Acute hospital discharge delays are a pressing concern for many health care administrators. In Canada, a delayed discharge is defined by the alternate level of care (ALC) construct and has been the target of many provincial health care strategies. Little is known on the patient characteristics that influence acute ALC length of stay. This study examines which characteristics drive acute ALC length of stay for those awaiting nursing home admission.
Population-level administrative and assessment data were used to examine 17,111 acute hospital admissions designated as alternate level of care (ALC) from a large Canadian health region. Case level hospital records were linked to home care administrative and assessment records to identify and characterize those ALC patients that account for the greatest proportion of acute hospital ALC days.
ALC patients waiting for nursing home admission accounted for 41.5% of acute hospital ALC bed days while only accounting for 8.8% of acute hospital ALC patients. Characteristics that were significantly associated with greater ALC lengths of stay were morbid obesity (27?day mean deviation, 99% CI?=?±14.6), psychiatric diagnosis (13?day mean deviation, 99% CI?=?±6.2), abusive behaviours (12?day mean deviation, 99% CI?=?±10.7), and stroke (7?day mean deviation, 99% CI?=?±5.0). Overall, persons with morbid obesity, a psychiatric diagnosis, abusive behaviours, or stroke accounted for 4.3% of all ALC patients and 23% of all acute hospital ALC days between April 1st 2009 and April 1st, 2011. ALC patients with the identified characteristics had unique clinical profiles.
A small number of patients with non-medical days waiting for nursing home admission contribute to a substantial proportion of total non-medical days in acute hospitals. Increases in nursing home capacity or changes to existing funding arrangements should target the sub-populations identified in this investigation to maximize effectiveness. Specifically, incentives should be introduced to encourage nursing homes to accept acute patients with the least prospect for community-based living, while acute patients with the greatest prospect for community-based living are discharged to transitional care or directly to community-based care.
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Although the care of inpatients is an important aspect of radiation oncology practice in many countries, it has never been studied in detail. The goal of this study was to describe the admissions to a radiation oncology inpatient service over a 1-year period with respect to patient characteristics, primary malignancies, common nonmalignant diagnoses, use of radiotherapy and outcome of admission.
Using computerized hospital databases, we analysed the utilization of 11 radiation oncology beds in a 424-bed teaching hospital from March 31, 1991, to April 1, 1992.
There were 342 admissions of 277 patients. The median age was 66.5 years; the male:female ratio was 1:1. The commonest primary neoplastic diagnoses were lung (42%), gynecological (15%), genitourinary (14%) and breast (8%) cancers. Only 17% of the patients had cancer as the sole diagnosis; most patients had multiple medical diagnoses. Infections (22%), neurological (20%), cardiovascular (13%) and endocrine (9%) conditions were the commonest. Mean length of stay was 11.25 days. Most of the admissions (71%) resulted in discharge to the patient's home; few patients (15%) died. Only half of admissions involved radiotherapy, indicating that the focus of patient care was the medical treatment of cancer complications or other active medical problems.
These data show that radiation oncology inpatients have complicated medical problems, and they support the training of radiation oncologists in the comprehensive medical care of patients.
This study aimed to investigate trends in first-time hospitalisations with chronic obstructive pulmonary disease (COPD) in a publicly financed healthcare system during the period from 2002 to 2008 with respect to incidence, outcome and characteristics of hospitalisations, departments, and patients.
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Decreasing rate of first-time COPD hospitalisations combined with shorter lengths of stay and increasing severity of cases indicates that the use of hospital beds for COPD exacerbations has been gradually restricted. This may be causally related to both the centralisation into overcrowded departments and the improved outside hospital treatment of COPD, also demonstrated in this study.
A shortage of intensive care beds and fully-booked intensive care units has a range of undesirable consequences for patients and personnel, eg. transfer to other intensive care units, cancellation of operations, tighter visitation criteria and an increase in the work-load. The problem is illustrated in a national survey.
The survey was undertaken in 3 parts and comprised all 50 adult intensive care units in Denmark. Part 1 was a questionnaire encompassing demographic data, the number of open intensive care beds and how often under or over capacity was experienced in the department. Parts 2 and 3 consisted of a daily registry of the capacity and occupancy rate in the intensive care departments for two weeks along with a contemporary registry of the number of admittances, transfers and cancellations of operations.
In Denmark only 2% of all somatic beds are intensive care beds. Under capacity, defined as a 100% occupancy rate, was experienced weekly or monthly in 80% of all intensive care units in Denmark. Occupancy rate was high, a medium of 78%, highest in level III intensive care units with an 88% occupancy rate. The numbers for transfers were equivalent to 800-1000 patient transfers per year. The number of cancelled operations was equivalent to 2000 per year.
This survey documents that there is a problem with the capacity in Danish intensive care units. Establishing more intensive care beds in selected departments, ensuring personnel for the beds already established and establishing intermediate care beds could relieve the shortage of beds.
Comment In: Ugeskr Laeger. 2007 May 7;169(19):1811; author reply 181117542086
To examine the lengths of stay of chronic status patients in an acute care hospital, to identify discharge stages that contribute to excessive stays, to estimate the length of stay at each discharge stage and to link hospital bed-day utilization by the discharge stage to the experience of the patient.
Two-year prospective cohort study. The number of hospital days retrospective to the date of the current admission were included in the analysis.
All 115 inpatients formally declared as achieving chronic status by July 31, 1987.
Lengths of stay (total days and days at acute and chronic status) for chronic status patients, including those still in hospital at the end of the study period. Each bed-day was assigned to a discharge stage that corresponded to the patient's status. The disposition of each patient by the end of the study period was reviewed.
The study population spent a total of 101 585 days in hospital. The total length of stay per patient was nearly four times that stated in the hospital's annual report, in which the figure was calculated only on the basis of discharge data. On average only 77.2 (8.7%) of the days were spent in acute care. The remaining days were at the chronic level: 24.1% were spent waiting for completion of an application to a long-term care facility, 25.3% for application approval and 41.9% for an available bed in the assigned long-term care institution. For 30 patients no initiation of the discharge process was ever undertaken. As the number of patients in each progressive discharge stage decreased, the wait per patient increased. By the end of the study period only 32 patients had been transferred to a public long-term care facility; 22 were still in hospital, and 35 had died waiting for placement.
Although considered to be a useful measure of hospital efficiency, length of stay determined from discharge data creates an iceberg effect when applied to chronic status patients in acute care hospitals. Lack of access to the assigned resource is the most important reason for a delay in discharge. Interventions, whether undertaken at the patient, hospital or provincial level, must to some degree address this issue. Further study is required to determine which risk factors will predict lags at each discharge stage. Since our discharge staging reflects not only the experience of the patient but also the utilization of hospital bed-days and access to provincial resources, it provides a common language for clinicians, hospital administrators and systems planners.
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This paper examines the utility and sustainability of a clinical pathway for treating nursing home residents with pneumonia from the perspective of nursing administrators and medical directors in Ontario, Canada. The discussion includes a comparison of the perspectives of the administrators and the nursing staff (reported in part I of this article).
A qualitative case study design was used.
Data were collected from 6 nursing homes in Southern Ontario that were drawn from a larger randomized controlled trial of a clinical pathway to help identify, diagnose, and manage cases of nursing home-acquired pneumonia.
Six interviews were conducted with nursing administrators and 2 with medical directors (1 per facility). Key themes were identified in the interview data using the template style of analysis described by Miller and Crabtree.
Administrators were in favor of using a clinical pathway for identifying and treating pneumonia in nursing home residents. Participants thought that during the study residents with pneumonia received better and more timely care, and that nurses' clinical skills, knowledge, and confidence had improved. In comparison with views expressed by nurses and medical directors in the same facilities, nursing administrators tended to report less clinical training and staff support were required to successfully implement the pathway.
Even though nurses and administrators strongly support the use of a pneumonia clinical pathway in nursing homes, implementation plans should be tailored to individual facilities and be informed by the perspectives of both administrators and staff.
This paper examines nursing staff's perspectives on the utility and sustainability of a clinical pathway for treating nursing home residents with pneumonia.
A qualitative (case study) design was used.
Data were collected from 6 nursing homes in Southern Ontario (5 from metro regions and 1 from a nonmetro region). Nursing homes were drawn from a larger randomized controlled trial of a clinical pathway for nursing home-acquired pneumonia conducted between 2001 and 2005. The clinical pathway was designed to assist in the identification, diagnosis, and management of pneumonia, including a decision tool for determining the appropriate location of treatment (hospital versus nursing home).
A total of 7 focus groups and 1 one-on-one interview were conducted between February 2003 and May 2004. Interview data were analyzed using the template style, described by Miller and Crabtree, to identify key themes.
Nurses strongly supported the idea of the clinical pathway and believed that providing pneumonia care in the nursing home was better for the resident. As a result of using the clinical pathway, nurses felt that pneumonia was being identified, diagnosed, and treated earlier, resulting in fewer hospitalizations. In addition to the benefits to resident care, the nurses felt that their skills and knowledge also improved. Nurses generally supported the implementation of the pathway although some concern was expressed about the additional responsibility and resources that would entail.
The implementation of a clinical pathway for treating pneumonia in nursing homes and quick access to a backup clinician are desired by nurses who also believe it will result in better care and fewer hospitalizations of residents.
A comparison of infection control program resources, activities, and antibiotic resistant organism rates in Canadian acute care hospitals in 1999 and 2005: pre- and post-severe acute respiratory syndrome.
The Resources for Infection Control in Hospitals (RICH) project assessed infection control programs and rates of antibiotic-resistant organisms (AROs) in Canadian acute care hospitals in 1999. In the meantime, the severe acute respiratory syndrome (SARS) outbreak and the concern over pandemic influenza have stimulated considerable government and health care institutional efforts to improve infection control systems in Canada.
In 2006, a version of the RICH survey similar to the original RICH instrument was mailed to infection control programs in all Canadian acute care hospitals with 80 or more beds. We used chi(2), analysis of variance, and analysis of covariance analyses to test for differences between the 1999 and 2005 samples for infection control program components and ARO rates.
72.3% of Canadian acute care hospitals completed the RICH survey for 1999 and 60.1% for 2005. Hospital size was controlled for in analyses involving AROs and surveillance and control intensity levels. Methicillin-resistant Staphylococcus aureus (MRSA) rates increased from 1999 to 2005 (F = 9.4, P = .003). In 2005, the mean MRSA rate was 5.2 (standard deviation [SD], 6.1) per 1000 admissions, and, in 1999, it was 2.0 (SD, 2.9). Clostridium difficile-associated diarrhea rates trended up from 1999 to 2005 (F = 2.9, P = .09). In 2005, the mean Clostridium difficile-associated diarrhea rate was 4.7 (SD, 4.3), and, in 1999, it was 3.8 (SD, 4.3). The proportion of hospitals that reported having new nosocomial vancomycin-resistant Enterococcus (VRE) cases was greater in 2005 than in 1999 (chi(2) = 10.5, P = .001). In 1999, 34.5% (40/116) of hospitals reported having new nosocomial VRE cases, and, in 2005, 61.0% (64/105) reported new cases. Surveillance intensity index scores increased from a mean of 61.7 (SD, 18.5) in 1999 to 68.1 (SD, 15.4) in 2005 (F = 4.1, P = .04). Control intensity index scores trended upward slightly from a mean of 60.8 (SD, 14.6) in 1999 to 64.1 (SD, 12.2) in 2005 (F = 3.2, P = .07). Infection control professionals (ICP) full-time equivalents (FTEs) per 100 beds increased from a mean of 0.5 (SD, 0.2) in 1999 to 0.8 (SD, 0.3) in 2005 (F = 90.8, P
ReprintIn: Can J Infect Control. 2009 Summer;24(2):109-1519697536