Acute Hospital Beds Research Articles

The influence of primary care quality on hospital admissions for people with dementia in England: a regression analysis.

ObjectivesTo test the impact of a UK pay-for-performance indicator, the Quality and Outcomes Framework (QOF) dementia review, on three types of hospital admission for people with dementia: emergency admissions where dementia was the primary diagnosis; emergency admissions for ambulatory care sensitive conditions (ACSCs); and elective admissions for cataract, hip replacement, hernia, prostate disease, or hearing loss.MethodsCount data regression analyses of hospital admissions from 8,304 English general practices from 2006/7 to 2010/11. We identified relevant admissions from national Hospital Episode Statistics and aggregated them to practice level. We merged these with practice-level data on the QOF dementia review. In the base case, the exposure measure was the reported QOF register. As dementia is commonly under-diagnosed, we tested a predicted practice register based on consensus estimates. We adjusted for practice characteristics including measures of deprivation and uptake of a social benefit to purchase care services (Attendance Allowance).ResultsIn the base case analysis, higher QOF achievement had no significant effect on any type of hospital admission. However, when the predicted register was used to account for under-diagnosis, a one-percentage point improvement in QOF achievement was associated with a small reduction in emergency admissions for both dementia (-0.1%; P=0.011) and ACSCs (-0.1%; P=0.001). In areas of greater deprivation, uptake of Attendance Allowance was consistently associated with significantly lower emergency admissions. In all analyses, practices with a higher proportion of nursing home patients had significantly lower admission rates for elective and emergency care.ConclusionIn one of three analyses at practice level, the QOF review for dementia was associated with a small but significant reduction in unplanned hospital admissions. Given the rising prevalence of dementia, increasing pressures on acute hospital beds and poor outcomes associated with hospital stays for this patient group, this small change may be clinically and economically relevant.

Providing effective and preferred care closer to home: a realist review of intermediate care.

Intermediate care is one of the number of service delivery models intended to integrate care and provide enhanced health and social care services closer to home, especially to reduce reliance on acute care hospital beds. In order for health and social care practitioners, service managers and commissioners to make informed decisions, it is vital to understand how to implement the admission avoidance and early supported discharge components of intermediate care within the context of local care systems. This paper reports the findings of a theory-driven (realist) review conducted in 2011-2012. A broad range of evidence contained in 193 sources was used to construct a conceptual framework for intermediate care. This framework forms the basis for exploring factors at service user, professional and organisational levels that should be considered when designing and delivering intermediate care services within a particular local context. Our synthesis found that involving service users and their carers in collaborative decision-making about the objectives of care and the place of care is central to achieving the aims of intermediate care. This pivotal involvement of the service user relies on practitioners, service managers and commissioners being aware of the impact that organisational structures at the local level can have on enabling or inhibiting collaborative decision-making and care co-ordination. Through all interactions with service users and their care networks, health and social care professionals should establish the meaning which alternative care environments have for different service users. Doing so means decisions about the best place of care will be better informed and gives service users choice. This in turn is likely to support psychological and social stability, and the attainment of functional goals. At an organisational level, integrated working can facilitate the delivery of intermediate care, but there is not a straightforward relationship between integrated organisational processes and integrated professional practice.

Metastatic non-small cell lung cancer: a benchmark for quality end-of-life cancer care?

To investigate the quality of end-of-life care for patients with metastatic non-small cell lung cancer (NSCLC). Retrospective cohort study of patients from first hospitalisation for metastatic disease until death, using hospital, emergency department and death registration data from Victoria, Australia, between 1 July 2003 and 30 June 2010. Emergency department and hospital use; aggressiveness of care including intensive care and chemotherapy in last 30 days; palliative and supportive care provision; and place of death. Metastatic NSCLC patients underwent limited aggressive treatment such as intensive care (5%) and chemotherapy (<1%) at the end of life; however, high numbers died in acute hospitals (42%) and 61% had a length of stay of greater than 14 days in the last month of life. Although 62% were referred to palliative care services, this occurred late in the illness. In a logistic regression model adjusted for year of metastasis, age, sex, metastatic site and survival, the odds ratio (OR) of dying in an acute hospital bed compared with death at home or in a hospice unit decreased with receipt of palliative care (OR, 0.25; 95% CI, 0.21-0.30) and multimodality supportive care (OR, 0.65; 95% CI, 0.56-0.75). Because early palliative care for patients with metastatic NSCLC is recommended, we propose that this group be considered a benchmark of quality end-of-life care. Future work is required to determine appropriate quality-of-care targets in this and other cancer patient cohorts, with particular focus on the timeliness of palliative care engagement.

Variation in the place of death among nursing home residents in France.

recent studies have reported that hospitals have become a common place of death for nursing home residents. This study aimed to (i) measure variations in the proportion of in-hospital deaths across regions after adjustment for facility-level characteristics and (ii) identify environmental risk factors that might explain these variations in France. a cross-sectional retrospective survey was conducted in 2013. coordinating physicians in 3,705 nursing homes in France. a regression model was used to construct risk-adjusted rates of in-hospital deaths considering the facilities' characteristics. At the regional level, the outcome was defined as the difference between the observed rate of in-hospital deaths and the expected risk-adjusted rate. Values exceeding zero indicated rates that exceeded the national predicted rate of in-hospital deaths and thus highlighted regions in which the risk-adjusted probability for nursing home residents to die in a hospital was greater than average. among 70,119 nursing home decedents, 25.4% (n = 17,789) died in hospitals. The characteristics of the facilities had a significant influence on the proportion of in-hospital deaths among the nursing home decedents. However, after adjustment for these facility-level risk factors, the proportion of nursing homes that reported worse-than-average outcomes showed significant variation (range 26.0-79.6%). At the regional level, both the rate of acute hospital beds and the rate of general practitioners were found to be strongly correlated with the probability of reporting worse-than-average outcomes (P < 0.001). our study demonstrates the existence of major differences across regions in France and highlights the need for targeted interventions regarding end-of-life care in nursing home facilities.

Comparison of different methods to forecast hospital bed needs

ObjectivesThis study compares three methods to forecast the number of acute somatic hospital beds needed in a Swiss academic hospital over the period 2010–2030. DesignInformation about inpatient stays is provided through a yearly mandatory reporting of Swiss hospitals, containing anonymized data. Forecast of the numbers of beds needed compares a basic scenario relying on population projections with two other methods in use in our country that integrate additional hypotheses on future trends in admission rates and length of stay (LOS). ResultsThe total number of beds in the hospital under study is projected to increase from 960 beds in 2010 to a range of 1188 to 1332 in 2030. This estimated growth equals to 24% to 39% of the hospital size at baseline, and these different figures are largely due to hypotheses about future reduction in LOS. Conversely, as the models’ hypotheses regarding future demand have balanced effects on global admission rates, the three methods lead to similar projections for the number of stays, which is estimated to increase by 33% between 2010 and 2030. ConclusionIn the context of population aging, forecasting the number of hospital beds should not rely on a unique scenario. Using different hypotheses about admission rates and LOS, and comparing projected versus real use are important to avoid shortage of beds.

Evidence of sustained benefit: Use of teleconsultation to support people living in residential care settings

Introduction: An increasing proportion of the population require long term supported care in nursing or residential care home settings. As high users of healthcare services, interventions that can be delivered in their place of residence offer substantial benefit to the patient, their carers and to the wider health system. Teleconsultation using 2 way video links has been used to deliver such interventions and its use appeared in early results to reduce the need for hospital admission and Emergency Department (ED) attendance. Aims: To evaluate, using 2nd year activity and outcome data, whether the impact a dedicated 24/7 teleconsultation service (the Hub) has on admissions, ED attendance and total hospital bed days used by the residents of a cohort of local nursing and residential care homes is sustained beyond the initial “honeymoon” period following introduction of a novel service. Results: From a population comprising the residents of the nursing and residential care homes in the locality served by a single acute hospital, hospital admissions, ED attendances and total bed days used were measured using routinely collected hospital statistics. Hub activity statistics were initially collected using manual audit. Data were recorded for the year before and the year after each care home began using teleconsultation. Initial findings, from 17 care homes supporting a population of just over 1000 people, showed that there appeared to be a 45% reduction in admissions and a 60% reduction in total bed days used by residents from these locations in the 12 months following introduction of the service. As the numbers of locations supported has risen and data collection methods have been automated, these figures have settled at a reduction in acute admissions of 35% (n=654 to 437), a reduction in ED attendance of 53% (n=798 to 379) and of total bed days used by 59% (n=8247 to 3435). These reductions equate to a fall in the number of hospital beds required to service this level of in-patient activity from 22.6 to 9.4 (-59%). Service user satisfaction remains high at >9/10 across a range of measures using a questionnaire-based International Digital Health and Care Congress, The King’s Fund, London, September 10-12 2014. International Journal of Integrated Care – Volume 14, 01 November – URN:NBN:NL:UI:10-1-116540– http://www.ijic.org/ approach. The service continues to grow, with 100 care homes now receiving support across a wide geographical area. Conclusions: Use of teleconsultation, delivered on a 24/7 basis, appears to be supporting sustained reductions in the need for in-patient and ED hospital services and service user satisfaction with the approach remains very high. These reductions equate to substantial falls in the number of hospital beds required by this frail and difficult to move population. At scale deployment of this approach could offer real benefit to patients and both commissioning and provider organisations.

Managing the increasing shortage of acute care hospital beds in Israel.

Israel's healthcare system has been facing increasing hospital bed shortage over the last few decades. Community-based services and shortening length of stay have helped to ease this problem, but hospitals continue to suffer from serious overload and saturation. The objective of this study is to present hospitalization trends in Israel's internal medicine departments. The data is based on the National Hospital Discharges database (NHDR) in the Israeli Health Ministry, pertaining to hospitalizations in all internal medicine departments nationwide between 2000 and 2012. Total yearly hospitalization days, representing healthcare burden, had increased by 4.2% during the study period, driven mainly by the most advanced age groups. The rate of total hospitalization days per 100,000 people for all the age groups has decreased by 17.6%, but the oldest patient group had a modest reduction in comparison (7.5%). The parameter of age correlated with length of stay and readmission rates, and neither decreased during the surveyed years. These results demonstrated that the healthcare burden on acute internal medicine services has been reduced mostly for middle-aged populations but only modestly for elderly populations. The length of hospital stay and the readmission rates have reached and maintained a plateau in recent years, regardless of age. The findings of this study call for planning specific to elderly populations in light of changing demographics. Possible directions may include renewed emphasis on internal medicine and geriatric medicine, and efforts to shorten hospitalization time by extended utilization of multidisciplinary primary care.

Patient Needs, Required Level of Care, and Reasons Delaying Hospital Discharge for Nonacute Patients Occupying Acute Hospital Beds

Abstract: This study aims to determine the proportion of nonacute patients occupying acute care beds and to describe their needs, the appropriate level of alternative care, and reasons preventing discharge. Data from 952 patients hospitalized in an acute care unit for 30 days were obtained from their medical charts and by consulting with the medical team at two tertiary teaching hospitals. Among them, 333 (35%) were determined nonacute on day 30 of hospitalization. According to the Appropriateness Evaluation Protocol (AEP), 55% had no medical, nursing, or patient needs. Among nonacute patients with AEP needs, 88% were related to nursing/life‐support services and 12% related to patient condition factors. Regarding alternative level of care, 186 (56%) were waiting for out‐of‐hospital resources, of which 36% were waiting for palliative care, 33% for long‐term care, 18% for rehabilitation, and 12% for home care. For the remaining 147 (44%) nonacute patients, the alternative resources remained undetermined although acute care was no longer required. Main reasons preventing discharge included unavailability of alternative resources, ongoing assessment to determine appropriate resources, ongoing process with community care, and family/patient education/counseling. Available subacute facilities and community‐based care would liberate acute care beds and facilitate their appropriate use.

Assessment and management of dementia in the general hospital setting

SummaryPopulations are ageing worldwide. The prevalence of dementia will rise exponentially with the oldest old the most rapidly growing segment of society. Caring for this ageing population with dementia, many of whom will have multiple chronic and disabling diseases, will be a challenge to healthcare systems, particularly general hospitals. At any one time, a quarter of acute hospital beds in the UK are in use by people with dementia. Delivery of high-quality care to this growing and vulnerable population must be high on any health service agenda.Current medical training not only generates relatively low numbers of geriatricians and specialists with interest in dementia, but also there is a lack of appropriate training in assessment and management of dementia. There remains huge need for better staff training and support to provide safe, holistic and dignified dementia care. Here we explore various key features for non-specialist assessment and management of older people with dementia in the general hospital setting.

A SPECIALIST PALLIATIVE CARE SERVICE FOR PARKINSON'S DISEASE: REVIEW OF END OF LIFE OUTCOMES

BackgroundNational guidance supports the need for specialist palliative care (SPC) in Parkinson's disease (PD). Access to SPC remains poor and evidence to support palliative care strategies in PD is scarce.InnovationThe...

In‐hospital costs associated with chronic constipation in Belgium: a retrospective database study

BackgroundReal-life data on the economic burden of chronic idiopathic constipation are scarce. The objectives of this study were to assess hospitalization resource use and costs associated with chronic constipation and its complications in Belgium.MethodsThis was a single country, retrospective study using the IMS Hospital Disease Database (2008), which comprises data on 34% of acute hospital beds in Belgium and contains information on patient demographics, length of stay (LOS), billed costs, drug use, diagnoses, and procedures. Stays with a primary diagnosis of constipation, or a secondary diagnosis of constipation and a concomitant diagnosis of a constipation-related complication, were selected. Patients with diagnoses of colorectal cancer, ulcerative colitis or Crohn's disease, or who had stays involving potentially constipation-inducing procedures, were excluded as having secondary constipation. Patients receiving opioids, calcium-antagonists, antipsychotics or antidepressants were excluded as having drug-induced constipation.Key ResultsIn total, 1541 eligible patients were identified. The average unadjusted cost per day in hospital for idiopathic constipation was €441 (€311 ± 1.4 in day clinic visits without overnight stays; €711 ± 14.0 in full hospitalizations with complications). The average LOS in a full hospitalization setting was 7.0 and 4.0 days in stays with and without complications, respectively. The most frequent drug and procedural treatments were osmotically acting laxatives (with complications: 42.61%; without complications: 35.69%), and transanal enema (2.32% and 2.03%), respectively.Conclusions & InferencesThe burden of constipation is often underestimated; it is a condition reflected by hospital-related costs comparable to such indications as migraine, which increase when associated with complications.

Reducing hospital bed use by frail older people: results from a systematic review of the literature

Numerous studies have been conducted in developed countries to evaluate the impact of interventions designed to reduce hospital admissions or length of stay (LOS) amongst frail older people. In this study, we have undertaken a systematic review of the recent international literature (2007-present) to help improve our understanding about the impact of these interventions. WE SYSTEMATICALLY SEARCHED THE FOLLOWING DATABASES: PubMed/Medline, PsycINFO, CINAHL, BioMed Central and Kings Fund library. Studies were limited to publications from the period 2007-present and a total of 514 studies were identified. A total of 48 studies were included for full review consisting of 11 meta-analyses, 9 systematic reviews, 5 structured literature reviews, 8 randomised controlled trials and 15 other studies. We classified interventions into those which aimed to prevent admission, interventions in hospital, and those which aimed to support early discharge. Reducing unnecessary use of acute hospital beds by older people requires an integrated approach across hospital and community settings. A stronger evidence base has emerged in recent years about a broad range of interventions which may be effective. Local agencies need to work together to implement these interventions to create a sustainable health care system for older people.

Impact of an out-patient based strategy for the management of acute deep venous thrombosis in Saudi Arabia

Introduction: In the past 20–30years, management of acute DVT has been revolutionarised with the advent of low molecular weight heparin [1,2,3]. There is good evidence that management of DVT on an out-patient basis is safe, feasible and effective [5,6,7]. Also, in today's environment, of pressure on beds in acute hospitals, there is a need for admission avoidance strategies to facilitate savings in terms of bed days and money. Methods: We conducted a retrospective chart analysis of patients diagnosed with DVT between 2005 and 2012 to identify those suitable for out-patient management.

Mapping the patterns of care, the receipt of palliative care and the site of death for patients with malignant glioma

High-grade malignant glioma patients face a poor prognosis, preceded by rapid functional and neurobehavioural changes, making multidisciplinary care incorporating supportive and palliative care important. This study aimed to quantify the association between symptoms,receipt of supportive and palliative care and site of death. We undertook a retrospective cohort study between 2003 and 2009 of incident malignant glioma cases who survived for at least 120 days between their first hospitalisation and their death (n = 678) in Victoria, Australia, using linked hospital, emergency department and death data. The median age of patients was 62 years, 40% were female, and the median survival was 11 months. Twenty-six percent of patients died outside of hospital, 49% in a palliative care bed/hospice setting and 25% in an acute hospital bed. Patients having 1 or more symptoms were more than five times as likely to receive palliative care. Patients who receive palliative care are 1.7 times more likely to die outside of hospital. In conclusion malignant glioma patients with a high burden of symptoms are more likely to receive palliative care and, in turn, patients who receive palliative care are more likely to die at home.

Trends in unscheduled care

British Journal of Healthcare ManagementVol. 19, No. 6 Money MattersTrends in unscheduled careRod JonesRod JonesSearch for more papers by this authorRod JonesPublished Online:27 Sep 2013https://doi.org/10.12968/bjhc.2013.19.6.301AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Appleby J (2013) Are accident and emergency attendances increasing? Available at: www.kingsfund.org.uk/blog/2013/04/are-accident-and-emergency-attendances-increasing (accessed 29 May 2013) Google ScholarBughio F, Elliott D, Goodrum F (2013) An endothelial cell-specific requirement for the UL133-UL138 locus of human cytomegalovirus for efficient virus maturation. J Virology 87 (6): 3062–75 Crossref, Google ScholarGandhoke I, Hussain A, Pash S et al. (2012) Glycoprotein B genotyping in congenital/perinatal cytomegalovirus infection in symptomatic infants. Indian Pediatrics S097475591200352 (Epub ahead of print) Google ScholarGkrania-Klotsas E, Langenberg C, Sharp S, et al. (2012) Seropositivity and higher IgG antibody levels against Cytomegalovirus are associated with mortality in the population based EPIC-Norfolk cohort. Clinical Infectious Diseases 206 (12): 1897–1903 Google ScholarJones R (2009a) Trends in emergency admissions. BJHCM 15 (4): 188–96 Google ScholarJones R (2009b) Cycles in emergency admissions. BJHCM 15 (5): 239–46 Google ScholarJones R (2009c) Emergency admissions and hospital beds. BJHCM 15 (6): 289–96 Google ScholarJones R (2009d) Emergency admissions and financial risk. BJHCM 15 (7): 344–50 Google ScholarJones R (2011a) Hospital bed occupancy demystified and why hospitals of different size and complexity must operate at different average occupancy. BJHCM 17 (6): 242–8 Google ScholarJones R (2011b) A&E performance and inpatient bed occupancy. BJHCM 17 (6): 256–7 Google ScholarJones R (2011c) Bed occupancy – the impact on hospital planning. BJHCM 17 (7): 307–13 Google ScholarJones R (2012) Diagnoses, deaths and infectious outbreaks. BJHCM 18 (10): 539–48 Google ScholarJones R (2013a) An unexplained increase in deaths in England & Wales during 2012. BJHCM 19 (5): 248–53 Google ScholarJones R (2013b) Could cytomegalovirus be causing widespread outbreaks of chronic poor health. In: Shoja M, Agutter PS, Tubbs RS et al., eds. Hypotheses in Clinical Medicine: Nova Science Publishers. New York, NY: 37–79 Google ScholarKaffash J (2013) GPs not to blame for pressure on A&E, says NHS England adviser. www.pulsetoday.co.uk/commissioning/commissioning-topics/emergency-admissions/gps-not-to-blame-for-pressure-on-ae-says-nhs-england-adviser/20002989.article#.UZojIIY1P-8 (accessed 29 May 2013) Google ScholarKyoto V, Vuorinen T, Saukko P et al. (2005) Cytomegalovirus infection of the heart is common in patients with fatal myocarditis. Clin Infect Dis 40 (5): 683–8 Crossref, Google ScholarMcWhorter A, Smith L, Masters L et al. (2013) Natural killer cell dependent within-host competition arises during multiple MCMV infection: consequences for viral transmission and evolution. PLoS Pathog 9 (1): e1003111 Crossref, Google ScholarOliver D (2013) Closing acute hospital beds for older people—the way to save our services? Available at: http://britishgeriatricssociety.wordpress.com/2013/05/20/closing-acute-hospital-beds-for-older-people-the-way-to-save-our-services/ (accessed 29 May 2013) Google Scholar FiguresReferencesRelatedDetailsCited byImmunosenenescence: Role of cytomegalovirusExperimental Gerontology, Vol. 54What is happening in urgent care?5 March 2014 | Journal of Paramedic Practice, Vol. 6, No. 2 1 June 2013Volume 19Issue 6ISSN (print): 1358-0574ISSN (online): 1759-7382 Metrics History Published online 27 September 2013 Published in print 1 June 2013 Information© MA Healthcare LimitedPDF download

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.

Long Stay Hospital Patients in Acute Care Hospital beds - What does Dementia have to do with this?

The Canadian Institute of Health Information (CIHI) has established a patient classification called Alternative Level of Care (ALC) that applies to patients who have completed the acute care phase of their treatment but remain in an acute care bed (1). It is estimated that 5-14% of all acute care beds in Canada are occupied by ALC patients (2). In Atlantic Canada specifically, an equivalent of 468 acute care beds were occupied by ALC patients in 2009-2010 (3). ALC patients tend to be older and the majority have a diagnosis of dementia.

The Relationship between Dementia and Falling in Long-stay Hospital Patients

Introduction: Adults with dementia have an increased risk for falling. Several studies indicate an annual falls incidence as high as 60% among people with dementia with as many as 4 falls per person annually (1). The key risk factors for falls include the many conditions associated with dementia such as cognitive impairment, gait and balance deficits, visual impairment, muscle weakness, impaired functioning and unsafe wandering (2). This study examines a sub-population of patients with a diagnosis of dementia taken from a larger sample of long-stay patients who were identified in acute care hospital beds. Their history of falls prior to admission to hospital as well as their medical history, functional, and social history were gathered and a comparison was done between those with dementia who had a history of falls and those that did not. Methods: Retrospective chart reviews were conducted on long-stay hospital patients in a a Regional Health Authority in New Brunswick, Canada. The initial sample was a stratified random sample of 223 of the 302 identified patients. The sub-population for this study consists of 119 of these patients with a known diagnosis of dementia, either made prior to admission or during their hospitalization. The history of falls prior to admission and during their hospital stay was collected. Comparisons between those who had a history of falls prior to admission and those who did not fall were done. The information gathered allows for comparisons in their medical history, medication usage, mobility status, functional status and living arrangements prior to admission. Results: In the sample of 119 patients with dementia, 68 (57.1%) had history of falls prior to admission. The mean age in the group that fell was 82.7 years (sd 8.5) and in those that did not fall the mean age was 78.5 years (sd 10.2). In those who fell, they most often lived with their spouse at home (39.7%) and in those who did not fall they most frequently lived alone (39.2%). The most common reason for admission to hospital was related to their dementia, 27.9% in the fallers, and 39.2% in the non-fallers. Fractures were the reason for admission in 11.8% of the fallers. In the group with a history of falls the majority (60.3%) had a history of falls within one month prior to admission. Benzodiazepine use and neuroleptic use was over 25% in both groups at the time of hospital admission. Prior to admission, the group that did not have a history of falls were more independent in their bathing and toileting. Incontinence of urine (42.6%) and stool (33.8%) was more common in those who fell, almost 2 fold. In those with a history of falls, 41.2% required the use of a walking aid compared to only 19.6% in those who did not fall. The majority (54.9%) of those who did not fall were independent ambulators before admission, compared to 35.6% in the group that fell. In both groups the majority needed assistance or was dependent in some of their instrumental activities of daily living. However those who did not fall were less dependent. For those with a history of falls prior to admission, 38.2% fell again during their hospital stay and 25.5% of those who had not fallen before admission fell while in hospital. Conclusions: In a group of long-stay hospital patients with dementia, the majority had a history of falls prior to admission (most within the last month). The group that fell used a walking device (cane or walker) more frequently and most were living at home with a spouse or other family member. Fractures were the reason for admission in some of these patients with a history of falls. Benzodiazepine and neuroleptic use was common in both fallers and non-fallers. The group with a history of falls needed more assistance with their activities of daily living and instrumental activities of daily living. The fall rate in hospital was greater in those with a history of falls prior to admission but a quarter of those with no fall history experienced falls during their hospital stay.

The ebbs and flows of changing acute bed capacity delays

This case study provides a summary of changes in acute hospital bed delays that have occurred over a 4-year period as identified through a Capacity Audit process. Royal Adelaide Hospital (RAH) designed a Capacity Audit process and tool that provides a systematic method to evaluate factors limiting access to inpatient bed capacity. The aim of the audit is to improve understanding of bed capacity by identifying key causes of delay for hospital inpatients and quantify the most frequent causes of blocked bed capacity. This can then be used to underpin targeted improvement work. The Capacity Audit has been undertaken at the RAH over three cycles. The Capacity Audit involves a survey of every open and staffed bed, identifying how the bed is being used: for acute care or treatment, if there was a delay to the patient for discharge, or if the bed was unavailable. The first and second cycle of the audit (2007-2008) involved a twice-daily survey over a 2-week period and the third audit cycle in 2010 occurred once daily for 1 week. On average, 620 beds were surveyed daily with an audit compliance rate ranging from 85-97%. This process has revealed almost 75% of beds are used positively for care. Of the remaining 25% of hidden capacity identified, non-clinical discharge delays account for 10% of total beds surveyed. Waiting for post-acute beds has consistently remained the main cause of acute bed delay. The Capacity Audit process and tool has been used to track progress, trends and change resulting from service improvement efforts, and to provide the evidence to commence strategies to reduce the hidden capacity issues. This case study has shown that whilst overall bed stock usage for positive care has not changed significantly there are various ebbs and flows over time in relation to the reasons for bed delays.

Delay in discharge and its impact on unnecessary hospital bed occupancy

BackgroundElderly 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.MethodsOver 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.ResultsA 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).ConclusionsElderly 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.