Community Hospital In Toronto Research Articles

A Dedicated Orthopaedic Trauma Room Improves Efficiency While Remaining Financially Net Positive.

To determine the impact of dedicated orthopaedic trauma room (DOTR) implementation on operating room efficiency and finances. Retrospective cost-analysis. Single midsized academic-affiliated community hospital in Toronto, Canada. All patients that underwent the most frequently performed orthopaedic trauma procedures (hip hemiarthroplasty, open reduction internal fixation of the ankle, femur, elbow and distal radius), over a 4-year period from 2016 to 2019 were included. Patient data acquired for 2 years before the implementation of a DOTR was compared with data acquired for a 2-year period after its implementation, adjusting for the number of cases performed. The primary outcome was surgical duration. The secondary outcome was financial impact, including after-hours costs incurred and opportunity cost of displaced elective surgeries. One thousand nine hundred sixty orthopaedic cases were examined pre- and post-DOTR. All procedures had reduced total operative time post-DOTR (mean improvement of 33.4%). The number of daytime operating hours increased 21%, whereas after-hours decreased by 37.8%. Overtime staffing costs were reduced by $24,976 alongside increase in opportunity costs of $22,500. This resulted in a net profit of $2476. Our results support the premise that DOTRs improve operating room efficiency and can be cost efficient. Our study also specifically addresses the hesitation regarding potential loss of profit from elective surgeries. Widespread implementation can improve patient care while still remaining financially favorable. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Mixed-methods study protocol for an evaluation of the mental health transition navigator model in child and adolescent mental health services: the Navigator Evaluation Advancing Transitions (NEAT) study

IntroductionTransition from child and adolescent mental health services (CAMHS) to community or adult mental health services (AMHS) is a highly problematic health systems hurdle, especially for transition-aged youth. A planned...

Presence of urinary symptoms in bacteremic urinary tract infection: a retrospective cohort study of Escherichia coli bacteremia

BackgroundIt is important to understand clinical features of bacteremic urinary tract infection (bUTI), because bUTI is a serious infection that requires prompt diagnosis and antibiotic therapy. Escherichia coli is the most common and important uropathogen. The objective of our study was to characterize the clinical presentation of E coli bUTI.MethodsRetrospective cohort study of consecutive adult patients admitted for community acquired E. coli bacteremia from January 1, 2015 to December 31, 2016 was conducted at 4 acute care academic and community hospitals in Toronto, Ontario, Canada. Logistic regression models were developed to identify E coli bUTI cases without urinary symptoms.ResultsOf 462 patients with E. coli bacteremia, 284 (61.5%) patients had a urinary source. Of these 284 patients, 161 (56.7%) had urinary symptoms. In a multivariable model, bUTI without urinary symptoms were associated with older age (age < 65 years as reference, age 65–74 years had OR of 2.13 95% CI 0.99–4.59 p = 0.0523; age 75–84 years had OR of 1.80 95% CI 0.91–3.57 p = 0.0914; age > =85 years had OR of 2.95 95% CI 1.44–6.18 p = 0.0036) and delirium (OR of 2.12 95% CI 1.13–4.03 p = 0.0207). Sepsis by SIRS criteria was present in 274 (96.5%) of all bUTI cases and 119 (96.8%) of bUTI cases without urinary symptoms.ConclusionThe majority of patients with E. coli bacteremia had a urinary source. A significant proportion of bUTI cases had no urinary symptoms elicited on history. Elderly and delirious patients were more likely to have bUTI without urinary symptoms. In elderly and delirious patients with sepsis by SIRS criteria but without a clear infectious source, clinicians should suspect, investigate, and treat for bUTI.

Is There a Role for Ivabradine in the Contemporary Management of Patients with Chronic Heart Failure in Academic and Community Heart Failure Clinics in Canada?

In patients with heart failure (HF) and reduced ejection fraction, increased heart rate (HR) is an independent risk factor for adverse outcomes. In systolic HF treatment with the If inhibitor ivabradine trial (SHIFT), Ivabradine improved survival when added to conventional treatment including β-blockers. However, the extent of benefit in the real world is unclear. We examined the characteristics of patients on guideline-directed therapy and determined who had SHIFT-like characteristics. A total of 1096 patients with chronic HF were reviewed from June 2014 to April 2015 in two HF clinics in Toronto: an academic institution (AI), and a community hospital (CH) clinic. SHIFT-like characteristics [left ventricular ejection fraction (LVEF) ≤35%; sinus rhythm; and HR≥70bpm] were described. For all patients, mean age was 75±13years, overall LVEF was 44±15%, AI less than CH (41.9±14.0% vs. 45.7±15.0%; p<0.0001). More than two-thirds of patients in both groups were on β-blockers; with less than one-third at target dose. The proportion of patients with SHIFT-like characteristics was 8.4% AI and 11.7% CH, respectively (p=0.0658). In HF clinics from both academic and community hospitals in Toronto, up-titration in the dose of β-blockers and other guideline therapy can be improved on. A small proportion of patients with HF and SHIFT-like characteristics may potentially benefit from the addition of Ivabradine, just approved in Canada; this number will be further reduced if target dosage for β-blockers is achieved. Servier Inc.

Assessing the Performance of a Modified LACE Index (LACE-rt) to Predict Unplanned Readmission After Discharge in a Community Teaching Hospital.

BackgroundThe LACE index was designed to predict early death or unplanned readmission after discharge from hospital to the community. However, implementing the LACE tool in real time in a teaching hospital required practical unavoidable modifications.ObjectiveThe purpose of this study was to validate the implementation of a modified LACE index (LACE-rt) and test its ability to predict readmission risk using data in a hospital setting.MethodsData from the Canadian Institute for Health Information’s Discharge Database (DAD), the National Ambulatory Care Reporting System (NACRS), and the hospital electronic medical record for one large community hospital in Toronto, Canada, were used in this study. A total of 3855 admissions from September 2013 to July 2014 were analyzed (N=3855) using descriptive statistics, regression analysis, and receiver operating characteristic analysis. Prospectively collected data from DAD and NACRS were linked to inpatient data.ResultsThe LACE-rt index was a fair test to predict readmission risk (C statistic=.632). A LACE-rt score of 10 is a good threshold to differentiate between patients with low and high readmission risk; the high-risk patients are 2.648 times more likely to be readmitted than those at low risk. The introduction of LACE-rt had no significant impact on readmission reduction.ConclusionsThe LACE-rt is a fair tool for identifying those at risk of readmission. A collaborative cross-sectoral effort that includes those in charge of providing community-based care is needed to reduce readmission rates. An eHealth solution could play a major role in streamlining this collaboration.

FOLFOX chemotherapy can safely be given to neutropenic patients with early-stage colorectal cancer for higher dose intensity and fewer visits.

How does giving adjuvant FOLFOX chemotherapy to patients with early-stage colorectal cancer (ESCRC) regardless of the day-before absolute neutrophil counts (ANC) effect chemotherapy-induced febrile neutropenia (CIFN) rates, received dose intensity (RDI), and chemotherapy cycle delay? Does an ANC level predict future neutropenia? A retrospective chart review was conducted on all patients receiving adjuvant chemotherapy for ESCRC at a mid-sized community hospital in Toronto, Ontario, Canada between April 2005 and May 2014. All patients were under one medical oncologist. Day-before CBC data were collected along with other patient characteristics. CIFN was confirmed by hospital records. Inclusion criteria were met by 132 patients. Overall, 1074cycles of chemotherapy were analyzed. Six episodes of CIFN were observed. There was a significant difference in the average day-before ANC between patients who developed CIFN (1.4×10(9)/L, 95% CI 0.76-2.0×10(9)/L) and those who did not (2.9×10(9)/L, 95% CI 2.8-3.0×10(9)/L, p=0.03). The RDI for oxaliplatin was 0.95 and for 5-fluorouracil (5-FU) was 0.96. A total of 170cycles were given at day-before ANC <1.5×10(9)/L (range 0.1×10(9)/L-1.4×10(9)/L), and 24 were delayed for 1week for hematologic reasons. Cycles given with grade 2 neutropenia predicted higher grades of neutropenia with a sensitivity of 0.22 (95% CI 0.12-0.38). Adjuvant FOLFOX chemotherapy may be given in the setting of low day-before ANC to patients with ESCRC. The benefits include higher RDI and a reduced number of clinic visits for the patient.

Use of Transthoracic Echocardiography in the Management of Low-Risk Staphylococcus aureus Bacteremia: Results From a Retrospective Multicenter Cohort Study

ObjectivesThe aim of this study was to develop a prediction model to identify patients with low-risk Staphylococcus aureus bacteremia (SAB), in whom infective endocarditis (IE) can be ruled out based on transthoracic echocardiogram (TTE). BackgroundS. aureus is a major cause of bacteremia and often leads to IE. Current guidelines recommend performing transesophageal echocardiography on all patients or treating all patients empirically with prolonged intravenous antibiotics; however, this approach is resource intensive, many physicians do not adhere to guidelines, and recent studies suggest that low-risk patients may not require transesophageal echocardiography. MethodsWe conducted a retrospective cohort study of 833 consecutive hospitalized patients with SAB from 7 academic and community hospitals in Toronto, Canada, over a 3-year period (2007 to 2010). Patients who received a TTE within 28 days of bacteremia (n = 536) were randomly divided into derivation and validation cohorts. Multivariable logistic regression analysis was used to determine high-risk criteria for IE in the derivation cohort, and criteria were then applied to the validation cohort to determine diagnostic properties. ResultsFour high-risk criteria predicted IE: indeterminate or positive TTE (p < 0.001), community-acquired bacteremia (p = 0.034), intravenous drug use (p < 0.001), and high-risk cardiac condition (p < 0.004). In the validation cohort, the presence of any 1 of the high-risk criteria had 97% sensitivity (95% confidence interval [CI]: 87% to 100%) and 99% negative predictive value (95% CI: 96% to 100%) for IE. The negative likelihood ratio was 0.05 (95% CI: 0.007 to 0.35). ConclusionsA normal TTE ruled out IE in patients without community-acquired SAB, high-risk cardiac conditions, and intravenous drug use. This study provides evidence that clinical risk stratification combined with a normal TTE may be adequate to rule out IE in most patients with SAB.

Transfer of care of postsurgical patients from hospital to the community setting: cross-sectional survey of primary care physicians

BackgroundPostsurgical management is often delegated to family physicians once patients are discharged from hospital, but management of such patients may not be effectively communicated. We examined transfer of care of postsurgical patients by surveying family physicians. MethodsAn electronic, self-administered survey was administered from November 2012 to March 2014 to family physicians affiliated with 4 academic and community hospitals in Toronto, Canada. ResultsA total of 109 of 589 (19% response rate) family physicians completed the survey. The majority (76%) did not believe that the current transfer of care process was adequate. Uncertainty regarding management resulted in one or more adverse patient events for over half of respondents (62%). ConclusionsA discrepancy exists between what family physicians desire to have included in transfer tools and the frequency with which these variables are included. Family physicians believe that the current process of transfer of care for postsurgical patients is inadequate and may contribute to adverse events.

Full-dose chemotherapy in early stage breast cancer regardless of absolute neutrophil count and without G-CSF does not increase chemotherapy-induced febrile neutropenia

Does giving full-dose adjuvant chemotherapy to patients with early stage breast cancer (ESBC) regardless of the day-before absolute neutrophil count (ANC) lead to an increased incidence of chemotherapy-induced febrile neutropenia (CIFN)? What factors may predispose patients to CIFN? This was a retrospective chart review conducted on all patients receiving adjuvant chemotherapy for ESBC at a mid-sized community hospital in Toronto, Ontario, Canada between September 2005 and August 2011. Day-before CBC data were collected along with other patient characteristics. CIFN was confirmed by hospital records. One hundred fifty-four patients met the inclusion criteria. Overall, 830 cycles of chemotherapy were analyzed. Univariate and multivariate logistic regression analyses were used to identify risk factors for CIFN. Twenty-two episodes of CIFN were observed. There was no significant difference in day-before ANC between patients who developed CIFN relative to those who did not. The day-before ANC was <1.5 × 10(9)/L for 88 cycles of chemotherapy. ANC analyzed as a continuous variable showed that the odds ratio (OR) for CIFN was 0.97 (95 % CI 0.82-1.13, p = NS). The pseudo R (2) statistic, which is a measure of variability accounted for by a regression model, was only 0.0008, indicating that ANC explained less than 1 % of the variability in the risk of CIFN. The most significant predictor of CIFN was the chemotherapy regimen, with docetaxel (Taxotere)/cyclophosphamide demonstrating the highest risk (OR 7.1, 95 % CI 1.4-34.9, p = 0.016). Full-dose adjuvant chemotherapy may be given to patients with ESBC regardless of the day-before ANC, without significantly increasing the risk of CIFN. The chemotherapy regimen is the most significant predictor for CIFN.

Disparity in infection control practices for multidrug-resistant Enterobacteriaceae

There is a lack of empiric evidence regarding the optimal approach to controlling the transmission of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) and carbapenem-resistant Enterobacteriaceae (CRE). In this context, we expect that infection control practices for these organisms vary widely between hospitals. A survey examining infection control practices for ESBL-E and CRE was distributed to 6 academic and 9 community hospitals in Toronto, Canada. All hospitals responded to the survey. Among 15 hospitals in 1 geographic area, 8 different approaches to the management of ESBL-E were utilized. There was wide variation in the use infection control practices including admission screening (53% and 53%), contact precautions (53% and 100%), and isolation (60% and 100%) for ESBL-E and CRE, respectively. Of hospitals performing admission screening, 75% used risk factor-based screening for ESBL-E and CRE. Even within a single geographic area, there is wide variation in infection control strategies to contain or control ESBL-E and CRE. These results are concerning given evidence that a coordinated approach may be required to prevent or limit the emergence of CRE.

Incorporation of laparoscopic D2 dissection into the management of gastric adenocarcinoma (GCa) in a community-based setting.

117 Background: A recent meta-analysis suggests that lymph node (LN) retrieval may be inferior when gastrectomy for GCa is performed laparoscopically rather than open. The purpose of this study was to examine the pathologic evaluation, postoperative morbidity and receipt of adjuvant treatment associated with adoption of D2 lymphadenectomy in a community setting. Methods: Routine D2 LN dissection was instituted as part of laparoscopic GCa resection at two community hospitals in Toronto in July 2008. Sequential cases up to Feb 2011 were identified and charts reviewed retrospectively. LN retrieval, margin status, morbidity, mortality and receipt of adjuvant treatment were examined. Results: Twenty-nine patients were identified; 69% were male and the median age was 69 (28-84). All patients underwent D2 lymphadenectomy, 10 with total gastrectomy (TG) and 19 with subtotal (STG). Pathologic evaluation showed that all patients underwent an R0 resection. Median number of LNs retrieved was 32 (15-62) and 93% of patients had adequate LN assessment according to AJCC 7 staging criteria. Sixty-five percent of patients had nodal metastases. There were 8 major complications in 7 patients including 3 post-operative deaths (10% mortality): one patient died in hospital from anastomotic leak and two after discharge from PE (1) and evisceration through the specimen extraction site (1). Four patients commenced neoadjuvant chemotherapy, but only 2 completed the planned pre-operative regimen. Ten additional patients started post-operative adjuvant chemo-radiotherapy, but only 5 completed it. Fifteen patients received no adjuvant treatment. Reasons for lack of adjuvant treatment were: early stage (n=4), medically unfit (2), post-operative death (2), patient declined (5) and early post-operative distant metastatic disease (2). Conclusions: Laparoscopic gastrectomy with D2 lymphadenectomy can be performed in a community setting with excellent margin status and LN retrieval results and complication rates comparable to those previously reported in prospective trials of open resection. Barriers to receipt/completion of adjuvant therapy in this setting should be explored.

A Web-Based System for Monitoring Patient Flow in an Emergency Department

Back to table of contents Previous article Next article LettersFull AccessA Web-Based System for Monitoring Patient Flow in an Emergency DepartmentDavid Gotlib, M.D., and Shirley Pullan, B.A.David GotlibSearch for more papers by this author, M.D., and Shirley PullanSearch for more papers by this author, B.A.Published Online:13 Jan 2015https://doi.org/10.1176/ps.62.11.pss6211_1395AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: We describe a simple-to-implement Web-based system that replaces the traditional dry-erase whiteboard for logging and tracking patient information in a psychiatry emergency consultation service. Patient information can be displayed for the treatment team and simultaneously shared with authorized users across a hospital's intranet.St. Joseph's Health Centre is a large community hospital in Toronto with four inpatient psychiatric units and a busy emergency psychiatry team (EPT) based in the emergency department. Efforts to improve the flow of admitted patients from the emergency department to the inpatient units revealed a critical bottleneck in communication. To manage workflow, the EPT used a traditional dry-erase whiteboard, entering detailed information about patients referred, currently being assessed, and admitted and their order in the queue for beds.Emergency department nursing staff and nurses on the inpatient units could obtain this information only by telephone contact with EPT clinicians. This method was unreliable because members of the EPT are often out of the office interviewing patients. The communication problems often resulted in significant delays in transfer to the inpatient units, and some patients were transferred out of the priority sequence.Our solution was to create a Web-based version of the same system (http://dl.dropbox.com/u/49189/e-whiteboard/index.html) on the hospital's intranet. EPT clinicians enter information at their workstations. The page is displayed on a large TV monitor that replaces the old whiteboard. Dedicated monitors have been placed in the emergency department, psychiatry inpatient nursing stations, and managers' offices. No monitor is visible to patients or visitors. The page can also be seen on any computer in the hospital as long as the user has been granted access permission by the medical director or EPT manager.The EPT medical director designed the Web-based system and conducted implementation and training. EPY members use a freeware HTML editing program (Kompozer), which operates like a word processer.Per-patient waiting time for an inpatient bed has been reduced by 38% since introduction of the new system in July 2009, which permits the EPT manager to monitor the emergency department situation in real time and to immediately detect and address delays in transfer to inpatient beds. Inpatient nurses now know as soon as a patient is admitted—sometimes well before the admission orders are processed. Phone calls to the EPT for information displayed on the board have stopped. Conflicts between emergency department staff and inpatient staff resulting from failure to convey information have been eliminated.The EPT clinicians find the system easy to use and much prefer it over the dry-erase whiteboard, which required them to frequently rewrite patient information as patients were discharged and the order in the queue changed.A snapshot of the Web page is saved every 15 minutes, allowing us to collect statistics about team performance, patient flow, and length of stay in the emergency department in relation to volume of patients being served.Computer technology is now both sufficiently advanced and user friendly that simple applications can create dramatic improvements in efficiency. Any organization with an intranet can apply this model to information sharing, without the expense of consultants and maintenance contracts.The authors are affiliated with the Department of Psychiatry, St. Joseph's Health Centre, Toronto, Ontario, Canada.Acknowledgments and disclosuresThe authors report no competing interests. FiguresReferencesCited byDetailsCited ByReducing Hospital Readmissions via Optimization of Emergency Department CareTransplantation, Vol. 100, No. 4Early Postoperative Emergency Department Care of Abdominal Transplant RecipientsTransplantation, Vol. 99, No. 8 Volume 62Issue 11 November 2011Pages 1395-1395 Metrics Acknowledgments and disclosuresThe authors report no competing interests.PDF download History Published online 13 January 2015 Published in print 1 November 2011

How Are Decisions to Introduce New Surgical Technologies Made? Advanced Laparoscopic Surgery at a Canadian Community Hospital: A Qualitative Case Study and Evaluation

The introduction of many new surgical technologies is associated with increased costs and uncertainty regarding risks and benefits. Currently, little is known about how decisions are made regarding the adoption of surgical innovations. To study the decision-making process for adoption of advanced laparoscopic surgical procedures at a community hospital in Toronto, Canada, we used qualitative case study methods. Data were collected using semi-structured interviews with key informants. We performed a modified thematic analysis of the data, using the conceptual framework for priority setting known as accountability for reasonableness, which consists of 4 conditions: relevance, publicity, appeals, and enforcement. Several advanced laparoscopic surgical procedures were introduced at the hospital between 2000 and 2005. During that time, there was no structured, explicit process for making decisions about introducing new surgical technologies. Use of the new surgical technologies was relevant, as measured by the perception of patient benefit and alignment with the hospital's strategic priorities. There was no systematic structure in place to oversee publicity, appeals, or enforcement. The decision to adopt advanced laparoscopic surgery at a community hospital in Toronto, Canada, was made primarily on the basis of its relevance to patient care. The process for making decisions about the adoption of new surgical technologies can be improved.

Discontinuity of chronic medications in patients discharged from the intensive care unit

BACKGROUND: Intensive care unit (ICU) admission may connote an elevated risk of unintentional chronic medication discontinuation because of its focus on acute illnesses and the multiple care transitions. OBJECTIVE: To determine the proportion of patients discharged from the ICU whose previously prescribed chronic medications were unintentionally discontinued during their hospitalization. DESIGN AND PARTICIPANTS: Hospital records of consecutive ICU discharges at 1 academic and 2 community hospitals in Toronto. Canada, throughout 2002 were reviewed. Eligible patients were prescribed at least 1 of 6 medication groups before hospitalization: (1) HMG co-A reductase inhibitors (statins); (2) antiplatelets/ anticoagulants (aspirin, clopidogrel, ticlopidine, warfarin); (3)l-thyroxine; (4) non-prn inhalers (anticholinergic, β-agonist, or steroid); (5) acid-suppressing drugs (H2 antagonists and proton pump inhibitors); and (6) allopurinol. MEASUREMENTS: Use of explicit criteria to assess the proportion of patients whose previously prescribed chronic medications were unintentionally discontinued at hospital discharge. RESULTS: A total of 1,402 charts were eligible for the study and 834 had prescriptions for at least 1 of the medication groups. Thirty-three percent (251/834) of patients had 1 or more of their chronic medications omitted at hospital discharge. Multivariable logistic regression analysis found that patients from the academic hospital (adjusted odds ratio [OR]=0.70, 95% confidence interval [CI] 0.49 to 1.0) and those with medical diagnoses (adjusted OR=0.48, 95% CI 0.31 to 0.75) had a decreased risk for chronic medication discontinuation. CONCLUSIONS: Patients discharged from the ICU often leave the hospital without note of their previously prescribed chronic medications. Careful review of medication lists at ICU discharge could avoid potential adverse outcomes related to unintentional discontinuation of chronic medications at hospital discharge.

Discontinuity of Chronic Medications in Patients Discharged from the Intensive Care Unit

Intensive care unit (ICU) admission may connote an elevated risk of unintentional chronic medication discontinuation because of its focus on acute illnesses and the multiple care transitions. To determine the proportion of patients discharged from the ICU whose previously prescribed chronic medications were unintentionally discontinued during their hospitalization. Hospital records of consecutive ICU discharges at 1 academic and 2 community hospitals in Toronto, Canada, throughout 2002 were reviewed. Eligible patients were prescribed at least 1 of 6 medication groups before hospitalization: (1) HMG co-A reductase inhibitors (statins); (2) antiplatelets/anticoagulants (aspirin, clopidogrel, ticlopidine, warfarin); (3) l-thyroxine; (4) non-prn inhalers (anticholinergic, beta-agonist, or steroid); (5) acid-suppressing drugs (H2 antagonists and proton pump inhibitors); and (6) allopurinol. Use of explicit criteria to assess the proportion of patients whose previously prescribed chronic medications were unintentionally discontinued at hospital discharge. A total of 1,402 charts were eligible for the study and 834 had prescriptions for at least 1 of the medication groups. Thirty-three percent (251/834) of patients had 1 or more of their chronic medications omitted at hospital discharge. Multivariable logistic regression analysis found that patients from the academic hospital (adjusted odds ratio [OR] = 0.70, 95% confidence interval [CI] 0.49 to 1.0) and those with medical diagnoses (adjusted OR=0.48, 95% CI 0.31 to 0.75) had a decreased risk for chronic medication discontinuation. Patients discharged from the ICU often leave the hospital without note of their previously prescribed chronic medications. Careful review of medication lists at ICU discharge could avoid potential adverse outcomes related to unintentional discontinuation of chronic medications at hospital discharge.

Psychiatric nurses expressed conflicting feelings in the decision to use physical restraints

(2000) J Adv Nurs 31, 362. Marangos-Frost S, Wells D. . Psychiatric nurses' thoughts and feelings about restraint use: a decision dilemma . . . Feb; . : . –9....

Troubled hearts, care pathways and hospital restructuring: Exploring health services research as active knowledge

This paper explores the socially active character of contemporary forms of expertise through an institutional ethnographic analysis of health services research. The paper draws primarily on interview research to investigate how health services research helps shape text-mediated relations linking government health-care policy with local reform initiatives. In the paper, I focus on the use of a particular research report by managers, physicians, and others at a community hospital in Toronto, Canada as part of their efforts to standardize and reduce the duration of care provided to heart attack patients. I discuss how, through its intertextual presence, health services research helps to co-ordinate medical and managerial practices and rationalities into medico-administrative relations. I offer two examples of this process. The first focuses on the relations co-ordinated through the textual observance of inefficiency. The second addresses how the report helped resolve the problem of physicians’ resistance to reforming cardiac care. My analysis contributes to current perspectives on the relationship between discourse and action.

Do Geriatric Programs Decrease Long‐Term Use of Acute Care Beds?

To determine whether the introduction of coordinated geriatric and discharge planning services at teaching and community hospitals in Toronto has changed the number of beds occupied by patients awaiting transfer to long-term care institutions. Retrospective review of social work records for the period 1985-1992. Two tertiary and four primary acute care hospitals in Metropolitan Toronto. Hospitals were matched for location, acuity, and teaching affiliation. The numbers of beds occupied by patients awaiting transfer to nursing homes or chronic care hospitals were noted. In those teaching and community hospitals that had introduced coordinated geriatric and discharge planning services, there was a reduction in the percentage of beds occupied by patients awaiting long-term care placement (average-51%), whereas in hospitals without geriatric services, the percentage of beds occupied by patients awaiting long-term care placement increased (average + 25%) (P = .05 by Fisher's exact method, 95% confidence limit odds ratio 0, .9999). The introduction of coordinated geriatric and discharge planning services was associated with a decrease in the percentage of beds occupied by patients awaiting long-term care in both teaching and community hospitals.