First year of an inner city general practitioner community hospital.

The first inner city general practitioner community hospital opened on 4 January 1982. This paper describes the operation of the hospital over the first 12 months. There were 316 admissions, with an average length of stay of 13 days. The average age of the patients was 73 and the most common reason for admission was disease of the respiratory system. Thirty five per cent of patients were admitted because of an acute illness and 37% were admitted on the same day as the request for admission. The policies of intermittent or phased care allowed for the admission of patients at regular intervals to relieve carers, and the assessment of the home circumstances of all patients allowed for planning the patient''s return home.     

The need for acute,subacute, and nonacute care at 105 general hospital sites on Ontario

BACKGROUND: Previous studies of hospital utilization have not taken into account the use of acute care beds for subacute care. The authors determined the proportion of patients who required acute, subacute and nonacute care on admission and during their hospital stay in general hospitals in Ontario. From this analysis, they identified areas where the efficiency of care delivery might be improved. METHODS: Ninety-eight of 189 acute care hospitals in Ontario, at 105 sites, participated in a review that used explicit criteria for rating acuity developed by Inter-Qual Inc., Marlborough, Mass. The records of 13,242 patients who were discharged over a 9-month period in 1995 after hospital care for 1 of 8 high-volume, high-variability diagnoses or procedures were randomly selected for review. Patients were categorized on the basis of the level of care (acute, subacute or nonacute) they required on admission and during subsequent days of hospital care. RESULTS: Of all admissions, 62.2% were acute, 19.7% subacute and 18.1% nonacute. The patients most likely to require acute care on admission were those with acute myocardial infarction (96.2% of 1826 patients) or cerebrovascular accident (84.0% of 1596 patients) and those admitted for elective surgery on the day of their procedure (73.4% of 3993 patients). However, 41.1% of patients awaiting hip or knee replacement were admitted the day before surgery so did not require acute care on admission. The proportion of patients who required acute care on admission and during the subsequent hospital stay declined with age; the proportion of patients needing nonacute care did not vary with age. After admission, acute care was needed on 27.5% of subsequent days, subacute care on 40.2% and nonacute care on 32.3%. The need for acute care on admission was a predictor of need for acute care during subsequent hospital stay among patients with medical conditions. The proportion of patients requiring subacute care during the subsequent hospital stay increased with age, decreased with the number of inpatient beds in each hospital and was highest among patients with congestive heart failure, chronic obstructive pulmonary disease and pneumonia. INTERPRETATION: In 1995, inpatients requiring subacute care accounted for a substantial proportion of nonacute care days in Ontario''s general hospitals. These findings suggest a need to evaluate the efficiencies that might be achieved by introducing a subacute category of care into the Canadian health care system. Generally, efforts are needed to reduce the proportion of admissions for nonacute care and of in-hospital days for other than acute care.     

Pursuing efficiency in surgical practice.

To examine fluctuations in numbers of patients on surgical wards the dates of admission from January of each of the 5556 patients admitted from 1 January 1985 to 31 December 1987 were examined during computerised audit of a single surgical firm. The numbers of patients under the care of the firm fluctuated widely, often exceeding the 38 beds nominally available. Duration of stay varied from two days or less (3062 admissions) to more than a month (163 admissions). One patient was in hospital for 278 days. The patients admitted for more than a month (2.9% of the total) filled 28% of the beds; not all these patients were elderly. A further increase in throughput of patients undergoing elective operations might be achieved by always admitting patients on the day of operation, and perhaps by discharging patients even sooner than at present. Efficiency would increase but so would overall costs.     

Use of hospital beds: a cohort study of admissions to a provincial teaching hospital.

An instrument was developed to study the use of hospital beds and discharge arrangements of a cohort of 847 admissions to the John Radcliffe Hospital, Oxford, for a three week period during February-March 1986. For only 38% of bed days were patients considered to have medical, nursing, or life support reasons for requiring a provincial teaching hospital bed. The requirements for a bed in the hospital decreased with the patient''s age and length of stay in hospital. For only a tenth of patients was the general practitioner concerned in discussions with hospital staff about the patient''s discharge and less than one third of patients had been given more than 24 hours'' notice of discharge. Several features might increase the proportion of bed days that are occupied by patients with positive reasons for being in hospital. Among these are an increased frequency of ward rounds by consultants, or delegating discharge decisions by consultants to other staff; providing diagnostic related protocols for planning the length of stay in hospital; planned discharges; and providing liaison nurses to help with communication with primary care staff.     

One Year's Experience in a Ministry of Health Dialysis Centre

A 10-bed dialysis unit, opened at the London Hospital in 1968, admitted 37 patients during its first year of operation. The aims of the unit were to prepare patients for renal transplantation and to provide instruction for dialysis treatment at home. A total of 2,012 days were spent in hospital, the average intervals between admission, the first dialysis, and discharge being 23·8 and 20 days, respectively. The overall number of readmissions was 1·5 per patient. These figures, together with the increasing number of patients accepted for such treatment, indicate the considerable number of supporting hospital beds, as well as medical and technical staff, required to maintain a dialysis unit.     

Impact of a province-wide nurses' strike on medical care in a regional referral centre.

A 4-week, province-wide nurses'' strike in Alberta in 1982 caused the closure of 57% of the acute care beds, including 47% of the intensive care beds, in Calgary. The effects of the strike on patient care at Foothills Provincial General Hospital, where nurses did not strike, were assessed. The number of emergency admissions, severity of illness and rate of death in the intensive care unit increased. On the other hand, the rate of death, length of stay and number of unexpected deaths on the medical wards were similar to those in the control periods before and after the strike. A subjective perception by hospital personnel of deteriorating patient care caused much anxiety; however, the results of analysis of measurable aspects of care suggested that the patients admitted to hospital received care during the strike that was comparable to care given before or after the strike. The inconvenience and potential harm to the patients not admitted because they had less severe illness were not measured.     

Emergency geriatric surgical admissions

The emergency surgical work load created by patients aged 80 and over in a district hospital was assessed and the results of treatment examined. Over one year 248 patients aged 80 or over were admitted as emergencies, and the overall mortality rate was 21·8%. When terminal disease was excluded mortality rate was 12·5%. These elderly patients had an average length of stay in the acute surgical ward of 14·7 days compared with a mean of 8·4 days for all patients, and all but seven patients were discharged to their original place of referral.Elderly patients do exacerbate the bed shortage in acute surgical wards because they tend to stay longer than younger patients, but these elderly surgical patients imposed only a small load on the inpatient geriatric services, as 78% were discharged straight to their own homes and a further 17% went home after a period on the surgical convalescent wards.     

Randomised controlled trial of day patient versus inpatient psychiatric treatment.

OBJECTIVE--To assess the proportion of acutely ill psychiatric patients who can be treated in a day hospital and compare the outcome of day patient and inpatient treatment. DESIGN--Prospective randomised controlled trial of day patient versus inpatient treatment after exclusion of patients precluded by severity of illness or other factors from being treated as day patients. All three groups assessed at three and 12 months. SETTING--Teaching hospital serving small socially deprived inner city area. Day hospital designed to take acute admissions because of few beds. PATIENTS--175 Patients were considered, of whom 73 could not be allocated. Of the remaining 102 patients, 51 were allocated to each treatment setting but only 89 became established in treatment--namely, 41 day patients and 48 inpatients. 73 Of these 89 patients were reassessed at three months and 70 at one year. INTERVENTIONS--Standard day patient and inpatient treatment. MAIN OUTCOME MEASURES--Discharge from hospital and return to previous level of social functioning; reduction of psychiatric symptoms, abnormal behaviour, and burden on relatives. RESULTS--33 Of 48 inpatients were discharged at three months compared with 17 of 41 day patients. But at one year 9 of 48 inpatients and three of 41 day patients were in hospital. 18 Of 35 day patients and 16 of 39 inpatients were at their previous level of social functioning at one year. The only significant difference at three months was a greater improvement in social role performance in the inpatients. At one year there was no significant difference between day patients and inpatients in present state examination summary scores and social role performance, burden, or behaviour. CONCLUSIONS--Roughly 40% of all acutely ill patients presenting for admission to a psychiatric unit may be treated satisfactorily in a well staffed day hospital. The outcome of treatment is similar to that of inpatient care but might possibly reduce readmissions. The hospital costs seem to be similar but further research is required to assess the costs in terms of extra demands on relatives, general practitioners, and other community resources.     

Results of Early Mobilization and Discharge after Myocardial Infarction

A total of 342 patients with acute myocardial infarction who were admitted to a coronary care unit are reviewed to assess the results of early mobilization and discharge. The mean duration of admission was 8·4 days and 89% of the survivors were discharged from hospital by the tenth day. The inpatient mortality was 15·5%. An additional 6·7% died during the six weeks'' follow-up period, giving a total mortality of 22·2%. Altogether, 7·6% of patients were readmitted. Venous thromboembolic phenomena occurred in 3·5% during the inpatient period. Of patients who were eligible 62% were back at work five months after their myocardial infarction. We think the results justify a short hospital admission period for acute myocardial infarction.     

Inappropriate hospital use by patients receiving care for medical conditions: targeting utilization review

OBJECTIVE: To describe characteristics associated with inappropriate hospital use by patients in Manitoba in order to help target concurrent utilization review. Utilization review was developed to reduce inappropriate hospital use but can be a very resource-intensive process. DESIGN: Retrospective chart review of a sample of adult patients who received care for medical conditions in a sample of Manitoba hospitals during the fiscal year 1993-94; assessment of patients at admission and for each day of stay with the use of a standardized set of objective, nondiagnosis-based criteria (InterQual). PATIENTS: A total of 3904 patients receiving care at 26 hospitals. OUTCOME MEASURES: Acute (appropriate) and nonacute (inappropriate) admissions and days of stay for adult patients receiving care for medical conditions. RESULTS: After 1 week, 53.2% of patients assessed as needing acute care at admission no longer required acute care. Patients 75 years of age or older consumed more than 50% of the days of stay, and 74.8% of these days of stay were inappropriate. Four diagnostic categories accounted for almost 60% of admissions and days, and more than 50% of those days of stay were inappropriate. Patients admitted through the emergency department were more likely to require acute care (60.9%) than others (41.7%). Patients who were Treaty Indians had a higher proportion of days of stay requiring acute care than others (45.9% v. 32.8%). Patients'' income and day of the week on admission (weekday v. weekend) were not predictive factors of inappropriate use. CONCLUSION: Rather than conducting a utilization review for every patient, hospitals might garner more information by targeting patients receiving care for medical conditions with stays longer than 1 week, patients with nervous system, circulatory, respiratory or digestive diagnoses, elderly patients and patients not admitted through the emergency department.     

Shortening hospital stay for psychiatric care: effect on patients and their families

A one-year cohort of patients from a defined catchment area with acute functional disorders were allocated at random to brief care (experimental group) or standard care (control group) in hospital to examine the effect of shortening hospital stay on the clinical and social functioning of patients and the distress abnormal functioning caused to others. A total of 127 patients were interviewed on entry to the study, and 106 were followed up. The brief care group had significantly shorter mean and median lengths of stay than the control group, but there was no difference between the groups in the number of days spent in hospital during subsequent admissions. The groups were well matched for clinical and social variables. Rates of improvement over 13 weeks were essentially the same by all measures of outcome, including the Present State Examination and Patient''s Behaviour Assessment Scale, which was developed for the study to measure deterioration in behaviour and social functioning and adverse effects and distress on others. There was no difference between the two groups in burden to the community supporting services, social security requirements, or GP attendances. Improvement rates were nearly identical on all measures within and across diagnostic subgroups. Brief care resulted in a 33% reduction in average length of stay compared with the year before but was associated with a corresponding increase in day hospital use. The short-stay policy continued the year after the study finished.The findings confirm the value of shortening hospital stay and improving day care facilities for most localities.     

Inpatients in an accident unit.

A one-year prospective study was undertaken in the 79-bed accident unit of the Bristol Royal Infirmary to define reasons for continuing inpatient care. This showed that, of a consecutive series of 466 patients staying in hospital for over two weeks, 35% lengthened their stay beyond that needed for acute nursing or continued medical care. A combination of factors usually led to total social dependence, the major problem being the absence of a caring relative. Other factors included pre-existing locomotor disorder or mental infirmity, unmanageable incontinence of urine after catheterisation, and institutional disorientation. If the pattern of management of elderly patients after injury is not changed and beds are to be kept available for the newly injured the unit will need about 50 new long-stay beds each year.     

The community hospital: a three-year study.

In a three-year period a community hospital of 40 beds discharged 2086 patients, their mean length of stay being 14.8 days. Some 68% of the patients treated were over 65, and 8.9% died in hospital. While the most common diagnosis on admission was disease of the respiratory tract, this does not indicate the actual cause of admission. For 142 patients from one practice this was acute illness in 44% of the cases, assessment in 20%, and a need for nursing care in 36%. If the community hospital had not been available about half these patients would have been admitted to the general hospital.     

Inpatient deaths from acute myocardial infarction, 1982-92: analysis of data in the Nottingham heart attack register.

OBJECTIVE: To assess longitudinal trends in admissions, management, and inpatient mortality from acute myocardial infarction over 10 years. DESIGN: Retrospective analysis based on the Nottingham heart attack register. SETTING: Two district general hospitals serving a defined urban and rural population. SUBJECTS: All patients admitted with a confirmed acute myocardial infarction during 1982-4 and 1989-92 (excluding 1991, when data were not collected). MAIN OUTCOME MEASURES: Numbers of patients, background characteristics, time from onset of symptoms to admission, ward of admission, treatment, and inpatient mortality. RESULTS: Admissions with acute myocardial infarction increased from 719 cases in 1982 to 960 in 1992. The mean age increased from 62.1 years to 66.6 years (P < 0.001), the duration of stay fell from 8.7 days to 7.2 days (P < 0.001), and the proportion of patients aged 75 years and over admitted to a coronary care unit increased significantly from 29.1% to 61.2%. A higher proportion of patients were admitted to hospital within 6 hours of onset of their symptoms in 1989-92 than in 1982-4, but 15% were still admitted after the time window for thrombolysis. Use of beta blockers increased threefold between 1982 and 1992, aspirin was used in over 70% of patients after 1989, and thrombolytic use increased 1.3-fold between 1989 and 1992. Age and sex adjusted odds ratios for inpatient mortality remained unchanged over the study period. CONCLUSIONS: Despite an increasing uptake of the "proved" treatments, inpatient mortality from myocardial infarction did not change between 1982 and 1992.     

Acute Myocardial Infarction in Doncaster. I—Estimating Size of Coronary Care Unit

A “no refusal” coronary care service (for one year) was offered to a selected sample of 10 general practices (total list 74,657). The patients were admitted to a three-bedded unit in Doncaster Royal Infirmary and data were collected to enable estimation of the size of unit necessary to serve the whole population in the area (census estimate 268,560; total G.P. list 315,811). This estimation was based on:1. The frequency of admission to hospital of suspected acute myocardial infarction in one year, estimated at 978 from the total population.2. The average duration of stay in the unit, which was 2·45 days.3. The distribution of observed occupancy was approximately Poissonian.From these the average expected bed occupancy was calculated as 6·56 and reference to probability tables gave the frequency of overload for different numbers of beds provided. The incidence of acute myocardial infarction in the area is estimated at 275 per 100,000 per annum, on calculations based on the practice list size, and at 323 per 100,000 per annum, on calculations based on census figures.     

Four years' experience of an interim secure unit.

An interim secure unit of 14 beds (Rainford Ward) at Rainhill Hospital has been functioning for four years. During that period 78 patients were referred and 39 were admitted from various sources. Of those admitted, 40% were women, all had committed dangerous acts, and the most common diagnosis was schizophrenia. Only seven patients have stayed for one year or more, and only one seems set to stay indefinitely. Patients discharged are followed up in roughly equal numbers by their catchment area psychiatric teams and by the regional forensic psychiatric service. The number of patients in the ward has settled to about 12 for a population of one million. The unit now functions unobtrusively in a large psychiatric hospital, has a high morale, has had few recruiting problems, and has suffered extremely few disturbing incidents.     

Elderly patients in a general surgical unit: do they block beds?

In a prospective study of patients aged 65 years and over admitted to a general surgical unit only one patient in 10 remained in hospital for more than a month and fewer than one patient in a hundred became a "bed-blocker." While the over-65s had mean and median durations of stay which were longer than those of younger patients, in almost all cases a prolonged stay in hospital resulted from postoperative morbidity and was not related to social or administrative factors. Only a reduction in the incidence of postoperative morbidity could achieve a significant saving in the number of bed-days occupied by elderly people.     

Evolution of an active psychogeriatric day hospital.

A geriatric day hospital was established as part of the psychogeriatric unit of the Royal Ottawa Hospital. While initially this day hospital was integrated with day hospital programs of other units, it became apparent that a separate facility was desirable. The activities and programs of the psychogeriatric day hospital, run by one registered nurse, were integrated with those of the geriatric inpatient unit. It was found to be advantageous for inpatients and day hospital patients to share the same physical facilities. The majority of day hospital patients came from the inpatient unit; almost all had affective disorders. The emphasis was on reintegration into the community. During the 1st year of operation there were 75 patients in the program; only 3 needed admission to the inpatient unit and 1 was readmitted after discharge.     

Blocked beds.

In a cross-sectional survey of 325 surgical and orthopaedic beds 43 (16%) of the 265 occupied beds were filled by patients who had no medical need to be in an acute ward. They had been in hospital for a median time of 40 weeks up to the survey date. Of the 43 patients, 11 were awaiting transfer to a geriatric ward; 13 to community residential care; and seven to their homes. There was no plan for discharge or transfer for the remaining 12 (28%). Those "at risk" of becoming long-stay patients for social reasons on these wards were women, over 75, living alone or with one relative, who had been admitted to hospital in emergency with a fractured femur, head injury, or other trauma. Action necessary to reduce the number of social long-stay patients includes (a) changing attitudes to the solving of social case problems; (b) revising procedures of assessment and planning of future care; (c) improving teamwork and record keeping within the hospital and the community services; (d) providing a better balance of acute, medium and long-stay hospital beds; and (e) putting more resources into rehabilitation.