Extra Beds Research Articles

A new approach for optimal design of intensive care unit

Planning and budgeting for healthcare facilities necessitate precise estimation and a thoughtful analysis of the required area for each department, as well as extensive knowledge of the most important elements that can influence the design and provide an appropriate environment for staff and patients. A gross conversion factor is influential in calculating the entire area of a department. However, there is no precise standard indicating how this factor should be calculated. To address this problem, quality function deployment (QFD) has been implemented. The intensive care unit (ICU) is one of the highly equipped departments that should be properly planned; therefore, it was selected for application. The five steps of the QFD are used to identify and rank the most important and efficient design features. Only the top factors are considered in calculating the required area for the ICU department. This approach presents a unique method for estimating the gross square area based on calculating the gross conversion factor. To demonstrate the proposed approach’s efficacy, it was applied to two Egyptian public hospitals. The results reveal that 15–16% of the total space of both hospitals can be reduced from the total department space. Moreover, an outstanding reduction in ICU design and preparation expenses has been achieved. The design reduces the required budget for a project while maintaining the same construction material quality and accommodating extra beds. Additionally, the QFD proves its ability to redesign the ICU department while reducing costs.

A multi-stage optimization model for managing epidemic outbreaks and hospital bed planning in Intensive Care Units

Intensive Care Unit (ICU) capacity can be significantly affected by disease outbreaks, epidemics, and pandemics, impeding the operational efficiency of healthcare systems and compromising patient care. This paper presents a multi-stage optimization approach to planning the location and distribution of ICU beds to increase accessibility and reduce mortality caused by a shortage of beds in a geographic region during epidemic events. Using a Brazilian state monthly hospital admissions due to Covid-19 from October 2020 to April 2021, we show the amount and the allocation of extra ICU beds that could reduce mortality, minimize patient travel and transportation, and increase accessibility while considering budget limitations. Our findings show coverage for 21 previously underserved municipalities, providing extra ICU beds for 69 municipalities, ranging from 880 to 1670 beds across seven months. On average, patients are displaced 56% less and access ICUs within 17 ± 2.3 kilometres (CI 95%). The strategy contributes to public health planning and the equitable allocation of hospital resources among the population.

Responding to the call of the NHS Nightingale, but at what cost? An auto-ethnography of a volunteer frontline mental health trainer's experiences during the COVID-19 pandemic.

Healthcare workers, globally, volunteered time and skills to the COVID-19 pandemic frontline response. In March 2020, the predicted high demand for extra critical care beds led to the rapid construction of the UK National Health Service (NHS) Nightingale field hospital, London. I volunteered to develop and deliver psychological preparedness training - coined 'Psychological PPE' - to over 2300 frontline staff over an 8-week period. Existing research has identified broad themes of the impact working on the COVID-19 frontline has on healthcare workers but does not capture in-depth accounts of individuals' experiences. Using autoethnographic enquiry, this research explores my frontline experience at the NHS Nightingale during this time, and the personal impact this had on me. Reflexive thematic analysis explored themes of recognition and sacrifice, emotional lability and fragility, and the impact of transitions. Findings inform personal recovery, as well as future research and policy development pertaining to the sustainable recovery of our NHS people.

Under Pressure–TrolleyGar, a Metric Reflecting a Hospital System at Crisis-Capacity

Introduction:Health service capacity has been an issue in Ireland since the 1980s swinging cuts. Government reports from 2003 have consistently identified a requirement for 3,000-5,000 extra beds on top of the current approximately 10,500 capacity. Acute hospital bed capacity issues have escalated, the formal system of recording “over capacity” patients or “patients on trolleys” has developed. A “Trolleygar” reports issues from the Health Service Executive (HSE) three times daily. This count is an underestimate as patients temporarily housed in day care units, surgical, or medical assessment units, discharge lounges and other clinical areas which have a bed space are not counted in this overcapacity measure. This study's aim is to calculate the annual number of days on which no patients were lodged on trolleys in Wexford General Hospital.Method:Descriptive study using anonymized freely available data from the national HSE Trolley GAR reports on trolley patients in Wexford General Hospital from January 2019 until September 2022. A Golden Zero trolley day was stated as a day on which there were no reported trolley-patients at the three time points, Silver Zero trolley day when two of the time periods recorded no trolleys and a Bronze Zero Trolley day when one period recorded a zero trolley count.Results:Data was collected on 1,369 days, with 90 days excluded due to missing data sets. There were 162 Golden days recorded (12.67% of total days). The year 2020 recorded the highest number of Golden days at 28.69% (105 days), followed by 2021 with 11.23% (41 days). During 2019 there were 3.84% (14 days) Golden days and 2022 had the lowest number (January-September) with 0.73% (2 days).Conclusion:Despite a zero-tolerance policy, Golden days are disappearing rapidly, capacity is urgently required with post-pandemic ED attendance surges worldwide. True recording of overcapacity patients is required for appropriate capacity modeling.

Phase-Type Survival Trees to Model a Delayed Discharge and Its Effect in a Stroke Care Unit

The problem of hospital patients’ delayed discharge or ‘bed blocking’ has long been a challenge for healthcare managers and policymakers. It negatively affects the hospital performance metrics and has other severe consequences for the healthcare system, such as affecting patients’ health. In our previous work, we proposed the phase-type survival tree (PHTST)-based analysis to cluster patients into clinically meaningful patient groups and an extension of this approach to examine the relationship between the length of stay in hospitals and the destination on discharge. This paper describes how PHTST-based clustering can be used for modelling delayed discharge and its effects in a stroke care unit, especially the extra beds required, additional cost, and bed blocking. The PHTST length of stay distribution of each group of patients (each PHTST node) is modelled separately as a finite state continuous-time Markov chain using Coxian-phase-type distributions. Delayed discharge patients waiting for discharge are modelled as the Markov chain, called the ‘blocking state’ in a special state. We can use the model to recognise the association between demographic factors and discharge delays and their effects and identify groups of patients who require attention to resolve the most common delays and prevent them from happening again. The approach is illustrated using five years of retrospective data of patients admitted to the Belfast City Hospital with a stroke diagnosis.

Response to winter pressures in acute services: analysis from the Winter Society for Acute Medicine Benchmarking Audit

BackgroundThere is increased demand for urgent and acute services during the winter months, placing pressure on acute medicine services caring for emergency medical admissions. Hospital services adopt measures aiming to compensate for the effects of this increased pressure. This study aimed to describe the measures adopted by acute medicine services to address service pressures during winter.MethodsA survey of acute hospitals was conducted during the Society for Acute Medicine Benchmarking Audit, a national day-of-care audit, on 30th January 2020. Survey questions were derived from national guidance.Acute medicine services at 93 hospitals in the United Kingdom completed the survey, evaluating service measures implemented to mitigate increased demand, as well as markers of increased pressure on services.ResultsAll acute internal medicine services had undertaken measures to prepare for increased demand, however there was marked variation in the combination of measures adopted. 81.7% of hospitals had expanded the number of medical inpatient beds available. 80.4% had added extra clinical staff. The specialty of the physicians assigned to provide care for extra inpatient beds varied. A quarter of units had reduced beds available for providing Same Day Emergency Care on the day of the survey. Patients had been waiting in corridors within the emergency medicine department in 56.3% of units.ConclusionWinter pressure places considerable demand on acute services, and impacts the delivery of care. Although increased pressure on acute hospital services during winter is widely recognised, there is considerable variation in the approach to planning for these periods of increased demand.

Challenges and management of spine trauma during Covid-19

The COVID-19 pandemic is the most serious threat to national health systems in a century. The rapid development and spread of the COVID-19 disease necessitated a significant shift in clinical practice and a restructuring of institutional structures. Elective surgery has been drastically reduced in Spinal Surgery Units around the world since the start of the pandemic, and spine trauma management techniques have changed dramatically. All elective treatments, including spinal surgeries, were cancelled due to the virus's highly contagious nature, reduced nosocomial infection, and freed up extra beds for COVID-19 diseases. Emergencies, such as growing neurological deficits or spine instability caused by fractures, infections, or malignancies, could not be postponed. While different considerations should have been made before performing routine spine procedures, the latter was rendered more difficult due to unknown characteristics of the COVID-19 infection. In one study, all patients were polytrauma patients with a higher risk of pneumonia complications due to trauma. The usefulness of corticosteroids in the treatment of spinal cord injury is debated. In the instance of COVID-19 infection, Russell et al. advised not to use corticosteroids. Pneumonia was linked to a 20percent increase in death rate following posterior lumbar fusion surgeries in research by Bohl et al.

Conditions and strategies to meet the challenges imposed by the COVID-19-related visiting restrictions in the intensive care unit: A Scandinavian cross-sectional study

ObjectivesTo examine conditions and strategies to meet the challenges imposed by the coronavirus disease 2019 (COVID-19)-related visiting restrictions in Scandinavian intensive care units. Research methodology/designA cross-sectional survey. SettingAdult intensive care units in Denmark, Norway and Sweden. Main outcome measuresLikert scale responses and free-text comments within six areas: capacity and staffing, visiting policies and access to the unit, information and conferences with relatives, written information, children as relatives and follow-up initiatives. ResultsThe overall response rate was 53% (74/140 participating units). All intensive care units had planned for capacity extensions; the majority ranging between 11 and 30 extra beds. From March–June 2020, units had a mean maximum of 9.4 COVID-19 patients simultaneously. Allowing restricted visiting was more common in Denmark (52%) and Norway (61%) than in Sweden where visiting was mostly denied except for dying patients (68%), due to a particular increased number of COVID-19 patients. The restrictions forced nurses to compromise on their usual standards of family care. Numerous models for maintaining contact between relatives and patients were described. ConclusionVisitation restrictions compromised the quality of family care and entailed dilemmas for healthcare professionals but also spurred initiatives to developing new ways of providing family care.

Non-invasive respiratory support in the management of COVID-19: Report of a series using a nasal CPAP mask

BackgroundDuring peak pandemic period of COVID-19, our hospital required rapid reorganization of resources and staff during between mid-March and early April 2020. Within this interval, the hospital responded to an overwhelming rate of admissions of patients in respiratory failure, rapidly reaching over 95% of its usual inpatient bed capacity and requiring 70 extra critical care beds and at least 40 intermediate care unit beds. This created a significant shortage of materials including ventilation equipment, requiring improvised use of available resources. AimsTo describe our use of non-invasive ventilation (NIV) with the continuous positive nasal airway pressure (CPAP) device SuperNO2VA™ (Vyaire Medical, Mettawa, IL) with hospitalized patients in acute respiratory failure due to presumed COVID-19. MethodsWe performed a retrospective analysis of 14 inpatients receiving NIV CPAP at the Hospital Ramón y Cajal in Madrid, Spain. These were inpatients presenting in respiratory failure during the peak pandemic period based on defined respiratory health, oxygenation, and comorbidity status criteria. Patient data were retrospectively acquired from patient medical records. ResultsAll 14 patients were reviewed. Our series consisted of 11 males and three females with an average age of 61.5 years. Ten of 14 patients (71.4%) NIV CPAP patients did not require intubation or reintubation. Of the four unsuccessful cases, one required intubation, two required reintubation, and one expired. ConclusionsIn a time of crisis, anesthesiologists and respiratory specialists implemented the use of NIV CPAP with SuperNO2VA to help meet the high care demand of patients in respiratory distress. Although the SuperNO2VA was not originally developed for the management of patients in respiratory failure or distress related to COVID-19, this case series demonstrates it can be used with mostly favorable results during a time of limited resources to improve the clinical situation in patients. Advantages and disadvantages are explored.

Patient Mix Optimization in Admission Planning under Multitype Patients and Priority Constraints.

Hospital beds are one of the most critical medical resources. Large hospitals in China have caused bed utilization rates to exceed 100% due to long-term extra beds. To alleviate the contradiction between the supply of high-quality medical resources and the demand for hospitalization, in this paper, we address the decision of choosing a case mix for a respiratory medicine department. We aim to generate an optimal admission plan of elective patients with the stochastic length of stay and different resource consumption. We assume that we can classify elective patients according to their registration information before admission. We formulated a general integer programming model considering heterogeneous patients and introducing patient priority constraints. The mathematical model is used to generate a scientific and reasonable admission planning, determining the best admission mix for multitype patients in a period. Compared with model II that does not consider priority constraints, model I proposed in this paper is better in terms of admissions and revenue. The proposed model I can adjust the priority parameters to meet the optimal output under different goals and scenarios. The daily admission planning for each type of patient obtained by model I can be used to assist the patient admission management in large general hospitals.

Swift Support

In April and May, Civil Engineering published online a “Special Coverage: COVID-19” series of articles that focused on how civil engineers quickly responded to the effects of the COVID-19 pandemic. Three of those articles dealt with how designers approached the call from cities and their health-care providers to rapidly expand the number of hospital beds available for patients. Luckily, fewer of those extra beds were required than initially feared, but the experience offered many lessons on how to create or repurpose structures swiftly to meet the immediate needs of communities in crisis. This feature excerpts those articles.

COVID-19 experience from an Intensive Treatment Unit (ITU) in London

This article will try to provide an insight into the CoViD – 19 situation in Barnet Hospital with regards to management of the hospital, disease pattern, ITU admission criteria & treatment plans, work pattern of doctors, staff safety, & a trainee doctor’s experience. Barnet Hospital is a District General Hospital (DGH) in North London, whereas, Chase Farm Hospital is an elective surgical Hospital in North East London. Overall management Barnet Hospital is a DGH with 450 beds which includes 2 wings of ITU consisting of 10 beds & 13 beds respectively. There are more than 100 confirmed cases, and they are increasing. During the emergency period, elective surgeries have been stopped. The only surgeries that are on are emergencies, trauma (directed to another dedicated trauma centre), cancer surgeries, and maternity. The high risk areas are Emergency dept., isolation wards (separate for confirmed cases and suspected cases), ITU, Theatres, & Maternity. These have been reasonably well stocked with Personal Protective Equipment (PPE). ITU expansion plan 2 extra beds have been setup in ITU North wing. Theatre recovery has been converted to an 8 bedded ITU with anaesthetic machines as ventilators. A ward adjacent to ITU South wing has been converted to an ITU wing with 6 beds with anaesthesia machine ventilators. That has expanded the ITU capacity to 39. If more beds are needed, 3 out of 5 Operation Theatres and Anaesthetic rooms will be converted to 9 beds with anaesthesia machines as ventilators. Anaesthesia machines have been transported from Chase Farm Hospital. There is also a plan to transfer acute patients, preferably with single organ failure, to other hospitals with less patient volume, and also a new facility (Nightingale Hospital, Excel Centre) with 4000 dedicated beds for CoViD-19 patients. Diagnosis Patients are coming in with a combination of any of the following symptoms : Fever, dry cough, sore throat, history of recent travel/contact, shortness of breath,

Scheduling of elective patients considering upstream and downstream units and emergency demand using robust optimization

Abstract Surgery is a vital process in Healthcare Centers (HCs). The importance of a surgery department is not only due to its direct impact on the health but also due to its high impact on the income and costs of HCs. Considering the upward trend of population aging in societies, increasing demand for surgery, and limited resources of HCs, providing an efficient schedule for Operating Room (OR) is essential. In this paper, a multi-objective mathematical model is proposed considering upstream and downstream units. The proposed model consists of three objectives in which the first one minimizes the number of deferred patients to the next planning horizon. The second one minimizes the waiting cost of scheduled patients and the cost of extra beds acquired in the ward, and the last one minimizes the idleness and overtime of ORs, lateness in operating children and earliness in operating patients far from HC. Then, the robust counterpart is proposed to evaluate some uncertain parameters, such as surgery t, Length of Stay (LoS) in upstream and downstream units and emergency demand. Since this problem is NP-hard, a new Mixed Integer Programming based Local Search Neighborhood (MIP-based LNS) algorithm is applied. Afterward, the effect of increasing number of slots on the CPU time is studied using a sensitivity analysis. Finally, a real case study entitled ‘Alborz Hospital’ is investigated. The obtained results show that applying the proposed model and increasing two beds in the Intensive Care Unit (ICU) could potentially decrease the number of deferred patients by 58.33% as compared to the traditional schedule (i.e., a schedule based on trial and error). Furthermore, the average idleness of ORs could be reduced by 36.58% as compared to the traditional schedule.

Improving the Hospital Quality of Care during Winter Periods by Optimizing Budget Allocation Between Rotavirus Vaccination and Bed Expansion.

BackgroundDuring each winter the hospital quality of care (QoC) in pediatric wards decreases due to a surge in pediatric infectious diseases leading to overcrowded units. Bed occupancy rates often surpass the good hospital bed management threshold of 85%, which can result in poor conditions in the workplace. This study explores how QoC-scores could be improved by investing in additional beds and/or better vaccination programs against vaccine-preventable infectious diseases.MethodsThe Cobb–Douglas model was selected to define the improvement in QoC (%) as a function of two strategies (rotavirus vaccination coverage [%] and addition of extra hospital beds [% of existing beds]), allowing improvement-isocurves to be produced. Subsequently, budget minimization was applied to determine the combination of the two strategies needed to reach a given QoC improvement at the lowest cost. Data from Jessa Hospital (Hasselt, Belgium) were chosen as an example. The annual population in the catchment area to be vaccinated was 7000 children; the winter period was 90 days with 34 pediatric beds available. Rotavirus vaccination cost per course was €118.26 and the daily cost of a pediatric bed was €436.53. The target QoC increase was fixed at 50%. The model was first built with baseline parameter values.ResultsThe model predicted that a combination of 64% vaccine coverage and 39% extra hospital beds (≈ 13 extra beds) in winter would improve QoC-scores by 50% for the minimum budget allocation.ConclusionThe model allows determination of the most efficient allocation of the healthcare budget between rotavirus vaccination and bed expansion for improving QoC-scores during the annual epidemic winter seasons.

Invest in district nurses if you want to cope with winter pressures

NHS England chief executive Simon Stevens announced that 2,000-3,000 extra hospital beds will be freed up to help the NHS cope with winter pressures. This is understandable given the growing number of frail, older people with complex long-term conditions who have an increased risk of falls during winter, are vulnerable to exacerbations of their illnesses or may require additional care at the end of life.

'Seeking affluent neighbourhoods?' a time-trend analysis of geographical distribution of hospitals in the Megacity of Tehran.

Access to hospitals in megacities in low and middle income countries might be hampered by travel barriers and distance. We assessed the 'inverse care law' hypothesis: whether hospitals tended to be built in the relatively better-off areas through the time. A longitudinal time-series study (1966 to 2011) in Tehran to measure inequality in the distribution of hospital beds. We assessed correlations between the district socioeconomic status and availability of hospital beds via regression analyses, estimated correlation, Gini and concentration indices, and used GIS models to map hospital distributions through time. We found a clear relationship between socioeconomic status and number of hospital beds per capita ( P -values <0.05). Gini coefficients were about 0.6 and 0.8 for public and private beds, respectively. A third of the variations in hospital bed distribution was explained by the welfare status of the district. For every extra residential room per capita, 130 to 280 extra beds were observed per ten thousand population at the district level. In 2011, out of 162 hospitals, 110 were located in six districts around the centre and northern part of the city. During the time period only two private hospitals were built in relatively disadvantaged districts. Over a period of about fifty years new hospitals had been established in the relatively affluent areas of the city and the relationship between socioeconomic status of district with total, private and public beds were direct and intensive. Results indicate the problem of inequality may remain over time and be resistant to policy initiatives and major political changes.

FCP AND THE ED: SAVING LIVES THROUGH ORGANISING CARE.

Objectives & BackgroundHospital overcrowding is a problem that manifests in the Emergency Department (ED) and causes poorer patient outcomes. In an effort to combat overcrowding full capacity protocols have been...

A Simple Method to Forecast Future Bed Requirements: A Pragmatic Alternative to Queuing Theory

Aims: To review the current state of hospital bed planning, and to develop a simple tool to estimate short-term future bed requirements using historical bed occupancy data. Study Design: Analysis of daily bed occupancy between January 2008 and October 2015. Synthesis of trends into a method for forecasting bed numbers for each day of the year. Place and Duration of Study: Daily occupied bed statistics for King’s College University Hospital, a large London Teaching Hospital having 1,600 beds. Methodology: An eight-year time-series of daily midnight bed occupancy covering elective, emergency and transfer admissions has been used to estimate the number of beds required to deliver a delay-free hospital. Results: In this large 1,600 bed hospital it is estimated that 100 extra beds (a 6.3% increase) are required to deliver delay free admissions, i.e. no delays to admission from the emergency department or delays due to cancelled elective operations. Conclusion: The analysis reveals that far higher flexibility is required in staffing levels than is currently available. Potential strategies are discussed to address this issue.

CO2 capture by vacuum swing adsorption: role of multiple pressure equalization steps

The performance of a 4-bed/16-step vacuum swing adsorption cycle containing three pressure equalization (PE) steps has been analysed in order to understand the role played by the multiple PE steps in the process performance. The cycle was designed for CO2 capture from a feed gas mixture of 15 %CO2/85 %N2, with zeolite ×13 adsorbent from UOP (PSO2HP). Simulations were performed with the help of the commercial Aspen Adsorption simulator to help interpret the experimental results. It was found that CO2 loading decreased only slightly, but N2 loading decreased significantly and uniformly across the bed after each PE step. Thus, while CO2 working capacity remained almost constant, working selectivity and CO2 product purity increased with the number of PE steps. An experimental purity of 91.3 mol% CO2 could be obtained at a recovery of 77 % at 3 kPa desorption pressure, with a cycle containing 3 pressure equalisation steps. Specific energy consumption (calculated with a constant pump efficiency of 70 %) was calculated as 0.3 MJ/kg CO2, which was lower than the 1 and 2 pressure equalisation cycles. We evaluated 2-bed and 3-bed cycles containing one and two pressure equalisation steps respectively, by means of simulation in order to compare their performance with the base 4-bed 3PE cycle. For a constant recovery of 75–77 %, CO2 product purities increase by 7.4 and 4.2 % (relative) in going from 1PE, to 2PE and 3PE cycles respectively, at an evacuation pressure of 3 kPa. Specific energy consumption also decreased with the number of PE steps, owing to the lowering of the starting pressure for desorption and some savings in repressurization energy with the number of PE steps. The specific energy dropped by 13 % in going from 1PE to 2PE and 3PE steps. However, the extra beds and extra cycle time required for the 3PE steps led to a reduction in productivity by almost 33 % in going from the 2PE to 3PE cycles. The choice for including additional PE steps therefore relies on the tradeoff of capital and operating costs which is strongly location and project specific.

66 The Management of Syncope on the Acute Medical Take. An Experience at a District General Hospital

<h3>Introduction</h3> Syncope accounts for up to 6% of admissions annually.¹ In the over 65 age group, 23% will have an episode of syncope over a 10 year period with a 30% recurrence rate over two years.²Up to 60% of patients presenting to A&amp;E with syncope are admitted, however only 50% will have syncope specific investigations and only 50% will receive a final diagnosis.² Financial restraints and bed pressures in the UK have increased the need for effective management of syncope. We aimed to assess the management of syncope on the acute medical take. <h3>Method</h3> An audit was devised to evaluate the management of patients referred to the medical team over a 50-day period. The medical notes of patients meeting the inclusion criteria were sourced, retrospectively analysed and compared with current NICE guidelines. The project was extended to assess whether development of a pathway with same day syncope services would impact hospital bed stays. <h3>Results</h3> Of 190 patients, 77 randomly sourced notes were analysed; 35 patients were identified as having had a syncopal event. 63% were female and the average age was 85 years (67–98). 11% of patients had a full history recorded and only 3% had a complete initial assessment including history, ECG and postural blood pressure recording. 51% of patients had CT brain imaging of which 74% were not indicated. 34% of patients had 24 h ECG monitoring of which none were indicated and no significant result identified. 29% of patients did not have an inpatient echocardiogram and 34% of patients did not have an inpatient cardiology review despite indications. 37% of patients were discharged with no diagnosis. 29% of all patients had previously been admitted with a similar presentation. 46% of patients admitted could have been discharged on the same day had rapid ECHO, cardiology review and injectable loop recorder services been available. This accounts for 160 days of inappropriate hospital stay and with extrapolation, 1168 days in one year. Thus, 3.2 extra beds could be made available at our DGH. <h3>Conclusion</h3> The initial assessment of syncope is inadequate and investigations are inappropriately requested or not considered. A proportion of patients do not receive a diagnosis and are unnecessarily admitted. A considerable number of bed days could be prevented with a clear syncope pathway including same day ECHO, cardiology review and injectable loop recorder service, thus relieving pressures on acute medical beds and accident and emergency services. This problem is not unique to our trust and represents a pattern currently prevalent across the UK and further afield. <h3>References</h3> Shen WK, Decker WW, Smars PA, <i>et al</i>. Syncope Evaluation in the Emergency Department Study (SEEDS): a multidisciplinary approach to syncope management. Circulation 2004;110(24):3636-45 Lipsitz L, Wei JY, Rowe JW. Syncope in an elderly, institutionalised population: prevalence, incidence, and associated risk. Q J Med. 1985;55(216):45-54