Minimally invasive surgery. Implications for hospitals,health workers,and patients.

Minimally invasive surgery is one of the great innovations of health care in the 20th century. It promises to revolutionise surgery by allowing many more operations to be performed with minimal hospitalisation. Pressure from patients has caused many techniques to spread rapidly before they have been adequately assessed. This must be resisted, and policy makers must pay more attention to minimally invasive surgery to ensure that good assessments are made. The widespread use of minimally invasive techniques has important implications for hospitals and health workers. As more patients are treated on an outpatient basis, fewer hospital beds will be needed, and traditional operating rooms will have to adapt to a greater turnover of patients. Surgeons will have to acquire new operating skills, possibly requiring formal training and accreditation, and, as different specialties fight for control of new technologies, surgery may eventually be merged with internal medicine so that specialists will deal with organ systems. Postoperative care will have to be carried out in the community rather than in hospitals, and policy makers will need to reorganise their health systems to cope with these developments.     

General-practitioner Hospital Beds: A Review

This paper reviews literature related to general-practitioner hospital beds. In England and Wales 21% of all maternity beds are controlled by general practitioners rather than consultants, and the proportion has increased considerably since 1955. Nearly one in five of these 21% are sited in the wards of a consultant hospital. General-practitioner beds, other than maternity, represent 3% of all hospital beds (excluding psychiatric beds) and this proportion has remained constant over the past 15 years. Only about 1% of these general-practitioner beds are located in a consultant hospital.In the discussion three questions are raised: Will general-practitioner inpatient care have a useful function in the future? What might that function be? Where should the care be located? The broader issue of the future role of the general practitioner needs to be considered before these questions can be satisfactorily answered. Unless a “hospital orientated” role of the general practitioner prevails there seems little place for practitioner inpatient care in urban areas. In the more rural areas, however, whatever the role of the practitioner becomes, certain groups of patients might advantageously receive inpatient care from their practitioners. Firmer answers to the questions raised cannot be given until a co-ordinated programme of research and development concerning different patterns of care is started.     

Pathogen-free isolation unit — Three years' experience

The results obtained during the first three years of a pathogen-free isolation unit containing five beds have shown that this type of unit can reduce the risk of infection in patients treated with intensive chemotherapy or in those who have granulocytopenia from various causes. It is suggested that treatment of cancer which involves these risks should be carried out routinely in sterile isolation units, and that it is urgent to build many more and much larger units.     

Is the medical value of the “personal touch” being underestimated as costs are cut?

Those involved in health care planning and the possible closure of health care facilities should remember that patients must have confidence and feel secure with the health care team in order to achieve rapid recovery. Dr. Jack Rothstein, staff surgeon at a Montreal hospital that has been slated for closure, points out the medical value of personalized, attentive care delivered by community hospitals. At a time when patients are being given more responsibility for managing their own care, he argues, elements of the health care system that help achieve continuity of care and patient empowerment should be protected. The issue is important in Montreal because the government has announced plans to close seven hospitals with 1224 acute-care beds.     

A Survey of Psychiatric Units in General Hospitals in Canada

The Canadian Psychiatric Association recently recommended that all general hospitals over 200 beds should have psychiatric in-patient units. Questionnaires were sent to the administrators of the 52 existing general hospital psychiatric units in Canada. Most administrators expressed approval of these units, although some noted the existence of problems. Statistics are given on the staffing of the units. Although the number of beds was small, these facilities accounted for a very large number of admissions. Most had active teaching programs. The advantages of implementing the C.P.A. recommendation are many. General hospital psychiatric units should be encouraged to undertake comprehensive psychiatry, that is, to accept all types of psychiatric patients, and to retain responsibility for long-term care.     

A flexible model for planning facilities for patients with end-stage renal failure.

Resource needs for patients with renal failure change as policies vary and survival improves. Thus a model was developed to estimate the facilities (number of beds) needed for such patients in the North-west Region; national resource needs could be obtained by multiplying the regional needs by eleven. The model predicted an unforeseen demand for hospital and satellite unit facilities and for unit back-up beds. The increasing survival of transplants is an important determinant of resource needs, and the model readily indicates the impact of changes in this factor.     

Minor Gynaecological Outpatient Operations

Altogether 143 patients had minor gynaecological operations performed under general anaesthesia in the outpatient department. This method proved to be very acceptable to patient, gynaecologist, and anaesthetist. No complications occurred requiring admission to hospital, and the short recovery time confirmed the safety of early discharge from hospital. This procedure had a beneficial effect on the waiting list, and expensive beds were used more efficiently for major surgical cases. It is recommended that this procedure should be more widely practised, provided that the patients are adequately screened.     

Unblocking beds: a geriatric unit's experience with transferred patients.

A study was made of all patients admitted to a geriatric unit over several years. The admission policy included a high degree of priority to requests for transfer from acute beds, which resulted in transferred patients accounting for 25% of admissions. Unblocking acute beds did not lead to prolonged delay in admitting patients from the community to the geriatric unit. Almost 30% of beds allocated to transferred patients were recovered in 30 days.     

What is the potential for moving adult surgery to the ambulatory setting?

Data from the Manitoba health insurance program were used to analyse the patterns of outpatient surgery in patients aged 20 years or older in the eight largest hospitals in the province (all with at least 125 beds) in 1983-84. With the exception of tooth extraction, only procedures that were not done more than 86% of the time as inpatient or outpatient procedures were considered. Large differences between the hospitals and between physicians within each hospital were found in the rates of outpatient surgery, even after adjustment for patient characteristics and differences in case mix. If the standard of the hospital with the highest rate of outpatient surgery were followed by the seven other hospitals, up to 17.5 inpatient beds could be closed or freed. However, the potential savings from substituting outpatient for inpatient procedures must be realistically appraised. The appropriate place for monitoring the use of inpatient and outpatient surgery may be the individual hospital, particularly those with high occupancy rates and a large demand for inpatient beds.     

Contribution of general practitioner hospitals in Scotland.

The results of a survey of 64 Scottish general practitioner hospitals showed that in 1980 these hospitals contained 3.3% of available staffed beds in Scotland; 13.6% of the resident population had access for initial hospital care, and 14.5% of Scottish general practitioners were on their staffs. During the year of the survey they discharged 1.8% of all non-surgical patients, treated almost 100 000 patients for accidents and emergencies and 140 000 outpatients, and 4.4% of all deliveries in Scotland were carried out in the hospitals surveyed. Most communities which are served by general practitioner hospitals in Scotland are rural and on average are more than 30 miles from their nearest district general hospital. The contribution that these small hospitals make to the overall hospital workload has not previously been estimated. It has been shown nationally to be small but not inconsiderable . In terms of the contribution to the health care of the communities they serve it cannot and should not be underestimated.     

"Homeward bound": a minimal care rehabilitation unit.

A 20 bed minimal care rehabilitation unit was set up by Newham District Health Authority in a small hospital originally scheduled for closure when a new district general hospital was opened. During the first year 114 patients were admitted (throughput 5.7), with a median length of stay of 30 days; in the second year 173 patients were admitted (throughput 8.65) with a median length of stay of 28.5 days. The cost per inpatient day was less than that of an inpatient day at the district''s long stay geriatric unit. Before the unit opened 24% of the acute beds had been occupied for more than six weeks, whereas two years later only 6% of the acute beds were occupied for such a period.     

Organisation of vascular surgical services: evolution or revolution?

The trend towards subspecialisation in hospital services is likely to lead to the development of vascular surgery as a separate specialty. If vascular surgery is to emerge as a high quality service then vascular emergencies--a substantial component of the workload--should be dealt with by surgeons with adequate training, and all patients should have equal access to the service. A specialist vascular surgical unit would have to be large enough to make efficient use of other services that it needs, such as radiology, and so may require the amalgamation of smaller health district units. Because of the differing local degrees of subspecialisation, national or regional strategies for vascular surgery must be developed.     

Alternatives to hospital care: what are they and who should decide?

OBJECTIVE--To examine potential for alternatives to care in hospitals for acute admissions, and to compare the decisions about these alternatives made by clinicians with different backgrounds. DESIGN--Standardised tool was used to identify patients who could potentially be treated in an alternative form of care. Information about such patients was assessed by three panels of clinicians: general practitioners without experience of general practitioner beds, general practitioners with experience of general practitioner beds, and consultants. SETTING--One hospital for acute admissions in a rural area of the South and West region of England. SUBJECTS--Of 620 patients admitted to specialties of general medicine and care of the elderly, details of 112 were assessed by panels. MAIN OUTCOME MEASURES--Proportion of hospitalised patients who could have received alternative care and identification of most appropriate alternative form of care. RESULTS--Both general practitioner panels estimated that between 51 and 89 of the hospitalised patients could have received alternative care (equivalent to 8-14% of all admissions). Consultants estimated that between 25 and 55 patients could have had alternative care (5.5-9% of all admissions). General practitioner bed and urgent outpatient appointment were the main alternatives chosen by all three panels. CONCLUSION--About 10% of admissions to general hospital might be suitable for alternative forms of care. Doctors with different backgrounds made similar overall assessments of most appropriate forms of care.     

Psychogeriatric Ward for Mentally Disturbed Elderly Patients

The operation is described of a special psychogeriatric ward of 23 beds set up in 1967 to provide treatment for mentally disturbed elderly patients who could not be kept in a general ward or at home. The unit is in a predominantly geriatric hospital which serves a population of 340,000 and in the four and a half years reviewed 600 patients were admitted. Half of the admissions were emergencies. A consultant geriatrician was in charge and the nursing staff were general trained. The number of beds was found to be adequate for the demand. Few patients had to be transferred to a psychiatric hospital, but, since the mental disturbance was often associated with severe illness and the patients were old, the death rate was high. The nursing staff have found the work interesting and stimulating.     

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.     

Comprehensive care of patients with head injuries.

The comprehensive head injury service run by the neurosurgeons at the Hull Royal Infirmary for the surrounding population of one million was analysed. The analysis showed that all patients with either a fractured skull or a lowered level of consciousness should be admitted to a district general hospital because the associated risk of their having a major head injury is over 20%. Those patients with both a fractured skull and a lowered level of consciousness have a 60% likelihood of a major head injury and should be transferred immediately to the neurosurgical unit. Patients with compound or complicated fractures of the skull and those without fractured skulls but with neurological impairment persisting for four hours or more, should also be transferred to the neurosurgical unit. If these guidelines are followed about 200 patients/million population will be referred to the neurosurgical centre. Patients with a minor head injury and none of the clinical risk factors may safely be sent home. This should reduce the rate of admissions to hospital for head injuries by 60%.     

Intensive care triage: priority should be independent of whether patients are already receiving intensive care

Intensive care units (ICUs) are not always able to admit all patients who would benefit from intensive care. Pressure on ICU beds is likely to be particularly high during times of epidemics such as might arise in the case of swine influenza. In making choices as to which patients to admit, the key US guidelines state that significant priority should be given to the interests of patients who are already in the ICU over the interests of patients who would benefit from intensive care but who have not been admitted. We examine four reasons that in principle might justify such a prioritization rule and conclude that none is convincing. We argue that the current location of patients should not, in principle, affect their priority for intensive care. We show, however, that under some but not all circumstances, maximizing lives saved by intensive care might require continuing to treat in the ICU a patient already admitted rather than transferring that patient out of the unit in order to admit a sicker patient who would also benefit more from intensive care. We conclude that further modelling is required in order to clarify what practical policies would maximize lives saved by intensive care.     

Terminal care: present services and future priorities.

Since 1975 hospices and other specialist services for terminal cancer have expanded rapidly. In December 1980 this survey found 72 such services in Britain providing 58 inpatient units, 32 home care teams, and eight hospital support teams. Many were outside the NHS. Inpatient units provided 1297 beds (modal size 21-25 beds) and dealt with under 7% of deaths from cancer. Home care teams provided 76.5 full-time equivalent nurses (modal size two nurses). Regional variations were considerable: from 10.9 beds/million population in Trent to 48.5 beds/million in South-west Thames; no home care nurses in Mersey and Wales, and 5.1 nurses/million in Wessex. Of 58 more services being planned, the 17 starting in 1981 will not substantially alter these regional imbalances. Respondents'' opinions suggest a target of 40-50 inpatient unit beds/million population. This might be reduced if hospitals were better equipped to deal with these patients. Suggested priorities are to redress regional inequalities, develop home care and hospital support teams rather than inpatient units, and improve teaching and training. Co-ordination of plans between the NHS and the voluntary sector is needed.     

Antibiotic anaphylaxis

Pulmonary cancer when localized to the lung, is curable by operation. Tumors found by routine x-ray examination before they cause symptoms are much more often confined to the lung and as such are curable. Unlike other internal growths which are more hidden, lung tumors can often be seen early on x-ray films of the chest.X-ray films of the chest were made routinely on all patients entering a hospital, regardless of the nature of their illness. In all, some 40,000 films were made. Sixty patients were found to have unsuspected solitary lesions in the lung. Twenty-four of the lesions were diagnosed and treated by operation and removal. Twelve were diagnosed by other methods. Of the 36, eight were cancer of the lung, an incidence of 22 per cent. There were also 14 localized tuberculous nodules which are best treated by removal. Since early cancer is surgically curable, it is felt that everyone over the age of 40 should have a routine x-ray examination of the chest every six months. Solitary lesions of the lung found should be excised for diagnosis.     

Edinburgh Emergency Asthma Admission Service: report on 10 years' experience.

In December 1968 an emergency service was begun in Edinburgh to expedite admission to hospital of patients with severe acute asthma. During the first 10 years requests were made to admit 112 patients to a respiratory unit with provision for intensive care on 360 occasions. Four of the patients died of their disease, one in hospital and three before admission. It was thought that the death rate would have been much higher had conventional admission procedures been observed. Owing to ethical objections to a controlled trial it was not possible to obtain substantive proof that the service reduced deaths from asthma. Nevertheless, there was strong circumstantial evidence that organised facilities for the immediate admission to hospital of patients with a history of life-threatening attacks would result in fewer deaths at home. Earlier admission also apparently reduced hospital mortality and the number of patients requiring tracheal intubation and mechanical ventilation. It is concluded that there is a prima facie case for an emergency asthma admission serivce similar to that operating in Edinburgh to be established in all cities and large towns.