Hospital Bed Days Research Articles

Comparative study between indwelling pleural drain and intercostal drainage followed by pleurodesis in management of malignant pleural effusion

<p class="abstract"><strong>Background:</strong> Malignant pleural effusion is a major cause of morbidity in lung cancer patients. Management involves repeated pleural aspirations or persistent intercostal drainage (ICD) tube. Using an indigenous method of putting ICD tube of smaller size with subcutaneous tunnelling allows draining fluid from lungs easily and painlessly when needed avoiding the need for repeated injections and chest tube insertion.</p><p class="abstract"><strong>Methods:</strong> In this prospective, 48 months study, 100 patients of malignant pleural effusion were included in the study and half of them were treated with intercostals drainage followed by pleurodesis and the remaining half were treated with a indwelling pleural catheter (IPC). The end points taken were hospital bed days, complications, cost and quality of life insertion<span lang="EN-IN">. </span><span lang="EN-IN"> </span></p><p class="abstract"><strong>Results:</strong> In the IPC group the average baseline dyspnoea score (visual analogue scale) of the patients was 61.23±22.10 and at 6 months it was 5.65 (p <0.05). In ICD group average baseline dyspnoea score was 64.44±27.40 and at 6 months it was 14.09 (p <0.05). In IPC group the average baseline quality of life score was found to be 41.18±9.40 and at 6 months it was 69.87 (p <0.05). In ICD group average baseline quality of life score was found to be 43.21±7.84 at 6 months it was 58.88 (p <0.05). In terms of hospital readmission around 8 patients (16%) belonging to IPC group needed it and in ICD group 17 patients (34%) needed it. The commonest complication found in IPC group was catheter blockage and it was seen in 13 patients (26%). In ICD group the commonest complication was the need for repeat drainage seen in 12 patients (24%).</p><p class="abstract"><strong>Conclusions:</strong> Indwelling pleural catheter is a low cost, easily available and successful alternative option to intercostals drainage in patients having persistent malignant pleural effusion and it provides a better quality of life to patients<span lang="EN-IN">. </span></p>

Anticipatory Care Planning in Scotland

Background : Innovative work is being undertaken across Scotland to reshape delivery of care. Effective Anticipatory Care Planning (ACP) is key to ensuring optimal delivery of an appropriate and sustainable model of health and care. This is supported through the use of information sharing technology, the Key Information Summary (KIS), to communicate across the primary and acute care interface. The initiative is aligned with the NHS Quality Strategy for Scotland, the 2020 vision and the National Health and Wellbeing Outcomes supporting Health and Social Care integration. At a time of significant change and challenge within our healthcare system there is a need to ensure provision of safe, high quality services at home or in a homely setting for people with disabilities, long term conditions or multiple morbidities. This is achievable by developing a robust community infrastructure with capacity and capability to optimise care and quality of life and manage more people more independently out of hospital. ACP is a person-centred, proactive, “thinking ahead” approach, requiring services and professionals to work with individuals and their carers to set personal goals ensuring the right thing is done at the right time by the right person with the right outcome. ACP evolves reflecting the individual’s situation and requires a supportive whole-system infrastructure to ensure delivery of positive outcomes. ACP provides opportunities to improve health literacy and understand personal health and care issues, circumstances and outcomes, enabling informed decision-making and expression of preferences. The work responds to the challenge of providing care for an ageing population with increasing prevalence of long term conditions and multiple morbidities. Currently, in Scotland, 80% of individuals admitted to hospital are over 75 years. 30% of admissions could potentially be avoided through mainstreaming an ACP approach supported by a model providing appropriate case management, interventions close to home, signposting, access to supported self management, local intermediate care, enablement and rehabilitation. Planning and improvement : A cross-sector *Anticipatory Care Planning Task and Finish Group* aligned with the *Living Well in Communities (LWIC)* initiative has developed a National Action Plan to support implementation of ACP principles across Scotland over two years to deliver best-model, person-centred care close to home with consequent reduction in avoidable hospital admissions and bed days. The National Action Plan : has been informed by continuous improvement work over the last decade to implement principles outlined by Kerr (2005) and learning from improvement through collaboration on reshaping care for long term conditions and multi-morbidities supported by local best practice initiatives. Population stratification estimates that 5-6% of the population could potentially benefit from ACP. Vulnerable individuals should be identified and offered interventions in a timely way to enable informed choice and ensure optimise outcomes. ACP triggers based on situation, condition and assessment support ACP initiation. Triggers include falls, which account for 10% of unplanned admissions, polypharmacy and dementia. 2% of the population, (high-resource individuals), utilise 77% of hospital inpatient days and 50% of combined prescribing resources. There is potential to improve efficiency through collaborative work for this group. Primary Drivers : The National ACP Action Plan focusses on 3 Primary Drivers (below) developed through extensive scoping work, improvement methodology informed by logic modelling and consultation with a wide range of stakeholders and service users. 1. Awareness-raising with public, services and organisations to embed ACP within each Locality to help those with multiple morbidities and ensure delivery of locally accessible services for those with most complex needs. 2. Carer support must be prioritised alongside ACP. 3. Provision of consistent ACP material to support individuals and appropriate information sharing between professionals to support collaborative work. The Key Information Summary (KIS) currently hosted on the GP IT system enables eACP access. Following successful pilot work, engagement with General Practice and Primary Care has been established by integrating KIS and ACP with the Quality and Safety Domain of the GP Contract QOF. In Year One, 151,641 individuals (3.2% of the population) had a KIS. Through partnership working KIS is accessible to unscheduled care services including NHS 24, Out of Hours, Emergency Department and hospital front door resulting in 3.32m KIS accesses/annum outside general practice. 81% KIS contain information considered valuable to informing appropriate interventions. Ongoing work is focussed on evolution of KIS to enable greater accessibility and cross sector working. Further improvement will also include an organisational scoping exercise, tests of change, learning needs analysis and developing an identifiable single “branded” Scottish ACP and national role out of a whole-system ACP model co-ordinated through a national ACP Partnership Network and communication strategy.

Outsourcing cleaning services increases MRSA incidence: Evidence from 126 english acute trusts

There has been extensive outsourcing of hospital cleaning services in the NHS in England, in part because of the potential to reduce costs. Yet some argue that this leads to lower hygiene standards and more infections, such as MRSA and, perhaps because of this, the Scottish, Welsh, and Northern Irish health services have rejected outsourcing. This study evaluates whether contracting out cleaning services in English acute hospital Trusts (legal authorities that run one or more hospitals) is associated with risks of hospital-borne MRSA infection and lower economic costs.By linking data on MRSA incidence per 100,000 hospital bed-days with surveys of cleanliness among patient and staff in 126 English acute hospital Trusts during 2010–2014, we find that outsourcing cleaning services was associated with greater incidence of MRSA, fewer cleaning staff per hospital bed, worse patient perceptions of cleanliness and staff perceptions of availability of handwashing facilities. However, outsourcing was also associated with lower economic costs (without accounting for additional costs associated with treatment of hospital acquired infections).

Novel Emergency Department Risk Score Discriminates Acute Coronary Syndrome Among Chest Pain Patients With Known Coronary Artery Disease.

Patients with known coronary artery disease presenting to the emergency department (ED) with chest pain are often admitted, yet may not be having an acute coronary syndrome (ACS). We assessed whether the use of a novel risk score and a modified thrombolysis in myocardial infarction risk score obtained in the ED could discriminate which of these high-risk patients have ACS. Chart review was performed on a cohort of 285 patients with known coronary artery disease presenting to the ED with chest pain thought to be of ischemic origin and admitted to the hospital. The ED variables were assessed with logistic regression for their association with eventual ACS diagnosis at hospital discharge. ACS was diagnosed in 74 (26%) of the patients. Non-ACS patients had a 2-day median length of stay and $6875 median inpatient (post ED) hospital charges (not including physician fees), totaling 566 hospital bed days and $1,871,250 for the 211 (74%) non-ACS patients. A novel risk score, including (1) history of prior revascularization, (2) comorbid chronic kidney disease, (3) onset of chest discomfort at rest, (4) dynamic electrocardiogram changes in the ED, (5) elevated troponin I (>0.05 ng/mL) in the ED, and (6) associated illness at presentation, discriminated ACS and non-ACS with a c statistic of 0.767; the c statistic for a modified thrombolysis in myocardial infarction risk score was 0.712. Application of these risk scores may reduce the number of potentially avoidable admissions and their associated hazards and costs.

Effect of a national 4C antibiotic stewardship intervention on the clinical and molecular epidemiology of Clostridium difficile infections in a region of Scotland: a non-linear time-series analysis

Whereas many antibiotics increase risk of Clostridium difficile infection through dysbiosis, epidemic C difficile ribotypes characterised by multidrug resistance might depend on antibiotic selection pressures arising from population use of specific drugs. We examined the effect of a national antibiotic stewardship intervention limiting the use of 4C antibiotics (fluoroquinolones, clindamycin, co-amoxiclav, and cephalosporins) and other infection prevention and control strategies on the clinical and molecular epidemiology of C difficile infections in northeast Scotland. We did a non-linear time-series analysis and quasi-experimental study to explore ecological determinants of clinical burdens from C difficile infections and ribotype distributions in a health board serving 11% of the Scottish population. Study populations were adults (aged ≥16 years) registered with primary carer providers in the community (mean 455 508 inhabitants) or admitted to tertiary level, district general, or geriatric hospitals (mean 33 049 total admissions per month). A mixed persuasive-restrictive 4C antibiotic stewardship intervention was initiated in all populations on May 1, 2009. Other population-specific interventions considered included limiting indications for macrolide prescriptions, introduction of alcohol-based hand sanitiser, a national hand-hygiene campaign, national auditing and inspections of hospital environment cleanliness, and reminders to reduce inappropriate use of proton-pump inhibitors. The total effect of interventions was defined as the difference between observations and projected scenarios without intervention. Primary outcomes were prevalence density of C difficile infection per 1000 occupied bed-days in hospitals or per 100 000 inhabitant-days in the community. Between Jan 1, 1997, and Dec 31, 2012, we identified 4885 cases of hospital-onset C difficile infection among 1 289 929 admissions to study hospitals, and a further 1625 cases of community-onset C difficile infection among 455 508 adults registered in primary care. Use of 4C antibiotics was reduced by 50% in both hospitals (mean reduction 193 defined daily doses per 1000 occupied bed-days, 95% CI 45-328, p=0·008) and the community (1·85 defined daily doses per 1000 inhabitant-days, 95% CI 0·23-3·48, p=0·025) during antibiotic stewardship. Falling 4C use predicted rapid declines in multidrug-resistant ribotypes R001 and R027. Hospital-onset C difficile infection prevalence densities were associated with fluoroquinolone, third-generation cephalosporin, macrolides, and carbapenem use, exceeding hospital population specific total use thresholds. Community-onset C difficile infection prevalence density was predicted by recent hospital C difficile infection rates, introduction of mandatory surveillance in individuals older than 65 years, and primary-case use of fluoroquinolones and clindamycin exceeding total use thresholds. Compared with predictions without intervention, C difficile infection prevalence density fell by 68% (mean reduction 1·01 per 1000 occupied bed-days, 0·27-1·76, p=0·008) in hospitals and 45% (0·083, 0·045-0·121 cases per 100 000 inhabitant-days, p<0·0001) in the community, during antibiotic stewardship. We identified no significant effects from other interventions. Limiting population use of 4C antibiotics reduced selective pressures favouring multidrug-resistant epidemic ribotypes and was associated with substantial declines in total C difficile infections in northeast Scotland. Efforts to control C difficile through antibiotic stewardship should account for ribotype distributions and non-linear effects. NHS Grampian Microbiology Endowment Fund.

Hyper acute stroke unit patient suitability for early supported discharge: Coordination and data analysis project

Research has shown the benefits of early supported discharge (ESD) from stroke units on patient outcomes as well as reducing bed days in hospital. This 6-month project identified that there are higher numbers of patients (12%) who could go home earlier from the hyper acute stroke unit via ESD services when there was an ESD coordinator role in place. In order for this to occur, however, there needs to be a closer interprofessional working relationship with social services with regards to ensuring that both patient health and social needs are met. This role could potentially increase the amount of appropriate patients being discharged to ESD teams, thus allowing access to evidence-based care. This short report describes how appropriate coordination can meet patient needs while saving the local stroke health economy over £230 000 in a 6-month period.

ISQUA16-1142IS READMISSION POLICY PENALISING HOSPITALS FOR KEEPING PEOPLE ALIVE?

Over the past 15 years emergency admissions (EA) in England have increased by 47 per cent to 5.3 million in 2012-13, yet the population has only grown by 10%. EAs are costing the English National Health Service (NHS) £12.5 billion and are accounting for two-thirds of all hospital bed days. There are several explanations cited for this, including: the aging population; a shift to provide more day-case care; accident and emergency arrival targets; and a move from block contracts to payments by results, which is argued incentivises hospitals to admit more patients and discharge them more quickly. However, new medical technologies and improvements in patient safety has simultaneously meant that more patients now survive hospital admission, indeed the …

A small-scale randomised controlled trial of home telemonitoring in patients with severe chronic obstructive pulmonary disease

Introduction This was a pilot study to examine the effects of home telemonitoring (TM) of patients with severe chronic obstructive pulmonary disease (COPD). Methods A randomised controlled 12-month trial of 42 patients with severe COPD was conducted. Home TM of oximetry, temperature, pulse, electrocardiogram, blood pressure, spirometry, and weight with telephone support and home visits was tested against a control group receiving only identical telephone support and home visits. Results The results suggest that TM had a reduction in COPD-related admissions, emergency department presentations, and hospital bed days. TM also seemed to increase the interval between COPD-related exacerbations requiring a hospital visit and prolonged the time to the first admission. The interval between hospital visits was significantly different between the study arms, while the other findings did not reach significance and only suggest a trend. There was a reduction in hospital admission costs. TM was adopted well by most patients and eventually, also by the nursing staff, though it did not seem to change patients’ psychological well-being. Discussion Ability to draw firm conclusions is limited due to the small sample size. However the trends of reducing hospital visits warrant a larger study of a similar design. When designing such a trial, one should consider the potential impact of the high quality of care already made available to this patient cohort.

Effect of paliperidone palmitate on hospitalisation in a naturalistic cohort – a four-year mirror image study

BackgroundClinical trial outcomes are heavily influenced by the non-naturalistic clinical trial process. Observations of outcomes in clinical practice are a valuable adjunct to clinical trial results. HypothesisOur null hypothesis was that clinically indicated switching to paliperidone palmitate had no effect on hospital admissions or hospital bed days. MethodThis was a part-prospective mirror image study examining outcomes 2years before starting paliperidone palmitate and 2years after. Sensitivity analyses examined the effect of different placings of the mirror in the mirror image design. ResultsWe prospectively followed-up 225 patients prescribed paliperidone palmitate in clinical practice. At 2years, 41.8% of patients were still receiving paliperidone palmitate. In the primary analysis, the mean number of admissions fell from 1.80 in the two years before starting paliperidone palmitate to 0.81 in two years following the drug's initiation (outpatients) or two years following hospital discharge (inpatients) (P<0.001). More than half of patients were not admitted to hospital during two years follow-up. Mean total bed days was reduced from 79.6 in the two years before to 46.2 in the two years after paliperidone palmitate initiation or discharge (P<0.001). Sensitivity analyses gave broadly similar outcomes. Continuers demonstrated better outcomes than discontinuers in sensitivity analyses but not in the primary analysis. ConclusionPaliperidone palmitate initiation is associated with a substantial reduction in hospital admissions and days spent in hospital. The reduction in costs associated with reduced use of health care facilities is likely to exceed the purchase and administration costs of the drug.

Thrombolysis in acute ischemic stroke is associated with lower long-term hospital bed day use: A nationwide propensity score-matched follow-up study.

Background Thrombolysis with intravenous recombinant tissue-type plasminogen activator improves functional outcome in acute ischemic stroke. Few studies have investigated the effects of thrombolysis in a real-world setting. We evaluated the impact of thrombolysis on long-term hospital bed day use and the risk of readmission due to stroke-related complications. Methods We conducted a register-based nationwide propensity score-matched follow-up study among ischemic stroke patients in Denmark (2004-2011). Thrombolysed patients were propensity-score matched with non-thrombolysed acute ischemic stroke patients admitted to stroke centers not yet offering thrombolysis in 2004-2006. The outcomes were length of the stroke admission, total all-cause hospital bed day use during the first year after the stroke, and the long-term risk of readmissions. Thrombolysed and non-thrombolysed patients were compared using multivariable log-linear regression and Cox regression. Results We identified 1095 thrombolysed and 1095 propensity score matched eligible but non-thrombolysed acute ischemic stroke patients. The median length of the stroke admission was 9 days in the thrombolysed group and 13 days in the non-thrombolysed group (adjusted geometric mean ratio, 0.88; 95% CI: 0.78-1.00). The median all-cause hospital bed day use within the first year was 12 days in the thrombolysed group and 19 days in the non-thrombolysed group (adjusted geometric mean ratio, 0.82; 95% CI: 0.73-0.92). There was no significant difference in the overall risk of readmission (adjusted hazard ratio, 0.91; 95% CI: 0.79-1.04); however, thrombolysis was associated with reduced risk of pneumonia (adjusted hazard ratio, 0.59; 95% CI: 0.35-0.97). Conclusions Thrombolysis in ischemic stroke was associated with lower long-term hospital bed day use and decreased risk of readmission due to pneumonia.

Reducing avoidable admissions in rural community palliative care: a pilot study of care coordination by General Practice registrars.

To investigate the feasibility of using a General Practice registrar (GPR) to coordinate rural palliative care services. A quasi-experimental design was used. Intervention group participants received the GPR service, which involved liaison among the patient, family, General Practitioner, specialist palliative care team and community nurses. Specified risk assessment, care planning and continuity of care were provided. Patients in the comparison group received the standard service. Rural community palliative care. One hundred and ninety-one rural community palliative care patients (99 intervention and 92 control patients). Hospital admissions per 100 patient-days, bed-days per 100 patient-days and proportion of deaths at home. Patients receiving standard care were twice as likely to spend ≥8 bed-days in hospital (OR 2.09 (95%CI 1.10-3.97); P = 0.02) and were more likely to have ≥ 2 admissions to hospital (OR 3.37 (95%CI 1.83-6.21); P < 0.001), per 100 patient-days than the intervention group after adjusting for diagnosis group (cancer or not) and residence in residential aged care. Controls were significantly less likely to die at home than the intervention group (OR 0.41 (95%CI 0.20-0.86); P = 0.02). This is a small proof of concept pilot study limited by lack of randomisation. The results demonstrate the feasibility of using a GPR to manage continuity of care for rural community palliative care patients. Given the potential confounding factors, further investigation via a larger randomised trial is required.

Community treatment orders and reduced time in hospital: a nationwide study, 2007-2012.

Aims and method Community treatment orders (CTOs) were introduced in Scotland in 2005, but are controversial owing to a lack of supportive randomised evidence. The non-randomised studies provide mixed results on their efficacy and utility. We aimed to examine hospital bed day usage across Scotland both before and after CTOs were initiated in a national cohort of patients, spanning 5 years.Results In total, 1558 individuals who were subject to a CTO between 2007 and 2012, of whom 63% were male, were included. After CTO initiation the number of hospital bed days fell, on average, from 66 to 39 per annum per patient. Those with a longer psychiatric history appeared to benefit more from a CTO, in terms of reduced time in hospital.Clinical implications Our data offer cautious support for the use of CTOs in routine practice, in terms of reducing time spent in psychiatric hospital. This finding is balanced by the more rigorous randomised studies which do not find any benefit to CTOs.

Cumulative number of hospital bed days among older adults in the last year of life: A retrospective cohort study

To determine whether age, proximity to death and long-term care insurance certification are related to receiving hospital inpatient care; the number of hospital bed days (HBD) among older Japanese adults in the last year of life; and to estimate the total number of HBD. Using health insurance claims and death certificate data, the present retrospective cohort study examined the HBD of city residents aged ≥65 years who died between September 2006 and October 2009 in Soma City, Japan. Using a two-part model, factors associated with receiving hospital inpatient care and the total number of HBD in each quarter in the last year of life were examined. The total number of HBD in the last year of life varied widely; 13% had no admission, and 27% stayed ≥90 days. Younger age, approaching death and having long-term care insurance certification were significantly associated with being more likely to receive hospital inpatient care during each quarterly period in the last year of life. In contrast, having long-term care insurance certification and the last 3-month period before death, compared with the first 3-month period, were significantly associated with a fewer number of HBD. The present study showed that older age was associated with being less likely to receive hospital inpatient care. The findings regarding the risk of inpatient care and total number of HBD in the last year of life help to understand resource use among older dying adults, and to develop evidence-based healthcare policies within aging societies. Geriatr Gerontol Int 2017; 17: 737-743.

Timing of onset and burden of persistent critical illness in Australia and New Zealand: a retrospective, population-based, observational study

Critical care physicians recognise persistent critical illness as a specific syndrome, yet few data exist for the timing of the transition from acute to persistent critical illness. Defining the onset of persistent critical illness as the time at which diagnosis and illness severity at intensive care unit (ICU) arrival no longer predict outcome better than do simple pre-ICU patient characteristics, we measured the timing of this onset at a population level in Australia and New Zealand, and the variation therein, and assessed the characteristics, burden of care, and hospital outcomes of patients with persistent critical illness. In this retrospective, population-based, observational study, we used data for ICU admission in Australia and New Zealand from the Australian and New Zealand Intensive Care Society Adult Patient Database. We included all patients older than 16 years of age admitted to a participating ICU. We excluded patients transferred from another hospital and those admitted to an ICU for palliative care or awaiting organ donation. The primary outcome was in-hospital mortality. Using statistical methods in evenly split development and validation samples for risk score development, we examined the ability of characteristics to predict in-hospital mortality. Between Jan, 2000, and Dec, 2014, we studied 1 028 235 critically ill patients from 182 ICUs across Australia and New Zealand. Among patients still in an ICU, admission diagnosis and physiological derangements, which accurately predicted outcome on admission (area under the receiver operating characteristics curve 0·898 [95% CI 0·897-0·899] in the validation cohort), progressively lost their predictive ability and no longer predicted outcome more accurately than did simple antecedent patient characteristics (eg, age, sex, or chronic health status) after 10 days in the ICU, thus empirically defining the onset of persistent critical illness. This transition occurred between day 7 and day 22 across diagnosis-based subgroups and between day 6 and day 15 across risk-of-death-based subgroups. Cases of persistent critical illness accounted for only 51 509 (5·0%) of the 1 028 235 patients admitted to an ICU, but for 1 029 345 (32·8%) of 3 138 432 ICU bed-days and 2 197 108 (14·7%) of 14 961 693 hospital bed-days. Overall, 12 625 (24·5%) of 51 509 patients with persistent critical illness died and only 23 968 (46·5%) of 51 509 were discharged home. Onset of persistent critical illness can be empirically measured at a population level. Patients with this condition consume vast resources, have high mortality, have much less chance of returning home than do typical ICU patients, and require dedicated future research. ICU clinicians should be aware that the risk of in-hospital mortality can change quickly over the first 2 weeks of an ICU course and be sure to incorporate such changes in their decision making and prognostication. None.

Integrated multidisciplinary community service for chronic obstructive pulmonary disease reduces hospitalisations.

Hospitalisations for chronic obstructive pulmonary disease (COPD) exacerbation affect patient outcomes and healthcare costs. The long-term impact of an integrated COPD disease-management approach on hospitalisation remains controversial. The aim of this study was to evaluate whether a multidisciplinary community service reduces respiratory hospitalisations for COPD patients. A total of 346 patients was followed for a mean duration of 27.3 months. The number of admissions, total bed days for respiratory (COPD exacerbation or pneumonia) or general medical causes and length of stay (LOS) per respiratory admission was compared before and after referral with the service. A secondary multivariate analysis examined which clinical parameters best predict benefit from such service. The total respiratory admission and hospital bed days after referral were reduced by 31% (288 vs 417, P < 0.001) and 40.4% (1637 vs 2746, P < 0.0001) respectively, compared with the equivalent duration prior. The average LOS for each respiratory admission was also significantly reduced after referral (6.61 vs 5.70, P = 0.02). Overall, 55% patients experienced a reduction in admission frequency and hospital days. The impact on admission frequency and hospital days was the greatest in those with an at least moderate disease (GOLD ≥2, odds ratio (OR): 3.2, 95% confidence interval (CI): 1.2, 8.9; P = 0.019) and those who completed pulmonary rehabilitation (PR) (OR: 1.7, 95% CI: 1.1, 2.8; P = 0.04). In contrast, general medical admissions increased, one-third attributable to a cardiovascular cause both before and after referral. The implementation of COPD multidisciplinary community service was associated with reduced respiratory hospitalisations in the long term. Patients with moderate or severe disease and who are able to complete PR are much more likely to benefit.

Stranded: causes and effects of discharge delays involving non-acute in-patients requiring maintenance care in a tertiary hospital general medicine service.

Objectives The aims of the present study were to identify causes of prolonged discharge delays among non-acute in-patients admitted to a tertiary general medicine service, quantify occupied bed days (OBDs) and propose strategies for eliminating avoidable delays. Methods A retrospective study was performed of patients admitted between 1 January 2012 and 31 May 2015 and discharged as non-acute cases requiring maintenance care and who incurred a total non-acute length of stay (LOS) >7 days and total hospital LOS >14 days. Long-stay patients with non-acute LOS ≥28 days were subject to chart review in ascertaining serial causes of discharge delay and their attributable OBDs. Literature reviews and staff feedback identified potential strategies for minimising delays. Results Of the 406 patients included in the present study, 131 incurred long-stays; for these 131 patients, delays were identified that accounted for 5420 of 6033 (90%) non-acute OBDs. Lack of available residential care beds was most frequent, accounting for 44% of OBDs. Waits for outcomes of guardianship applications accounted for 13%, whereas guardian appointments, Public Trustee applications and funding decisions for equipment or care packages each consumed between 4% and 5% of OBDs. Family and/or carer refusal of care accounted for 7%. Waits for aged care assessment team (ACAT) assessments, social worker reports, geriatrician or psychiatrist reviews and confirmation of enduring power of attorney each accounted for between 1% and 3% of OBDs. Of 30 proposed remedial strategies, those rated as high priority were: greater access to interim care or respite care beds or supported accommodation, especially for patients with special needs; dedicated agency officers for hospital guardianship applications and greater interagency collaboration and harmonisation of assessment and decision processes; and formal requests from hospital administrators to patients and family to accept care options and attend mediation meetings. Conclusions Delayed discharge of non-acute maintenance care patients results principally from impaired access to residential care, administrative delays involving external agencies and patient or family refusal of care. Proposed remedial actions require concerted interjurisdictional advocacy. What is known about this topic? Delays in discharge of non-acute patients requiring maintenance care can occur for many reasons and incur inordinately long hospital stays. What does this paper add? The present detailed chart review of 131 long-stay non-acute patients identified causes of serial discharge delays and quantified their prevalence and attributable bed days. Waits for residential care accounted for less than half the bed days, administrative delays involving decisions by agencies external to the hospital accounted for one-quarter and patient or family refusal of care options accounted for one-tenth. Strategies are proposed that may minimise these delays. What are the implications for practitioners? Delayed discharge of non-acute patients requiring maintenance care threatens to consume an ever-increasing proportion of acute hospital bed days. Remedial action is required from stakeholders both within and outside hospitals to reverse this trend.

Factors associated with variation in hospital use at the end of life in England

ObjectiveTo identify the relative importance of factors influencing hospital use at the end of life.DesignRetrospective cohort study of person and health system effects on hospital use in the past 12...

Association of Opioids and Sedatives with Increased Risk of In-Hospital Cardiopulmonary Arrest from an Administrative Database.

BackgroundWhile opioid use confers a known risk for respiratory depression, the incremental risk of in-hospital cardiopulmonary arrest, respiratory arrest, or cardiopulmonary resuscitation (CPRA) has not been studied. Our aim was to investigate the prevalence, outcomes, and risk profile of in-hospital CPRA for patients receiving opioids and medications with central nervous system sedating side effects (sedatives).MethodsA retrospective analysis of adult inpatient discharges from 2008–2012 reported in the Premier Database. Patients were grouped into four mutually exclusive categories: (1) opioids and sedatives, (2) opioids only, (3) sedatives only, and (4) neither opioids nor sedatives.ResultsAmong 21,276,691 inpatient discharges, 53% received opioids with or without sedatives. A total of 96,554 patients suffered CPRA (0.92 per 1000 hospital bed-days). Patients who received opioids and sedatives had an adjusted odds ratio for CPRA of 3.47 (95% CI: 3.40–3.54; p<0.0001) compared with patients not receiving opioids or sedatives. Opioids alone and sedatives alone were associated with a 1.81-fold and a 1.82-fold (p<0.0001 for both) increase in the odds of CPRA, respectively. In opioid patients, locations of CPRA were intensive care (54%), general care floor (25%), and stepdown units (15%). Only 42% of patients survived CPRA and only 22% were discharged home. Opioid patients with CPRA had mean increased hospital lengths of stay of 7.57 days and mean increased total hospital costs of $27,569.ConclusionsOpioids and sedatives are independent and additive risk factors for in-hospital CPRA. The impact of opioid sparing analgesia, reduced sedative use, and better monitoring on CPRA incidence deserves further study.

Reduction in resource use with the misoprostol vaginal insert vs the dinoprostone vaginal insert for labour induction: a model-based analysis from a United Kingdom healthcare perspective.

BackgroundIn view of the increasing pressure on the UK’s maternity units, new methods of labour induction are required to alleviate the burden on the National Health Service, while maintaining the quality of care for women during delivery. A model was developed to evaluate the resource use associated with misoprostol vaginal inserts (MVIs) and dinoprostone vaginal inserts (DVIs) for the induction of labour at term.MethodsThe one-year Markov model estimated clinical outcomes in a hypothetical cohort of 1397 pregnant women (parous and nulliparous) induced with either MVI or DVI at Southmead Hospital, Bristol, UK. Efficacy and safety data were based on published and unpublished results from a phase III, double-blind, multicentre, randomised controlled trial. Resource use was modelled using data from labour induction during antenatal admission to patient discharge from Southmead Hospital. The model’s sensitivity to key parameters was explored in deterministic multi-way and scenario-based analyses.ResultsOver one year, the model results indicated MVI use could lead to a reduction of 10,201 h (28.9 %) in the time to vaginal delivery, and an increase of 121 % and 52 % in the proportion of women achieving vaginal delivery at 12 and 24 h, respectively, compared with DVI use. Inducing women with the MVI could lead to a 25.2 % reduction in the number of midwife shifts spent managing labour induction and 451 fewer hospital bed days. These resource utilisation reductions may equate to a potential 27.4 % increase in birthing capacity at Southmead Hospital, when using the MVI instead of the DVI.ConclusionsResource use, in addition to clinical considerations, should be considered when making decisions about labour induction methods. Our model analysis suggests the MVI is an effective method for labour induction, and could lead to a considerable reduction in resource use compared with the DVI, thereby alleviating the increasing burden of labour induction in UK hospitals.

Predicting admissions and time spent in hospital over a decade in a population-based record linkage study: the EPIC-Norfolk cohort

ObjectiveTo quantify hospital use in a general population over 10 years follow-up and to examine related factors in a general population-based cohort.DesignA prospective population-based study of men and women.SettingNorfolk, UK.Participants11...