention of a cardiac disease, unclear pattern of consultation and institutionalized way of life.

Does clinical governance influence the appropriateness of hospital stay?

Background

Clinical Governance provides a framework for assessing and improving clinical quality through a single coherent program. Organizational appropriateness is aimed at achieving the best health outcomes and the most appropriate use of resources. The goal of the present study is to verify the likely relationship between Clinical Governance and appropriateness of hospital stay.

Methods

A cross-sectional study was conducted in 2012 in an Italian Teaching Hospital. The OPTIGOV^© (Optimizing Health Care Governance) methodology was used to quantify the level of implementation of Clinical Governance globally and in its main dimensions. Organizational appropriateness was measured retrospectively using the Italian version of the Appropriateness Evaluation Protocol to analyze a random sample of medical records for each clinical unit.

Pearson-correlation and multiple linear regression were used to test the relationship between the percentage of inappropriate days of hospital stay and the Clinical Governance implementation levels.

Results

47 Units were assessed. The percentage of inappropriate days of hospital stay showed an inverse correlation with almost all the main Clinical Governance dimensions. Adjusted multiple regression analysis resulted in a significant association between the percentage of inappropriate days and the overall Clinical Governance score (β = −0.28; p < 0.001; R-squared = 0.8). EBM and Clinical Audit represented the Clinical Governance dimensions which had the strongest association with organizational appropriateness.

Conclusions

This study suggests that the evaluation of both Clinical Governance and organizational appropriateness through standardized and repeatable tools, such as OPTIGOV^© and AEP, is a key strategy for healthcare quality. The relationship between the two underlines the central role of Clinical Governance, and especially of EBM and Clinical Audit, in determining a rational improvement of appropriateness levels.

Prevalence of and factors associated with prolonged length of stay in older hospitalized medical patients

AIM

To characterize elderly medical patients and identify factors associated with prolonged length of stay.

METHODS

The present prospective observational study evaluated consecutive patients aged ≥65 years admitted in acute geriatric and medical wards. A comprehensive assessment including demographic, clinical, functional and cognitive variables was carried out. Delayed discharge was defined when patients were discharged later than the date they were deemed medically ready for discharge by physicians. The analysis was initially carried out on the total sample and subsequently according to whether hospital admission had been from home, or from intermediate or long-term facilities.

RESULTS

Among 1568 patients (age 81.3 ± 7.3 years, 712 men), we observed a high prevalence of functional dependence, cognitive impairment, chronic immobilization and frailty (50%, 25%, 20% and 40%, respectively). Overall, delayed discharge occurred in 442 cases - resulting in 2637 days of prolonged hospital stay - and was independently associated with impairment in activities of daily living, frailty, high comorbidity and inappropriate admission. Among patients admitted from home (roughly 90% of the sample), delayed discharge occurred in 392 patients, and was independently associated with cognitive impairment, functional dependence, low severity of comorbidity and inappropriate admission (OR 3.39). Among patients admitted from intermediate or long-term facilities, lower cognitive impairment and greater severity of functional dependence were independently associated with prolonged stay.

CONCLUSIONS

Poor health conditions and high prevalence of geriatric syndromes are extremely common among older medical inpatients. Delayed discharge was mainly observed in patients admitted from home, and associated with cognitive impairment (OR 1.12) and functional dependence (OR 1.49).

Reasons for discharge delays in teaching hospitals

OBJECTIVE

To analyze the causes of delay in hospital discharge of patients admitted to internal medicine wards.

METHODS

We reviewed 395 medical records of consecutive patients admitted to internal medicine wards of two public teaching hospitals: Hospital das Clínicas of the Universidade Federal de Minas Gerais and Hospital Odilon Behrens. The Appropriateness Evaluation Protocol was used to define the moment at which notes in the medical records indicated hospital stay was no longer appropriate and patients could be discharged. The interval between this estimated time and actual discharge was defined as the total number of days of delay in hospital discharge. An instrument was used to systematically categorize reasons for delay in hospital discharge and frequencies were analyzed.

RESULTS

Delays in discharge occurred in 60.0% of 207 hospital admissions in the Hospital das Clínicas and in 58.0% of 188 hospital admissions in the Hospital Odilon Behrens. Mean delay per patient was 4.5 days in the former and 4.1 days in the latter, corresponding to 23.0% and 28.0% of occupancy rates in each hospital, respectively. The main reasons for delay in the two hospitals were, respectively, waiting for complementary tests (30.6% versus 34.7%) or for results of performed tests to be released (22.4% versus 11.9%) and medical-related accountability (36.2% versus 26.1%) which comprised delays in discussing the clinical case and in clinical decision making and difficulties in providing specialized consultation (20.4% versus 9.1%).

CONCLUSIONS

Both hospitals showed a high percentage of delay in hospital discharge. The delays were mainly related to processes that could be improved by interventions by care teams and managers. The impact on mean length of stay and hospital occupancy rates was significant and troubling in a scenario of relative shortage of beds and long waiting lists for hospital admission.

Derivation and validation of a quality indicator of acute care length of stay to evaluate trauma care

OBJECTIVE

To derive and internally validate a quality indicator (QI) for acute care length of stay (LOS) after admission for injury.

BACKGROUND

Unnecessary hospital days represent an estimated 20% of total LOS implying an important waste of resources as well as increased patient exposure to hospital-acquired infections and functional decline.

METHODS

This study is based on a multicenter, retrospective cohort from a Canadian provincial trauma system (2005-2010; 57 trauma centers; n = 57,524). Data were abstracted from the provincial trauma registry and the hospital discharge database. Candidate risk factors were identified by expert consensus and selected for model derivation using bootstrap resampling. The validity of the QI was evaluated in terms of interhospital discrimination, construct validity, and forecasting.

RESULTS

The risk adjustment model explains 37% of the variation in LOS. The QI discriminates well across trauma centers (coefficient of variation = 0.02, 95% confidence interval: 0.011-0.028) and is correlated with the QI on processes of care (r = -0.32), complications (r = 0.66), unplanned readmissions (r = 0.38), and mortality (r = 0.35). Performance in 2005 to 2007 was predictive of performance in 2008 to 2010 (r = 0.80).

CONCLUSIONS

We have developed a QI on the basis of risk-adjusted LOS to evaluate trauma care that can be implemented with routinely collected data. The QI is based on a robust risk adjustment model with good internal and temporal validity, and demonstrates good properties in terms of discrimination, construct validity, and forecasting. This QI can be used to target interventions to reduce LOS, which will lead to more efficient resource use and may improve patient outcomes after injury.

Hospital stay on acute care units for non-acute reasons: Effects of patient pre-hospitalization and admission factors

This study identifies patient risk factors present prior to an acute hospitalization that are associated with occupying acute care beds for non-acute reasons on the 30^th day of a hospitalization. Data from 952 adult patients were obtained, among which 333 (35%) were evaluated as non-acute on their 30^th day. Inability to move in and out of the bed, cognitive impairment, receiving home or community healthcare services prior to hospitalization, unavailable family resources, a secondary diagnosis within the mental and behavioural category, and age ≥75 years were found to increase the risk of occupying acute care beds for non-acute reasons, while patients with a feeding tube were less likely to be non-acute at day 30.

National trends and local delivery in old age mental health services: towards an evidence base. A mixed-methodology study of the balance of care approach, community mental health teams and specialist mental health outreach to care homes

Background

The rising number of older people with mental health problems makes the effective use of mental health resources imperative. Little is known about the clinical effectiveness and/or cost-effectiveness of different service models.

Aims

The programme aimed to (1) refine and apply an existing planning tool [‘balance of care’ (BoC)] to this client group; (2) identify whether, how and at what cost the mix of institutional and community services could be improved; (3) enable decision-makers to apply the BoC framework independently; (4) identify variation in the structure, organisation and processes of community mental health teams for older people (CMHTsOP); (5) examine whether or not different community mental health teams (CMHTs) models are associated with different costs/outcomes; (6) identify variation in mental health outreach services for older care home residents; (7) scope the evidence on the association between different outreach models and resident outcomes; and (8) disseminate the research findings to multiple stakeholder groups.

Methods

The programme employed a mixed-methods approach including three systematic literature reviews; a BoC study, which used a systematic framework for choosing between alternative patterns of support by identifying people whose needs could be met in more than one setting and comparing their costs/outcomes; a national survey of CMHTs’ organisation, structure and processes; a multiple case study of CMHTs exhibiting different levels of integration encompassing staff interviews, an observational study of user outcomes and a staff survey; national surveys of CMHTs’ outreach activities and care homes. A planned randomised trial of depression management in care homes was removed at the review stage by the National Institute for Health Research (NIHR) prior to funding award.

Results

BoC: Past studies exhibited several methodological limitations, and just two related to older people with mental health problems. The current study suggested that if enhanced community services were available, a substantial proportion of care home and inpatient admissions could be diverted, although only the latter would release significant monies. CMHTsOP: 60% of teams were considered multidisciplinary. Most were colocated, had a single point of access (SPA) and standardised assessment documentation. Evidence of the impact of particular CMHT features was limited. Although staff spoke positively about integration, no evidence was found that more integrated teams produced better user outcomes. Working in high-integration teams was associated with poor job outcomes, but other factors negated the statistical significance of this. Care home outreach: Typical services in the literature undertook some combination of screening (less common), assessment, medication review, behaviour management and training, and evidence suggested intervention can benefit depressed residents. Care home staff were perceived to lack necessary skills, but relatively few CMHTs provided formal training.

Limitations

Limitations include a necessary reliance on observational rather than experimental methods, which were not feasible given the nature of the services explored.

Conclusions

BoC: Shifting care towards the community would require the growth of support services; clarification of extra care housing’s (ECH) role; timely responses to people at risk of psychiatric admission; and improved hospital discharge planning. However, the promotion of care at home will not necessarily reduce public expenditure. CMHTsOP: Although practitioners favoured integration, its goals need clarification. Occupational therapists (OTs) and social workers faced difficulties identifying optimal roles, and support workers’ career structures needed delineating. Care home outreach: Further CMHT input to build care home staff skills and screen for depression may be beneficial. Priority areas for further study include the costs and benefits for older people of age inclusive mental health services and the relative cost-effectiveness of different models of mental health outreach for older care home residents.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Diagnosing unexplained fever: can quick diagnosis units replace inpatient hospitalization?

BACKGROUND

Outpatient quick diagnosis units (QDUs) have become an increasingly recognized alternative to hospitalization for the diagnosis of a number of potentially serious diseases. No study has prospectively evaluated the usefulness of QDU for the diagnosis of unexplained fever.

MATERIALS AND METHODS

We prospectively assessed patients referred to QDU due to fever of uncertain nature (FUN), defined as a temperature > 38 °C during at least 1 week and no diagnosis after a previous evaluation. We also evaluated consecutive patients with FUN who were hospitalized during the same period. QDU and hospital costs were analysed by micro-costing techniques.

RESULTS

We evaluated 176 QDU patients and 168 controls. QDU patients were younger and required fewer investigations than controls. QDU patients had higher prevalence of viral infections (36% vs. 8%, P < 0·001) and lower prevalence of bacterial infections (6% vs. 46%, P < 0·001) and malignancies (2% vs. 14%, P < 0·001). While time-to-diagnosis of QDU patients was longer than length-of-stay of controls (25·82 vs.12·89 days, P < 0·001), 56% of QDU patients only required up to two visits. Cost per QDU patient was €644·59, while it was €4404·64 per hospitalized patient.

CONCLUSIONS

QDU patients with FUN were younger and had less serious diseases than controls including more viral and less bacterial infections and fewer malignancies. Mainly owing to untimely diagnostic reports, time-to-diagnosis was longer in QDU patients. Cost-savings in QDU were substantial. Using objective tools to evaluate the condition severity and general health status of FUN patients could help decide the most appropriate setting for their diagnostic study.

Health system reform in rural China: voices of healthworkers and service-users

Like many other countries China is undergoing major health system reforms, with the aim of providing universal health coverage, and addressing problems of low efficiency and inequity. The first phase of the reforms has focused on strengthening primary care and improving health insurance coverage and benefits. The aim of the study was to explore the impacts of these reforms on healthworkers and service-users at township level, which has been the major target of the first phase of the reforms. From January to March 2013 we interviewed eight health officials, 80 township healthworkers and 80 service-users in eight counties in Zhejiang and Yunnan provinces, representing rich and poor provinces respectively. Thematic analysis identified key themes around the impacts of the health reforms. We found that some elements of the reforms may actually be undermining primary care. While the new health insurance system was popular among service-users, it was criticised for contributing to fast-growing medical costs, and for an imbalance of benefits between outpatient and inpatient services. Salary reform has guaranteed healthworkers' income, but greatly reduced their incentives. The essential drug list removed perverse incentives to overprescribe, but led to falls in income for healthworkers, and loss of autonomy for doctors. Serious problems with drug procurement also emerged. The unintended consequences have included a brain drain of experienced healthworkers from township hospitals, and patients have flowed to county hospitals at greater cost. In conclusion, in the short term resources must be found to ensure rural healthworkers feel appropriately remunerated and have more clinical autonomy, measures for containment of the medical costs must be taken, and drug procurement must show increased transparency and accountability. More importantly the study shows that all countries undergoing health reforms should elicit the views of stakeholders, including service-users, to avoid and address unintended consequences.

Professional perspectives on systemic barriers to admission avoidance: learning from a system dynamics study of older people's admission pathways

BACKGROUND

There is debate worldwide about the best way to manage increased healthcare demand within ageing populations, particularly rising rates of unplanned and avoidable hospital admissions.

OBJECTIVES

To understand health and social care professionals' perspectives on barriers to admission avoidance throughout the admissions journey, in particular: the causes of avoidable admissions in older people; drivers of admission and barriers to use of admission avoidance strategies; and improvements to reduce unnecessary admissions.

DESIGN

A qualitative framework analysis of interview data from a System dynamics (SD) modelling study.

METHODS

Semi-structured interviews were conducted with twenty health and social care professionals with experience of older people's admissions. The interviews were used to build understanding of factors facilitating or hindering admission avoidance across the admissions system. Data were analysed using framework analysis.

RESULTS

Three overarching themes emerged: understanding the needs of the patient group; understanding the whole system; and systemwide access to expertise in care of older people. There were diverse views on the underlying reasons for avoidable admissions and recognition of the need for whole-system approaches to service redesign.

CONCLUSIONS

Participants recommended system redesign that recognises the specific needs of older people, but there was no consensus on underlying patient needs or specific service developments. Access to expertise in management of older and frailer patients was seen as a barrier to admission avoidance throughout the system.

IMPLICATIONS FOR PRACTICE

Providing access to expertise and leadership in care of frail older people across the admissions system presents a challenge for service managers and nurse educators but is seen as a prerequisite for effective admission avoidance. System redesign to meet the needs of frail older people requires agreement on causes of avoidable admission and underlying patient needs.

Sociodemographic, clinical and organisational factors associated with delayed hospital discharges: a cross-sectional study

Background

Evidence from studies conducted in Western countries indicates that a significant proportion of hospital beds are occupied by patients who experience a delayed hospital discharge (DHD). However, evidence about this topic is lacking in Italy, and little is known on the patients’ and organisational characteristics that influence DHDs. Therefore, we carried out a survey in all the hospitals of a Northern Italian region to analyse the prevalence and the determinants of DHD.

Methods

A cross-sectional study was carried out during an index period of 15 days in 256 operative units in Emilia-Romagna, a Northern Italian region with 4.4 million inhabitants, to identify patients medically fit for discharge but still hospitalised. The characteristics of these patients (n = 510) were compared with all the other patients (n = 5,815) hospitalised in the same operative units during the index period using multilevel logistic regression models.

Results

The one-day prevalence of DHD was 8.1%. More than half of DHD patients (52.7%) waited to access long-term/rehabilitation units or residential care homes, 16.7% experienced a delay for family-related reasons, and 14.5% were waiting to be admitted to other rehabilitation services. Among DHD patients hospitalised in long-term/rehabilitation units, 45.3% were waiting to be transferred to residential care homes. Patients’ characteristics associated with a higher likelihood of DHD in multilevel logistic regression were older age, provision of intensive care, a diagnosis of dementia, tumours or femoral/shoulder fractures, and a number of comorbidities. Patients hospitalised in long-term/rehabilitation units, as well as in orthopaedics/traumatology units, were significantly more likely to have a DHD compared with patients hospitalised in general surgery units. Moreover, compared with Local Health Authority Hospitals, being hospitalised in Hospital Trusts was associated with a higher likelihood of DHD.

Conclusions

Although the prevalence of DHD in the present study is markedly lower than that reported in the literature, we submit that the DHD problem should be addressed with major organisational innovations, with a special focus on the ageing of the population and epidemiological trends. Organisational changes imply new ways of managing emerging clusters of patients whose needs are not efficiently or effectively met by traditional organisation models and services.

An examination of factors influencing delayed discharge of older people from hospital

OBJECTIVE

This study aimed to investigate the factors associated with the delayed discharge of older people from hospital and their length of stay (LOS).

METHODS

Data were collected retrospectively from inpatient records and adult social care services on older patients referred to the latter prior to hospital discharge.

RESULTS

Data on two related measures--delayed discharge and LOS--were analysed separately within a four-stage sequential framework. Using bivariate analysis, we found that cognitive impairment and dependency were significantly associated with delay. Patients admitted to trauma and orthopaedics specialties were significantly more likely to be delayed on discharge. Respiratory illness was negatively associated with delay. Factors related to care received as an inpatient associated with delayed discharge from hospital were not being in the responsible consultant's bed for part of their stay, two or more moves between specialties and receipt of rehabilitation services. Admission to a care home and receipt of domiciliary care if returning to a private dwelling on discharge were associated with delay. In the multivariate analysis, dependence and cognitive impairment impacted differently on delay and LOS. Hospital variables were the most important predictors of LOS and social care variables in respect of delayed discharge.

CONCLUSION

Patient characteristics and especially the organisation of care in hospital and the provision of services on discharge are related to the likelihood of delayed discharge and LOS. Improved services and structures to systematically assess and treat patient needs in hospital, together with the timely provision of services providing post-discharge services tailored to individual circumstances, are required.

Quick diagnosis units--an effective alternative to hospitalization for diagnostic workup: a systematic review

INTRODUCTION

This era of healthcare reform emphasizes improving value of care. Inpatient admissions for diagnostic evaluation put economic pressure on an already strained healthcare system. We conducted a systematic review of effectiveness of quick diagnosis units (QDUs), an established outpatient model for early diagnostic workups in Europe.

METHODS

We searched MEDLINE and Embase for studies that focused on implementation of quick/rapid diagnosis units, with relevant Medical Subject Headings terms and keywords. Of 2047 studies, we selected 13 for full-text screening and bibliography review. Of these, 5 studies included at least 2 primary outcomes of interest and were included in our review. These units functioned as outpatient clinics, staffed by internists, nurses, and clerical staff, with expedited scheduling of outpatient diagnostic tests. Our primary outcome measures were final diagnosis, the mean time to final diagnosis, inpatient bed-days saved per patient, and costs saved per patient. We also studied discharge disposition, care preferences, and safety data.

RESULTS

About 18% to 30% of patients were diagnosed with malignancy, with an average time to diagnosis of 6 to 11 days. Inpatient bed-days saved per patient ranged from 4.5 to 7. Savings from fixed costs of hospitalization ranged from $2336(€1764) to $3304(€2514) for each patient enrolled in the protocol. The QDU model was preferred by 88% of patients, and patient satisfaction rates were 95% to 97%.

CONCLUSIONS

QDUs seem an effective and cost-saving alternative to inpatient hospitalization, and appear to be a safe approach for diagnostic workup of potentially severe diseases in select patient populations, although there are limited safety data available.

Does integrated governance lead to integrated patient care? Findings from the innovation forum

Good integration of services that aim to reduce avoidable acute hospital bed use by older people requires frontline staff to be aware of service options and access them in a timely manner. In three localities where closer inter-organisational integration was taking place, this research sought patients' perceptions of the care received across and within organisational boundaries. Between February and July 2008, qualitative methods were used to map the care journeys of 18 patients (six from each site). Patient interviews (46) covered care received before, at the time of and following a health crisis. Additional interviews (66) were undertaken with carers and frontline staff. Grounded theory-based approaches showed examples of well-integrated care against a background of underuse of services for preventing health crises and a reliance on 'traditional' referral patterns and services at the time of a health crisis. There was scope to raise both practitioner and patient awareness of alternative care options and to expand the availability and visibility of care 'closer to home' services such as rapid response teams. Concerns voiced by patients centred on the adequacy of arrangements for organising ongoing care, while family members reported being excluded from discussions about care arrangements and the roles they were expected to play. The coordination of care was also affected by communication difficulties between practitioners (particularly across organisational boundaries) and a lack of compatible technologies to facilitate information sharing. Finally, closer organisational integration seemed to have limited impact on care at the patient/practitioner interface. To improve care experienced by patients, organisational integration needs to be coupled with vertical integration within organisations to ensure that strategic goals influence the actions of frontline staff. As they experience the complete care journey, feedback from patients can play an important role in the service redesign agenda.

The Appropriateness Evaluation Protocol is a poor predictor of in-hospital mortality

BACKGROUND

The Appropriateness Evaluation Protocol (AEP) proposes admission criteria based only on physiological and laboratory parameters and has recently informed an Irish national bed utilisation review. Severity of illness tools can be poorly predictive of outcomes, particularly in older patients.

AIMS

To assess the clinical utility of the AEP in moribund older and younger patients.

METHODS

The study was conducted in four acute hospitals in South Munster, Ireland, and was of retrospective analytical cohort study design. The Hospital In-Patient Enquiry Scheme was used to ascertain patients who died within 10 days of hospital admission, over a 2-year period. Proximate death was used as a robust measure of validity of admission. Emergency department (ED) records were screened retrospectively to allocate the AEP criteria.

RESULTS

There were 803 eligible in-hospital deaths. Establishment of AEP criteria was available in 72.9 % (585 patients, 50.8 % female). The median length of stay until death was 4 days. Just over 30 % (179/585) of patients did not meet AEP criteria, two-fifths (72/179) of whom had been coded as severely unwell on arrival to the ED. There was no significant difference in AEP identification rates between older and younger age groups.

CONCLUSIONS

Our study illustrates that the AEP is a poor predictor of mortality in all age groups, having failed to identify approximately one-third of our cohort. Based on our findings, we feel that this tool should not be used to assess the appropriateness of admission.

Strategies for reducing potentially avoidable hospitalizations for ambulatory care-sensitive conditions

PURPOSE

Hospitalizations for ambulatory care-sensitive conditions (ACSCs) are seen as potentially avoidable with optimal primary care. Little is known, however, about how primary care physicians rate these hospitalizations and whether and how they could be avoided. This study explores the complex causality of such hospitalizations from the perspective of primary care physicians.

METHODS

We conducted semistructured interviews with 12 primary care physicians from 10 primary care clinics in Germany regarding 104 hospitalizations of 81 patients with ACSCs at high risk of rehospitalization.

RESULTS

Participating physicians rated 43 (41%) of the 104 hospitalizations to be potentially avoidable. During the interviews the cause of hospitalization fell into 5 principal categories: system related (eg, unavailability of ambulatory services), physician related (eg, suboptimal monitoring), medical (eg, medication side effects), patient related (eg, delayed help-seeking), and social (eg, lack of social support). Subcategories frequently associated with physicians' rating of hospitalizations for ACSCs as potentially avoidable were after-hours absence of the treating physician, failure to use ambulatory services, suboptimal monitoring, patients' fearfulness, cultural background and insufficient language skills of patients, medication errors, medication nonadherence, and overprotective caregivers. Comorbidities and medical emergencies were frequent causes attributed to ACSC-based hospitalizations that were rated as being unavoidable.

CONCLUSIONS

Primary care physicians rated a significant proportion of hospitalizations for ACSCs to be potentially avoidable. Strategies to avoid these hospitalizations may target after-hours care, optimal use of ambulatory services, intensified monitoring of high-risk patients, and initiatives to improve patients' willingness and ability to seek timely help, as well as patients' medication adherence.

Reducing unnecessary hospital days to improve quality of care through physician accountability: a cluster randomised trial

BACKGROUND

Over 20% of hospital bed use is inappropriate, implying a waste of resources and the increase of patient iatrogenic risk.

METHODS

This is a cluster, pragmatic, randomised controlled trial, carried out in a large University Hospital of Northern Italy, aiming to evaluate the effect of a strategy to reduce unnecessary hospital days. The primary outcome was the percentage of patient-days compatible with discharge. Among secondary objectives, to describe the strategy's effect in the long-term, as well as on hospital readmissions, considered to be a marker of the quality of hospital care. The 12 medical wards with the longest length of stay participated. Effectiveness was measured at the individual level on 3498 eligible patients during monthly index days. Patients admitted or discharged on index days, or with stay >90 days, were excluded. All ward staff was blinded to the index days, while staff in the control arm and data analysts were blinded to the trial's objectives and interventions. The strategy comprised the distribution to physicians of the list of their patients whose hospital stay was compatible with discharge according to a validated Delay Tool, and of physician length of stay profiles, followed by audits managed autonomously by the physicians of the ward.

RESULTS

During the 12 months of data collection, over 50% of patient-days were judged to be compatible with discharge. Delays were mainly due to problems with activities under medical staff control. Multivariate analysis considering clustering showed that the strategy reduced patient-days compatible with discharge by 16% in the intervention vs control group, (OR=0.841; 95% CI, 0.735 to 0.963; P=0.012). Follow-up at 1 year did not yield a statistically significant difference between the percentages of patient-days judged to be compatible with discharge between the two arms (OR=0.818; 95% CI, 0.476 to 1.405; P=0.47). There was no significant difference in 30-day readmission and mortality rates for all eligible patients (N=3498) between the two arms.

CONCLUSIONS

Results indicate that a strategy, involving physician direct accountability, can reduce unnecessary hospital days. Relatively simple interventions, like the one assessed in this study, should be implemented in all hospitals with excessive lengths of stay, since unnecessary prolongation may be harmful to patients.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT01422811.

Community Stepdown Care: A Safe Alternative for Selected Elderly Patients Attending Emergency Department?

Background. The Community Stepdown Care Initiative attempts to provide right siting of care for elderly emergency department attendees whose main need is rehabilitation. Objectives. The aim of this study was to compare reattendance and rehospitalisation rates, length of stay, medical complication rates, and discharge destination between the community hospital cohort and the acute hospital cohort. Methods. A retrospective cohort study was conducted from June 2007 to November 2008. Results. Two hundred and thirty patients were enrolled in the study. 68 patients were successfully transferred to stepdown care; 162 patients were admitted to acute hospital. The odds ratio of reattendance was similar in both cohorts at 2 weeks, 6 months, and 12 months. The odds ratio of rehospitalisation was similar in both cohorts at 2 weeks, 3 months, 6 months, and 12 months. There was no statistical difference in the medical complication rates between the cohorts. Patients were more likely to be discharged home from the community hospital compared to acute hospital (adjusted OR 4.11, P=0.03). 14% of patients from the acute hospital cohort was discharged to community hospital. Conclusions. For selective elderly emergency department attendees whose predominant need is rehabilitation, stepdown care is a safe alternative compared to usual acute hospital care.

Delay in discharge and its impact on unnecessary hospital bed occupancy

Background

Elderly patients are potentially more vulnerable to prolonged hospital stay as they frequently require additional resources to facilitate their discharge. In an acute hospital setting, we aimed to quantify and compare length of stay (LOS) for all patients over and under the age of 65, and identify the number and cause of days lost under the care of a single surgical unit.

Methods

Over a 4 month period from January to April 2010, data on the management and source of potential delay was collected daily on consecutive patients admitted and discharged under the care of one consultant surgeon at a district general hospital. Statistical analysis was then performed with particular focus on actual delays affecting elderly patients.

Results

A total of 99 complete inpatients episodes were recorded. There were 30 elective and 69 acute admissions. 10 (33%) elective vs. 42 (61%) acute patients encountered delays, losing 39 and 232 days respectively (χ² [1, N = 99] = 6.36, p = .012). 23 of a total 39 elderly patients admitted acutely required specialist care of the elderly opinion and placement in community hospitals resulting in delays of 188 days. vs. 36 days for the 16 discharged home and 8 days for 30 patients under 65 (χ² (2, N = 69) = 26.54, p = <.001).

Conclusions

Elderly patients experiencing acute surgical admission and discharge to community hospitals had prolonged LOS due to significant delays associated with care of the elderly provision. The financial considerations behind bed capacity in primary and secondary care and the provision of care of elderly services need to be balanced against unnecessary occupancy of acute hospital beds with its associated health and economic implications.

Standardizing admission and discharge processes to improve patient flow: a cross sectional study

Background

The aim of this study was to evaluate how hospital capacity was managed focusing on standardizing the admission and discharge processes.

Methods

This study was set in a 900-bed university affiliated hospital of the National Health Service, near Barcelona (Spain). This is a cross-sectional study of a set of interventions which were gradually implemented between April and December 2008. Mainly, they were focused on standardizing the admission and discharge processes to improve patient flow. Primary administrative data was obtained from the 2007 and 2009 Hospital Database. Main outcome measures were median length of stay, percentage of planned discharges, number of surgery cancellations and median number of delayed emergency admissions at 8:00 am. For statistical bivariate analysis, we used a Chi-squared for linear trend for qualitative variables and a Wilcoxon signed ranks test and a Mann–Whitney test for non-normal continuous variables.

Results

The median patients’ global length of stay was 8.56 days in 2007 and 7.93 days in 2009 (p < 0.051). The percentage of patients admitted the same day as surgery increased from 64.87% in 2007 to 86.01% in 2009 (p < 0.05). The number of cancelled interventions due to lack of beds was 216 patients in 2007 and 42 patients in 2009. The median number of planned discharges went from 43.05% in 2007 to 86.01% in 2009 (p < 0.01). The median number of emergency patients waiting for an in-hospital bed at 8:00 am was 5 patients in 2007 and 3 patients in 2009 (p < 0.01).

Conclusions

In conclusion, standardization of admission and discharge processes are largely in our control. There is a significant opportunity to create important benefits for increasing bed capacity and hospital throughput.

Triumph of hope over experience: learning from interventions to reduce avoidable hospital admissions identified through an Academic Health and Social Care Network

BACKGROUND

Internationally health services are facing increasing demands due to new and more expensive health technologies and treatments, coupled with the needs of an ageing population. Reducing avoidable use of expensive secondary care services, especially high cost admissions where no procedure is carried out, has become a focus for the commissioners of healthcare.

METHOD

We set out to identify, evaluate and share learning about interventions to reduce avoidable hospital admission across a regional Academic Health and Social Care Network (AHSN). We conducted a service evaluation identifying initiatives that had taken place across the AHSN. This comprised a literature review, case studies, and two workshops.

RESULTS

We identified three types of intervention: pre-hospital; within the emergency department (ED); and post-admission evaluation of appropriateness. Pre-hospital interventions included the use of predictive modelling tools (PARR - Patients at risk of readmission and ACG - Adjusted Clinical Groups) sometimes supported by community matrons or virtual wards. GP-advisers and outreach nurses were employed within the ED. The principal post-hoc interventions were the audit of records in primary care or the application of the Appropriateness Evaluation Protocol (AEP) within the admission ward. Overall there was a shortage of independent evaluation and limited evidence that each intervention had an impact on rates of admission.

CONCLUSIONS

Despite the frequency and cost of emergency admission there has been little independent evaluation of interventions to reduce avoidable admission. Commissioners of healthcare should consider interventions at all stages of the admission pathway, including regular audit, to ensure admission thresholds don't change.

Quick diagnosis units or conventional hospitalisation for the diagnostic evaluation of severe anaemia: a paradigm shift in public health systems?

BACKGROUND

Acute hospital bed utilisation is a growing concern for health care systems in most countries with public health models, as it represents a significant share of health costs. Anaemia with haemoglobin levels below 8 g/l has traditionally been a criterion used to hospitalise patients in our centre for diagnosis.

METHODS

We conducted a longitudinal study with a prospective and retrospective cohort to investigate the usefulness of a Quick Diagnosis Unit (QDU) for the evaluation of patients with severe anaemia as compared with hospitalisation in a tertiary public hospital. We recorded pretransfusion haemoglobin and haematocrit values, Charlson comorbidity index, waiting time for the first visit, time to diagnosis (length-of-stay in hospitalised patients), final diagnosis, costs, and responses to an opinion survey.

RESULTS

QDU patients were significantly younger [65.63 years (17.44)] than hospitalised patients [76.11 years (12.68)] (P<.0001). No significant differences were observed regarding time to diagnosis/length-of-stay, haemoglobin concentrations and Charlson index. Iron-deficiency anaemia was the commonest type of anaemia in both cohorts and benign digestive lesions accounted for most cases. The mean cost per process (admission-discharge episode) was 2920.62 Euros in the QDU and 18,278.01 Euros in hospitalised patients. If further diagnostic tests were required, 85% of patients would prefer the QDU care model to conventional hospital admission.

CONCLUSIONS

For diagnostic purposes, patients with severe anaemia can be managed similarly in a QDU or in-hospital setting, but the QDU model is more cost-saving than traditional hospitalisation. Most QDU patients preferred the QDU model to hospital admission.

Admissions to a Norwegian emergency psychiatric ward: patient characteristics and referring agents. A prospective study

BACKGROUND

In Norway, general practitioners serve as gatekeepers for specialist psychiatric care. Out-of-hours primary healthcare (i.e. casualty clinics) is responsible for the major part of acute psychiatric referrals. There are concerns regarding regular general practitioners' (rGPs') role in emergency psychiatric care of their enlisted patients. Also, the quality of casualty clinics' care and their gatekeeper function are questioned.

AIMS

To investigate differences between acute admissions to a psychiatric hospital from casualty clinics, rGPs, specialist psychiatric services and other specialist services regarding characteristics of patients and circumstances of the referrals.

METHODS

A prospective observational study. In the period of 1 May 2005 to 30 April 2008, anonymous information was recorded for all consecutive admissions (n = 5317) to the psychiatric acute unit (PAU) at a psychiatric hospital serving 400,000 inhabitants. The recorded information was: referring agent, circumstances of the referral, patient characteristics, and assessments by the receiving psychiatric resident and the therapist in charge of treatment at the PAU.

RESULTS

There were only small differences between patients referred to PAU from casualty clinics, rGPs, specialist psychiatric services and other specialist services. The referrals from the different referring agents seemed equally well founded. However, the casualty clinics used more police assistance and coercion, and legal basis for admissions was more frequently converted than for other referring agents.

CONCLUSION

Casualty clinics seem to function adequately as gatekeepers. The high proportion of casualty clinic referrals with converted legal basis might indicate unnecessary use of coercion.

Quick diagnosis units versus hospitalization for the diagnosis of potentially severe diseases in Spain

OBJECTIVES

We describe the functioning of a quick diagnosis unit (QDU) in a Spanish public university hospital to ascertain the utility and cost of the model compared to conventional hospitalization.

DESIGN

Observational study with a prospective and retrospective cohort.

SETTING

Spanish tertiary public university hospital.

PATIENTS

Two thousand consecutive patients evaluated between December 2007 and July 2010 with potentially severe diseases normally requiring hospitalization for diagnosis. For comparative purposes, we analyzed a randomized, retrospective cohort of 1454 hospitalized patients.

MEASUREMENTS

Variables measured included source of referral, reason for consultation, time to diagnosis and length-of-stay, hospitalizations avoided, Charlson comorbidity index, costs, and patient satisfaction using a telephone survey.

RESULTS

Suspected anemia, cachexia-anorexia syndrome, febrile syndrome, adenopathies and/or palpable masses, abdominal pain, diarrhea, and lung abnormalities accounted for 88% of QDU patients. The most-frequent diagnoses were cancer (26.3%) and iron-deficiency anemia. QDU patients with anemia were significantly younger than hospitalized patients with the same diagnosis (P < 0.0001). Other parameters were similar between QDU and hospitalized patients. The mean cost of treatment was 3153.87 Euros for hospitalization and 702.33 Euros for the QDU. Patients expressed a high degree of satisfaction with QDU care.

CONCLUSIONS

QDUs can manage the diagnosis of patients with potentially severe diseases equally as well as traditional hospitalization, and saves costs. QDU patients expressed a high degree of satisfaction, with most preferring this model to hospitalization.

Inappropriate hospital admission: interaction between patient age and co-morbidity

The aim of the study is to determine the prevalence of inappropriate admission, and to identify the factors that influence appropriateness of hospital admission. Data were prospectively collected from all 345 consecutive patients admitted during the period of 1 month for acute hospital care at a 110-bed division of internal medicine using socio-demographic and medical information. Statistical analyses included χ2 tests, t tests, and logistic regression analyses. According to the European version of the Appropriateness Evaluation Protocol of hospital admission, 28.1% of medical admissions for acute care in the Central Hospital of Bolzano, Italy, have been classified as inappropriate. Factors that reduced appropriateness included female gender, age and chronic illness that are significantly associated with appropriateness of medical admission, whereas time of day or day of week of the emergency department (ED) visit does not influence appropriateness. In multiple logistic regression analyses, age and co-morbidity are not independently related to appropriateness, however, when tested for interaction, inappropriateness is significantly more frequent at a young age in the absence of co-morbidities, and, numerically most relevant, in elderly patients presenting with co-morbidities. In this evaluation of a single centre North Italian hospital admission, co-morbidity turns out to be an important age-dependent determinant of appropriateness. Although in the young age group, co-morbidity increases the likelihood of being appropriately admitted, the presence of chronic illness in the elderly increases the risk of inappropriate hospital use.

A unit-coordinator system: an effective method of reducing inappropriate hospital stays

BACKGROUND

Many hospitals would benefit from a reduction in the length of inpatient hospital stays; in this regard, nursing approaches require complementation to ensure optimized nursing care. Such action is particularly important in general hospitals in Korea, where the ratio of patients to nurses is more than 10:1.

OBJECTIVES

This study aimed to determine the effectiveness of a unit-coordinator system in complementing primary nursing in general hospitals as a means of reducing inappropriate hospital stays.

METHODS

The unit-coordinator system was implemented in seven wards in a hospital in Seoul for 8 weeks. The existing primary nursing system was maintained, and newly placed unit-coordinators organized the activities within each ward. The numbers of early admissions and early discharges were determined by assessing the electronic administrative records of the hospital. Further, the number of patients who had undergone check-ups and chemotherapy on the day of admission was confirmed from the daily reports of each ward. The effect of the unit-coordinator system on nurse satisfaction was assessed through direct interviews.

FINDINGS

Early-discharge and early-admission numbers increased significantly after implementation of the unit-coordinator system. Early admission allowed check-ups and treatments to be performed on the day of admission. Thus, this system reduced the length of hospital stay by 1 day, and the total reduction of inappropriate hospital stays over the 8-week study period was 66 days. Further, the unit-coordinator system also increased nurse satisfaction.

CONCLUSION

The unit-coordinator system is an effective method of complementing primary nursing and reducing inappropriate hospital stays.

From bed-blocking to delayed discharges: precursors and interpretations of a contested concept

Delayed hospital discharges have been identified as a problem for the English National Health Service and have prompted several policy and service development responses in the last decade. However, bed-blocking is an issue surrounded by rival interpretations on how and why hospital delays occur and the way in which they are measured. To better understand this contested concept, this paper provides a brief description of the historical accounts that framed the emergence of delayed hospital discharges as a phenomenon. Three key features of the bed-blocking concept are also analysed: the reduction of patients' length of stay to improve efficiency, the intrinsic methodological difficulties of measuring hospital delays and the most common reasons for delayed discharges. A description of the characteristics of the patients frequently labelled as delayed discharge, their common traits and how these have been examined by previous research is also provided. Finally, this paper argues that the presence of hospital delays in a health system tends to be considered as an indicator of two possible system inefficiencies: a failure in the discharge planning process, which generally blames social services departments for not ensuring timely services, or a shortage of alternative forms of care for this group of patients.

Long-stay inpatients in short-term emergency units in France: A case study

Lacking any conventional definition, the phenomenon of so-called "bed-blockers" concerns the issue of long-stay inpatients in short-term units. Our paper explores this question in the context of French Emergency Rooms (ERs) and focuses not on "bed-blocking" as a patient phenomenon but rather on the social constructs developed around these patients by ER professionals. In this paper, we present a case study on one of these "bed-blockers" and venture some hypotheses regarding this phenomenon. On the one hand, it appears as a dysfunction in the healthcare system. Indeed, French ERs take on patients that specialized medical units are reluctant to admit, either because they do not fit into any one specific scientific or clinical category, or because they are not "profitable" when analyzed using care-management tools. On the other hand, bed-blockers play an important role in building a positive identity for the French emergency doctors and personnel performing the "dirty work" of treating them.

Validation of a tool assessing appropriateness of hospital days in rehabilitation centres

OBJECTIVE

To develop and validate a list of objective criteria to assess the appropriateness of hospital days for patients admitted to rehabilitation centres and sub-acute care units.

DESIGN

Sixteen appropriateness criteria were defined by a multidisciplinary panel of 33 experts using a formalized consensus method. A single ticked criterion classifies the hospital day as appropriate. Reliability was studied by measuring concordance between two independent and simultaneous ratings using the instrument. External validity was tested by comparing conclusions derived from the instrument with the individual judgements of one, two or three experts on the same random sample of hospital days.

PARTICIPANTS

The assessment on these criteria was performed on a randomized sample of 406 hospital days from 17 French wards.

MAIN OUTCOME MEASURES

Inter-rater reliability and external validity were evaluated using the kappa statistic and prevalence-adjusted and bias-adjusted kappa (PABAK).

RESULTS

The inter-rater reliability test showed a kappa-value of 0.71 [95% confidence interval (95% CI) 0.63-0.78] and a PABAK of 0.77 (95% CI 0.70-0.83). There was a good agreement between the conclusions reached using the instrument and the individual judgements of experts with a kappa coefficient of 0.42 (95% CI 0.35-0.50) and a PABAK of 0.60 (95% CI 0.52-0.67).

CONCLUSIONS

The instrument is reliable and valid for assessing appropriateness of hospital days in rehabilitation centres and sub-acute care units. The next step in this study is the development of a tool for the analysis of causes of inappropriateness.

Appropriateness of acute admissions and last in-patient day for patients with long term neurological conditions

Background

To examine the appropriateness of admissions and in-patient stay for patients with long term neurological conditions (LTNCs). To identify variables predictive of appropriateness and explore management alternatives.

Methods

Adults admitted as acute patients to Derby Hospitals NHS Foundation Trust (England). Data were collected prospectively and examined by a multi-disciplinary expert panel to determine the appropriateness of admission and length of stay (LoS). Management alternatives were discussed.

Results

A total of 119 participants were recruited. 32 admissions were inappropriate and 83 were for an inappropriate duration. Whether a participant lived in their own home was predictive of an inappropriate admission. The number of LTNCs, number of presenting complaints and whether the participant lived alone in their own home were predictive of an inappropriate LoS. For admissions judged to be inappropriate, the panel suggested management alternatives.

Conclusion

Patients with LTNCs are being admitted to hospital when other services, e.g. ambulatory care, are available which could meet their needs. Inefficiencies in hospital procedures, such as discharge planning and patient transfers, continue to exist. Recognition of the need to plan for discharge at admission and to ensure in-patient services are provided in a timely manner may contribute towards improved efficiency.

Predictors of PTSD symptoms in response to psychosis and psychiatric admission

The experiences of psychosis and psychiatric admission have the potential to act as events precipitating posttraumatic stress disorder (PTSD) symptoms. Known risk factors for the development of PTSD symptoms in adults were identified. These included childhood trauma, current psychiatric symptoms, perceived coercion, and relationships with mental health service providers. These factors were analyzed to determine if they were important in the development of PTSD symptoms in response to psychosis and admission. We used a cross-sectional design with a sample of 47 participants recruited from a service in Northern Ireland who had experienced psychosis and been discharged from inpatient treatment within 12 months of data collection. The main outcome measure was the impact of events scale-revised. Data was subject to correlation analyses. A cut-off point of r = +/- 0.25 was used to select variables for inclusion in hierarchical regression analyses. Forty-five percent and 31% of the sample had moderate to severe PTSD symptoms related to psychosis and admission, respectively. The majority of participants identified positive symptoms and the first admission as the most distressing aspects of psychosis and admission. Childhood sexual and physical traumas were significant predictors of some PTSD symptoms. Strong association was found between current affective symptoms and PTSD symptoms. A reduced sense of availability of mental health service providers was also associated with PTSD symptoms and depression. Awareness of risk factors for the development of PTSD symptoms in response to admission and psychosis raises important issues for services and has implications for interventions provided.

UK Consensus Conference on Acute Medicine

The ageing population and the growth in numbers of patients suffering from long-term conditions demands an adequate response from the health service to provide care and support. This is particularly true when individuals experience an acute deterioration in their health: they have a right to expect prompt, effective treatment from competent clinicians who are properly equipped. This pressure on the NHS has been reflected in the increasing numbers of acute admissions to medical beds and the increasing percentage of acute bed days occupied by patients aged over 80 years. Recognizing the need to provide good care at the front door, the NHS looked for solutions and appointed a number of doctors to manage acute medical units. None of these doctors had been trained specifically for this task but, subsequently, training programmes were developed. However, the place of acute medicine remains the subject of debate.

Increasing appropriateness of hospital admissions in the Emilia-Romagna region of Italy

Objectives:

The Emilia-Romagna region of Italy has reduced the number of available hospital beds and introduced financial incentives to curb hospital use. The goal of this study was to assess the impact of these policies on changes over time in the number of acute hospital admissions classified in diagnosis related groups (DRGs) that could be treated safely and effectively in alternative, less costly settings.

Methods:

The assessment of the appropriate site of care was based on analysis of hospital discharge data for all hospitals for the selected diagnosis related groups in the Emilia-Romagna region for 2001 to 2005. The necessity for acute hospital admission was based on the severity of a patient's principal diagnosis, co-morbid diseases and, for surgical admissions, procedure performed.

Results:

From 2001 to 2005, potentially inappropriate medical admissions of more than one day decreased from 20,076 to 11,580, a 42% decrease. Inappropriate admissions decreased in both public and private hospitals but there remained a higher rate of inappropriate admissions to private hospitals. Potentially inappropriate medical admissions accounted for 128,319 bed-days in 2001 and 68,968 bed-days in 2005, a reduction of 59,351 bed-days. Potentially inappropriate surgical admissions decreased from 7383 in 2001 to 4349 in 2005, a 41% decrease. Bed-days consumed by inappropriate surgical admissions decreased from 23,181 in 2001 to 13,660 in 2005.

Conclusions:

The Emilia-Romagna region has succeeded in reducing the use of acute hospital beds for patients in selected diagnosis related groups. However, there are still substantial numbers of admissions that could potentially be treated in less costly settings.