Acute Care Beds Research Articles

Pattern of care at the end of life: does age make a difference in what happens to women with breast cancer?

In the last 40 years, palliative care has become the standard of care at the end of life. However, there are limited data about the degree of access to such care at the population level. Using administrative databases, a care-oriented profile score was created to describe the care received during the last 6 months of life for 2,291 women who were dying of breast cancer in the province of Quebec, Canada, during the years 1992 to 1998. The care received was described through indicators of care that would reflect a palliative care philosophy. An ordinal score was developed for comparisons among age groups of women using a proportional odds ordinal regression model. We found that only 6.9% of women died at home, while 69.6% of them died in acute care beds. While most women (75%) had few indicators indicating provision of palliative care during the last 6 months of life, younger women (< 50 years) were even less likely (odds ratio, 0.70; 95% CI, 0.54 to 0.90) to receive such care compared with middle aged women (50 to 59 years; serving as the reference group), while older women (> 70 years) were more likely (odds ratio, 1.85; 95% CI, 1.49 to 2.29). Our study indicates that a sizeable proportion of women terminally ill from breast cancer do not have access to palliative care-an issue that health care policy makers may wish to explore further.

Evaluating and planning ICUs: methods and approaches to differentiate between need and demand

Objective: In all western countries the demand for ICU-services is increasing and complaints about a lack of ICU-beds arise – independent of the actual density of ICU-services. The demand for more ICU-beds triggered a debate on whether it is possible to define an “objective” need. It was the aim of the assessment to analyze conventional as well as innovative approaches to plan and to evaluate ICU-services. Method: Systematic review, multistep searches in Medline, EmBase, Cochrane, HTA-Database, websearches, informal searches through planning and HTA-networks. Introduction: The differences between the density of intensive care in Europe and other parts of the western world is enormous. At a first superficial glance, Austria and Germany – in absolute figures – have many more ICU-beds than any other European country. In relative figures, taken into consideration that Austria and Germany have also many more acute care beds, the number of ICU-beds is among European average. It is therefore, impossible to analyze the need for ICU-beds without taking into account the national context of delivered acute hospital services. Although ICU-services take about 15–20% of the hospital budgets, there are still more questions than answers. Results: • Recent planning-documents: a review of trends in recent planning shows that all planners calculate on the basis of existing style of practice within their countries; the figures change only marginally. But while planners in countries with a relatively low ICU-bed density (Great Britan, Australia, Canada) certify a certain need for an increase, planners in countries with high density (USA, Germany, Austria) state a “satisfied need” and an over-provision of ICU-services. • Innovative planners apply an “appropriateness of ICU-use” approach with analysing the actual utilisation by interpreting scores (especially TISS) and by identifying “low-risk” groups and propose a more flexible organisation of ICUs and a higher proportion of (intermediate care unit) IMCU-beds. • Clinical and ICU-management tools, such as admission and discharge guidelines, strategies to reduce treatment-variations, certain organisational changes (leadership, horizontal hierarchy) and costing methods gain importance for better, more efficient and co-ordinated use of ICU-resources. Conclusion: In countries with a high density of ICU-services – such as Austria and Germany – not an expanding of the capacities, but a better use of the existing resources is recommended. For a fair comparison, participation in national databases, in registers as well as benchmarking and quality-assurance programs should be enforced.

Health care for older persons: a country profile-Korea.

The Korean healthcare system is faced with a crisis caused by rapidly changing social values tending toward westernization, increasing insurance benefit requests for elder health care, financial instability of the National Health Insurance (NHI) program, and a lack of social infrastructure for the elderly. The demand for health care for the elderly has increased markedly, because of a rapidly aging population, growing female participation in the labor market, elevated expectations for health care, and a change in the pattern of medical conditions in the elderly from acute illness to chronic disability. NHI lacks the finances to meet the benefit request for long-term care (LTC). Only 0.39% of the elderly can be accommodated in LTC beds. Consequently, the chronically disabled elderly overflow to acute care beds in general hospitals, which places an undue burden on the already strained NHI system in terms of longer stays and higher cost of treatment in hospitals compared with care specific to the elderly in LTC facilities. It is clear that the Korean healthcare system does not have the facilities to meet such challenges and is in a state of disorder. Korea has failed to predict and prepare for population needs before they arise, including financing and the development of appropriate care models, particularly concerning the adequate provision of LTC. This paper advocates the necessity of international discussion of the prospects for developing health care for aging populations and encourages the sharing of differing national experiences concerning care for the elderly.

Nationwide surveillance of nosocomial infections in Switzerland--methods and results of the Swiss Nosocomial Infection Prevalence Studies (SNIP) in 1999 and 2002

The first multi-center prevalence study of nosocomial infections in Switzerland took place in 1996. Since then, the number of participating hospitals has steadily increased. Today, 72 hospitals of various sizes are part of the Swiss-NOSO surveillance network and represent 30% of all Swiss acute care hospitals, which include approximately 10,000 acute care beds. This article describes the methodology of the national prevalence studies and the results of the 1999 and 2002 surveys. The proportion of infected patients was 10.1% and 8.1% in 1999 and 2002, respectively. The highest prevalence occurred in intensive care units. The most prevalent nosocomial infections were surgical site infections, urinary tract infections, pneumonia, and bloodstream infections. Increasingly, crude rates of nosocomial infections serve as a quality indicator and are used for interhospital comparison and benchmarking. This may be misleading due to differences in case-mix between hospitals as shown in the 1999 study. Using a coordinated approach within a national network, surveillance of nosocomial infections has established itself as an indispensible part of infection control and prevention in Swiss hospitals.

The role of international medical graduates in America's small rural critical access hospitals.

Critical access hospitals (CAHs) are a federal Medicare category for isolated rural facilities with 15 or fewer acute care beds that receive cost-based reimbursement from Medicare. This study examines the role of foreign-born international medical graduates (IMGs) in the staffing of CAHs. Chief executive officers (CEOs) of CAH facilities answered a telephone survey on their use of IMGs and the characteristics of those IMGs in winter 2002 (388 responded, for a 96% response rate). This descriptive report presents roles and characteristics of IMGs in CAH facilities and the opinions of the CEOs about these practitioners. Overall, 1 (24%) in 4 admitting physicians in CAHs are graduates of non-US medical schools (compared with 23% of physicians nationally), although the rates are higher for CAHs in persistent poverty counties, CAHs that report recruitment problems, and CAHs with smaller medical staffs. Hospitals east of the Mississippi River are more heavily reliant on IMGs than hospitals in the west. Most IMGs are internists (59%) and most (61%) come from India, the Philippines, or Pakistan. Hospital administrators rate the clinical skills of their IMGs highly and their interpersonal skills only slightly lower. Almost half of CAH administrators said their communities recruited their first IMGs during or after 1994, the year of pro-IMG legislative changes. IMG physicians play a significant and possibly growing role in staffing CAHs.

Toward benchmarks for tertiary care for adults with severe and persistent mental disorders.

Scarce attention has been paid to establishing benchmarks for tertiary care for adults with severe mental disorders. Yet, the availability and efficient utilization of residential resources partly determines the capacity of a comprehensive system of care to avoid clogging ever-shrinking acute care bed facilities. To describe the actual utilization of and projected needs for residential resources, one part of tertiary care, in the catchment area of a psychiatric hospital in east-end Montreal. To compare results obtained against actual utilization and projected needs evaluated in other Canadian provinces and in other countries, with a view to establishing national benchmarks. Two surveys were undertaken to establish the number of places in these facilities that were utilized and needed for adults aged 18 to 65 years with severe mental disorders, without a primary diagnosis of mental retardation or organic brain syndrome, and originally from the catchment area. A first survey ascertained the number of places utilized and of those needed for residential care among all long-stay inpatients and all adults in supervised residential facilities. A second survey identified the need for such long-stay hospitalization, nursing homes, and supervised facilities as an alternative or as a complement to hospitalization among acute care inpatients. The actual ratio of places in long-stay hospital units, nursing homes, and supervised residential facilities was 150:100,000 inhabitants. The ideal ratio, according to estimated needs, is 171:100,000. The figure breakdown is as follows: 20:100,000 for long-stay hospital units, 20:100,000 for nursing homes, 40:100,000 for group homes, 40:100,000 for private hostels or foster families, and 51:100,000 for supervised apartments. The needs of this urban, blue-collar population for supervised residential places hovered in the upper range of utilization and standards for European countries and within the proposed standards for Canadian provinces. Needs for long-stay hospitalization or for supervised residential facilities cannot be treated as absolute. For example, evaluation conducted in this hospital-led system of psychiatric care may produce higher estimates of institutional care. Comparing actual utilization and projected needs in this urban catchment area with current utilization in other jurisdictions in Canada and Europe should contribute to establishing sound national benchmarks within ranges. It is possible to establish benchmarks that guide the development of supervised residential settings to best meet the needs of the population of adults with severe and persistent mental disorders. The methods used here to assess needs should serve as guidelines for future research, because they were designed to contain the bias of over- or underprovision of care in the current utilization.

The state of infection surveillance and control in Canadian acute care hospitals

Background: Nosocomial infections and antibiotic-resistant pathogens cause significant morbidity, mortality, and economic costs. The infection surveillance and control resources and activities in Canadian acute care hospitals had not been assessed in 20 years. Methods: In 2000, surveys were mailed to infection control programs in all Canadian hospitals with more than 80 acute care beds. The survey was modeled after the US Study on the Efficacy of Nosocomial Infection Control instrument, with new items dealing with resistant pathogens and computerization. Surveillance and control indices were calculated. Results: One hundred seventy-two of 238 (72.3%) hospitals responded. In 42.1% of hospitals, there was fewer than 1 infection control practitioner per 250 beds. Just 60% of infection control programs had physicians or doctoral professionals with infection control training who provided services. The median surveillance index was 65.6/100, and the median control index was 60.5/100. Surgical site infection rates were reported to individual surgeons in only 36.8% of hospitals. Conclusions: There were deficits in the identified components of effective infection control programs. Greater investment in resources is needed to meet recommended standards and thereby reduce morbidity, mortality, and expense associated with nosocomial infections and antibiotic-resistant pathogens. (Am J Infect Control 2003;31:266-73.)

Side Rails Faulted for Acute Care Bed Recall

Side Rails Faulted for Acute Care Bed Recall

Are longer hospital stays beneficial for the elderly?

Utilization review is a way to manage healthcare costs and is widespread in Canada, as managers attempt to use available acute-care beds in a best practice manner. As we reduce beds and decrease length of stay, we often wonder if the outcomes for patients are affected, particularly if the patients are elderly.

Care of injection drug users with soft tissue infections in San Francisco, California.

Illicit injection drug use results in serious soft tissue infections that are the number one nonpsychiatric reason for admission to San Francisco General Hospital (SFGH), San Francisco, Calif. To establish a specialized clinic to provide accessible, high-quality, and cost-effective medical care to patients with soft tissue infections. DESIGN, SETTING, INTERVENTION, AND OUTCOME MEASURES: The Integrated Soft Tissue Infection Services (ISIS) Clinic was established to provide coordinated surgical intervention, substance abuse counseling, and social services for patients with soft tissue infections treated in a public hospital. Demographic information, treatment outcome, and hospital utilization data were analyzed. In the clinic's first year of operation, there were 3365 patient visits and 2255 surgical procedures. A large number of patients reported recent injection of illicit drugs (61%), were homeless (30%), and either had hepatitis C, hepatitis B, or human immunodeficiency virus infection (62%). Patients using heroin were enrolled in either a detoxification or maintenance program (42%). Few patients were designated as treatment failures (2%) or were lost to follow-up (14%). The ISIS Clinic dramatically reduced emergency department visits (-33.9%), surgical service admissions (-47.3%), inpatient acute care bed days (-33.7%), and operating room procedures (-71%), saving approximately $8 765 200 in the first year of operation. This clinical intervention was notably cost-effective while preserving a high quality of medical services. Owing to limited data, we can only assume that other communities are similarly confronted with this public health problem. The ISIS Clinic could serve as a model intervention and thus have significant impact on the treatment of this prevalent but often overlooked challenge.

Staffing requirements for infection control programs in US health care facilities: Delphi project

Background: The guideline for staffing infection control programs of 1 infection control professional (ICP) for every 250 occupied acute care beds has been used in many health care facilities in the United States since 1985. Since that time, the health care system, patient populations, and expectations about the work of infection prevention and control programs have changed substantially. Methods: The Delphi method was used; data were obtained from a group of ICPs through a series of 10 surveys. Through this iterative process, participant responses were progressively synthesized and areas of agreement and disagreement identified. These surveys were conducted by electronic and paper mail to identify the personal ICP characteristics and structural variables associated with performance of activities required for contemporary infection prevention and control programs in a variety of health care settings. Results: Delphi panel members (n = 32) from 20 states and who represented acute care, long-term care, and community care settings reported tasks in addition to those identified in earlier task analyses as well as expanded responsibilities. Competing responsibilities and lack of adequate resources were the most frequently cited reasons for nonperformance of essential infection control tasks. A ratio of 0.8 to 1.0 ICP for every 100 occupied acute care beds was suggested as adequate staffing by the Delphi panel. Conclusions: Infection control responsibilities have expanded beyond the traditional acute care setting. Recommendations for staffing must not only consider the number of occupied beds (average daily census) but also include the scope of the program, the complexity of the health care facility or system, the characteristics of the patient population, and the unique or urgent needs of the facility and community. (Am J Infect Control 2002;30:321-33.)

A Case for Community and Hospital-Based Long-Term Care Facilities in Saudi Arabia

A Case for Community and Hospital-Based Long-Term Care Facilities in Saudi Arabia

Spain: The WHO Demonstration Project of Palliative Care Implementation in Catalonia: Results at 10 Years (1991–2001)

Xavier Gomez-Batiste, MD, Josep Porta, PhD, MD, Albert Tuca, MD, Esther Corrales, RN, Federico Madrid, MD, Jordi Trelis, MD, Dulce Fontanals, SW, Josep M. Borras, PhD, MD, Jan Stjernsward, PhD, MD, Antoni Salva, MD, and Eduard Rius, MD Palliative Care Service (X.G.-B., J.P., A.T., E.C., F.M., J.T.), Institut Catala d’Oncologia, Barcelona, Spain; Fundacio SAR (D.F.), Barcelona, Spain; Institut Catala d’Oncologia (J.M.B), Barcelona, Spain; Global Cancer Concern (J.S.), Stockholm, Sweden; Divisio Sociosanitaria (A.S.), Servei Catala de la Salut, Barcelona, Spain; and Ministry of Health (E.R.), Government of Catalonia, Barcelona, Spain

Time Spent in Hospital in the Last Six Months of Life in Patients Who Died of Cancer in Ontario

PURPOSE: To describe hospital bed utilization in the final 6 months of life in patients dying of cancer in Ontario, Canada. PATIENTS AND METHODS: Hospital separation records were linked to a population-based cancer registry to identify factors associated with hospitalization in the 203,713 patients who died of cancer in Ontario between 1986 and 1998. RESULTS: Between 1986 and 1998, 5.3% of all acute care beds in Ontario were devoted to the care of cancer patients in the last 6 months of life. The mean time spent in hospital in the last 6 months of life decreased from 34.3 days in 1986 to 22.7 days in 1998. Hospitalization rates increased exponentially during the last month of life. Patients younger than 50 years of age, women, and residents of poorer communities spent significantly longer in hospital than others. Hospitalization rates differed very little among the common solid tumors, but patients with CNS malignancies, the lymphomas, and the leukemias spent significantly longer in hospital than the othe...

Time spent in hospital in the last six months of life in patients who died of cancer in Ontario.

To describe hospital bed utilization in the final 6 months of life in patients dying of cancer in Ontario, Canada. Hospital separation records were linked to a population-based cancer registry to identify factors associated with hospitalization in the 203,713 patients who died of cancer in Ontario between 1986 and 1998. Between 1986 and 1998, 5.3% of all acute care beds in Ontario were devoted to the care of cancer patients in the last 6 months of life. The mean time spent in hospital in the last 6 months of life decreased from 34.3 days in 1986 to 22.7 days in 1998. Hospitalization rates increased exponentially during the last month of life. Patients younger than 50 years of age, women, and residents of poorer communities spent significantly longer in hospital than others. Hospitalization rates differed very little among the common solid tumors, but patients with CNS malignancies, the lymphomas, and the leukemias spent significantly longer in hospital than the other groups. There was significant interregional variations in hospitalization that were not explained by differences in case mix. There was a statistically significant inverse correlation between the rate of use of palliative radiotherapy and the hospital bed use in the county in which the patient resided. The total time spent in hospital in the last 6 months of life has decreased over the last decade, but acute care hospitals continue to play a large role in the care of patients who are dying of cancer.

Alternatives to Acute Hospital Psychiatric Care in East-End Montreal

As pressure mounts to reduce the number of costly acute care beds, governments and the literature propose top-down ratios. Is this reasonable and fair to the responsible medical officers who, as the key care providers, will need to admit patients and develop discharge plans in a reduced-beds environment? Treating physicians of all acute care inpatients on a given day (n = 212) and all new acute care admissions over a 2-week period (n = 125) completed an adapted version of the Nottingham Acute Beds Use Survey (NABUS) Questionnaire. On a given day, only 62 of 212 inpatients were unsuited for any alternative to acute care hospitalization. A floor ratio of 18 acute care beds per 100,000 inhabitants seems adequate for the catchment area in question, provided that alternatives to hospitalization are fully and efficiently available. Alternatives essentially involve an array of the following: supervised residential settings, day hospitals, and intensive home care (2 to 6 hours weekly). The ratio of intensive home care workers required would be 25 per 100,000 inhabitants.

Rural hospitals: trends, challenges, and a future research and policy analysis agenda.

Previous reviews of the status of rural hospitals conclude that rural hospitals play a major role in ensuring the provision of health services in rural areas, are an essential part of the social and economic identity of rural communities, have had mixed success in their ability to respond to environmental threats, and are very sensitive to public policies due, in part, to their small size. The evolving hospital paradigm in the United States and a turbulent economic and health care environment have created an uncertain future for the rural hospital. Hospitals are being forced to shift their emphasis from filling acute inpatient care beds to providing a more diversified set of services through linkages with other institutions and provider groups. This presents challenges for rural hospitals, which often serve as the foundation for health care delivery in rural communities yet struggle to overcome the effects of troubled local economies, shortages of health professionals, and public policy inequities. This article reviews key trends and challenges facing rural hospitals from the perspective of their structure and organization, financial sustainability, quality of care provided, and strategic linkages with other entities. It concludes with the presentation of a research and policy analysis agenda that addresses the feasibility of the role of the rural hospital as the hub or coordinator of the rural health care delivery system, the fiscal viability of the rural hospital in the post-Balanced Budget Act period, strategies for measuring and improving the quality of care provided by rural hospitals, and the structure and value of horizontal and vertical linkages of rural hospitals.

Does the Availability of Hospital Beds Affect Utilization Patterns? The Case of End-of-Life Care

Hospital downsizing in Canada during the 1990s raised public concern over the availability of hospital care, in addition to heightening administrative interest in improving or maximizing hospital utilization. One ongoing concern about hospital utilization is that a disproportionately large share of hospital resources is used by terminally ill and dying people. A research study using 1992/1993–1996/1997 in-patient abstracts data for the province of Alberta, Canada, was undertaken to explore and describe hospital utilization by dying in-patients. This investigation found only 48.2% of all deaths in Alberta over the five years studied involved hospital in-patients. An 18.5% reduction in the number of in-patient deaths and an 83.3% reduction in length of final stay occurred when 50% of acute care beds were closed, which was followed by an increase when beds began reopening — in terms of both the number of in-patient deaths (4.8%) and the average length of stay (2.6%). The ratio of men to women, the average age of dying in-patients, and the intensity of hospital care changed relatively little over those five years. Most in-patients were admitted for nursing care; in 51.3% of all cases, no diagnostic or therapeutic procedures were performed prior to death. These findings indicate hospital bed availability influences admission to hospital and length of stay, but not treatment decisions affecting seriously ill and dying patients. In addition, reduced length of stay appears to have been a widespread response to hospital downsizing, with this change substantially preserving individual access to hospitals.

Does the availability of hospital beds affect utilization patterns? The case of end-of-life care.

Hospital downsizing in Canada during the 1990s raised public concern over the availability of hospital care, in addition to heightening administrative interest in improving or maximizing hospital utilization. One ongoing concern about hospital utilization is that a disproportionately large share of hospital resources is used by terminally ill and dying people. A research study using 1992/1993-1996/1997 in-patient abstracts data for the province of Alberta, Canada, was undertaken to explore and describe hospital utilization by dying in-patients. This investigation found only 48.2% of all deaths in Alberta over the five years studied involved hospital in-patients. An 18.5% reduction in the number of in-patient deaths and an 83.3% reduction in length of final stay occurred when 50% of acute care beds were closed, which was followed by an increase when beds began reopening--in terms of both the number of in-patient deaths (4.8%) and the average length of stay (2.6%). The ratio of men to women, the average age of dying in-patients, and the intensity of hospital care changed relatively little over those five years. Most in-patients were admitted for nursing care; in 51.3% of all cases, no diagnostic or therapeutic procedures were performed prior to death. These findings indicate hospital bed availability influences admission to hospital and length of stay, but not treatment decisions affecting seriously ill and dying patients. In addition, reduced length of stay appears to have been a widespread response to hospital downsizing, with this change substantially preserving individual access to hospitals.

Old school values.

Two thirds of acute care beds are occupied by people aged65 and over, yet many nurses have little training in caring for older people