Norwegian General Hospital Research Articles

A retrospective study of non-ventilator hospital-acquired pneumonia in a Norwegian hospital: a serious medical condition in need of better and timelier microbiological diagnostics

Background Hospital-acquired pneumonia (HAP) is the most common hospital-acquired infection (HAI). HAP is associated with a high burden of morbidity and mortality, but the diagnosis is difficult to establish and the incidence uncertain. Methods Patients aged ≥ 18 years hospitalised with radiologically verified non-ventilator hospital acquired pneumonia (NV-HAP) during 2018 were retrospectively identified at Drammen Hospital, a Norwegian general hospital. Infectious Diseases Society of America and the American Thoracic Society’s definition of HAP was used. Results In total 119 cases of NV-HAP were identified among 27,701 admissions. The incidence was 4.3 per 1000 admissions and 1.2 per 1000 patient-days. The median age was 74 years, 63% were male and median Charlson comorbidity index was 5. Coronary heart disease (42%) was the most common comorbidity. Median length of stay was 17.2 days. A blood culture was obtained in 53.8% of patients, while samples from lower airways were seldom obtained (10.9%). In-hospital mortality was 21%, accumulated 30-day mortality was 27.7% and accumulated 1-year mortality was 39.5%. Thirty-day readmission rate among survivors was 39.4%. Conclusion NV-HAP was present in approximately 1 in 250 hospitalisations, most had multiple comorbidities, and 1 in 5 died in hospital. Although thorough microbiological sampling is recommended when NV-HAP is suspected, our data indicate that airway sampling is infrequent in clinical practice. Our findings underscore the need to develop microbiological diagnostic strategies to achieve targeted antimicrobial treatment that may improve patient outcomes and reduce broad-spectrum antibiotic usage.

Work status and work ability after radical prostatectomy or active surveillance for prostate cancer

Objective: Being able to work is important for health-related quality of life (HRQoL), and little is known about work life after radical treatment for prostate cancer (PCa). The aim was to investigate work status (WS) and work ability (WA) after radical prostatectomy (RP) or active surveillance (AS) for PCa, and to identify factors associated with reduced WA.Materials and methods: This is a retrospective cross-sectional study of 606 men treated with RP (n = 442) or AS (n = 164) at two Norwegian general hospitals. In 2017, they were asked to complete questionnaires measuring adverse effects (AE), HRQoL, aspects of work life and psychological factors at a median of 4.1 (range 1.3–8.1) years after diagnosis. Clinical data were retrieved from medical records. WS was categorized into employed, unemployed or retired. WA was rated using the Work Ability Index. Regression analyses were performed to find factors associated with reduced WA.Results: WS was similar for the RP and AS groups at diagnosis and survey. There was a small reduction in WA from diagnosis to survey and the difference between the RP and AS groups was non-significant. Older age, poorer self-rated health, poorer incontinence score, more chronic fatigue, and increased anxiety and depressive symptoms were associated with reduced WA, while treatment method, urinary bother and use of pads were not.Conclusion: The impact of RP and AS on WS and WA was almost similar. Age and psychological variables were more strongly associated with reduced WA than cancer-related variables.

Quality improvement of metabolic control for patients with type 2 diabetes treated at a general hospital: a quantitative open cohort study.

Most patients with type 2 diabetes have metabolic risk factors above recommend goals. The present intervention aimed to escalate medical treatment to improve metabolic control. The study was carried out at a Norwegian general hospital as a quantitative open cohort study. The audit evaluated 191 patients treated from 2007 to 2012. To improve metabolic control, a medical intervention used stepped care and goals for the metabolic risk factors. A database was used to overview the intervention. Multiple regression analyses assessed whether baseline characteristics and components of the intervention were associated with change of metabolic risk factors. The intervention increased number of antihypertensive drugs and dose of metformin and insulin. The intensification lowered mean systolic blood pressure from 142 to 132 mmHg, low-density lipoprotein cholesterol from 2.6 to 2.1 mmol L(-1) and glycated haemoglobin, HbA1c, from 8.5 to 7.6% (64-57 mmol mol(-1) , P < 0.001, t-tests). At end of the study, 25 (13%) patients fulfilled targets for the three metabolic risk factors. Multiple linear regression analyses showed that changes of the three metabolic risk factors were significantly associated with levels at start of the study and number of visits or length of follow-up. Stepped care was an effective treatment for type 2 diabetes at a general hospital. The database supported the intervention. It improved metabolic control over 4 years.

Improving hospital bed utilisation through simulation and optimisation: With application to a 40% increase in patient volume in a Norwegian general hospital

PurposeThis paper analyses the problem of allocating beds among hospital wards in order to minimise crowding. MethodWe present a generic discrete event simulation model of patient flow through the wards of a hospital. In the generic model, each ward can have separate probability distributions for arrival times and length of stay, which may be time dependent. Output of the model is a matrix, with statistics on the utilisation of different hypothetical numbers of beds for each ward. This matrix is fed into an allocation algorithm, which distributes the available beds among the wards in an optimal way. We define bed utilisation either in terms of how often it is in use (prevalence), or in terms of how often a newly arriving patient is placed in it (incidence). For these classes of utilisation measures we develop efficient allocation algorithms, which we prove to be optimal. ApplicationThe model was applied to Akershus University Hospital in Norway. In 2011, some of the wards of this hospital experienced a high occupancy rate, while others had a lower utilisation. Our model was applied in order to reallocate the hospital beds among the wards. For each ward, acute arrivals were modelled with Poisson-distributions with time-varying intensity, while elective arrivals were programmed to arrive in specific numbers at specific times. The arrival rates were based on empirical data for 2010, scaled up by an expected increase of 40% due to a restructuring of the hospital districts in Oslo and the greater metropolitan area in 2011. Length of stay was modelled as beta-distributions, using a combination of subject matter experts’ evaluations and empirical data from 2010. The model has been verified and validated. ResultsIntuitively, both prevalence (average number of crowding beds in use) and incidence (number of patients placed in crowding beds) might seem like relevant optimisation criteria. However, our experiments show that prevalence optimisation gives more sensible solutions than incidence optimisation, as the latter tends to sacrifice entire wards where length of stay is long and patient turnover is slow. Prevalence optimisation was therefore used. The main results show that when the bed distribution is optimised, the share of crowding patient nights is reduced from 6.5% to 4.2%. ConclusionThis model provides a powerful tool for optimising hospital bed utilisation, and the application showed an important reduction in crowding bed usage. The generic model is flexible, as the level of detail in the modelling of arrivals and length of stay can vary according to the data available and accuracy required.

A new pathway for elective surgery to reduce cancellation rates

BackgroundThe cancellation of planned surgeries causes prolonged wait times, harm to patients, and is a waste of scarce resources. To reduce high cancellation rates in a Norwegian general hospital, the pathway for elective surgery was redesigned. The changes included earlier clinical assessment of patients, better planning and documentation systems, and increased involvement of patients in the scheduling of surgeries. This study evaluated the outcomes of this new pathway for elective surgery and explored which factors affected the outcomes.MethodsWe collected the number of planned operations, performed operations, and cancellations per month from the hospital’s patient administrative system. We then used Student's t-test to analyze differences in cancellation rates (CRs) before and after interventions and a u-chart to analyze whether the improvements were sustained. We also conducted semi-structured interviews with employees of the hospital to explore the changes in the surgical pathway and the factors that facilitated these changes.ResultsThe mean CR was reduced from 8.5% to 4.9% (95% CI for mean reduction 2.6-4.5, p < 0.001). The reduction in the CR was sustained over a period of 26 months after the interventions. The median number of operations performed per month increased by 17% (p = 0.04). A clear improvement strategy, involvement of frontline clinicians, introduction of an electronic scheduling system, and engagement of middle managers were important factors for the success of the interventions.ConclusionThe redesign of the old clinical pathway contributed to a sustained reduction in cancellations and an increased number of performed operations.

Temporary cardiac pacemaker treatment in five Norwegian regional hospitals

Objectives. Over the last few decades the number of temporary pacemaker placements has declined, while the number of operators has increased. The present study was undertaken in order to assess the quality of present day temporary pacing in Norwegian general hospitals. Design. Prospective, multi-center study from five general hospitals in Norway with a catchment area of 998,000 inhabitants. All temporary pacing procedures performed at these hospitals during a 1-year period should be registered. Results. Fifty patients were treated with temporary pacing and six repeated procedures were performed due to pacing failure. The yearly procedure-rate was five per 100,000 inhabitants. Twenty-nine physicians were involved in these procedures, of whom five were experienced implanters, and 18 physicians participated in only one procedure each. Following temporary pacing a permanent pacemaker was implanted in 60% of patients. In-hospital mortality was 18%, and the incidence of bacteremia was 6%. Conclusions. Temporary pacemaker treatment is currently performed with less than the required amount of skill, with a high number of complications. Cardiologists on call and the possibility of fast-track permanent implantation could improve the quality of care of patients with acute bradyarrhythmias.

The importance of aesthetic surroundings: a study interviewing experts within different aesthetic fields

The purpose of this article is to present and discuss the results from interviews of experts within various aesthetic fields. This study aimed to describe experts' evaluation and wishes for aesthetics in hospitals. The scope is aesthetics in the hospital environment and surroundings. An underlying assumption was that the field of aesthetics is a neglected area in many hospital environments. The strength of the manuscript and what is new is the information concerning the expert, as patient, evaluation of aesthetics in hospital environment and surroundings and data on how the experts would prefer things to be. The basis is a corpus of 16 semi-structured individual qualitative interviews that were performed by the first author. The 16 informants were experts in different aesthetic fields. The interviews revealed the following: (i) Aesthetics and design are practically absent in the Norwegian general hospitals. (ii) The aesthetic surroundings are very important for the health and well-being of the patients. (iii) The aesthetic area has many aspects. Guidelines are worked out based on the expert/patient focus, their wishes and recommendations and based on a conviction that certain objective, basic and general criteria do exist for basing an aesthetic environment on an innate and shared common sense.

The aesthetic dimension in hospitals—An investigation into strategic plans

Background and rationale The underlying assumption was that the aesthetics of the hospital surroundings are often neglected. Aims This article is the first part of a larger study into the aesthetics of general hospitals. The aim of the study is to throw light on the influence of aesthetics on the health and well-being of patients and the professional personnel, and to examine how aesthetic considerations are dealt with. We present a survey of how the aesthetic dimension is planned and it is considered important in the strategic plans of Norwegian general hospitals. Methods Data were sampled by analyzing the strategic plans of somatic hospitals. Sixty-four of 86 hospitals responded (74%). Concepts were categorized in a matrix of 11 main categories, each with subcategories. The method was quantitative, in that the analyzed material was amenable to counting. Results Very few concrete guidelines or directions for the aesthetic dimension have been included in written documents. This indicates that the aesthetic area is a neglected field in the directions for the daily management of hospitals. Conclusions The research available today on the contribution of environmental aesthetics to health, rehabilitation, and well-being suggests that it is important to have concrete guidelines recorded in strategic plans. This field concerns the maintenance of high quality in the caring professions.

Norwegian General Hospitals, 1970–2002: County Ownership—An Interlude between Welfare Localism and State Direction

Over the last three decades, Norway has experienced two fundamental reforms in hospital organization and direction. In 1970 the nineteen county authorities took over ownership and budget responsibilities for hospitals within their areas, replacing a highly varied and complex structure of ownership, typically generated locally. In 2002 hospitals were transferred to the state and amalgamated into five regional government enterprises. These, in turn, have organized all hospitals in their region under local health enterprises. Both regional and local enterprises are separate legal entities, with their own executive boards and managing directors. The Minister of Health appoints the boards of the regional enterprises, while their directors and the boards of the local enterprises are appointed by the regional boards. Both regional and local enterprises are supposed to have full autonomy for day-to-day operations, while being subject to strategic and political decisions by the Minister of Health as the ultimate authority of the enterprise assembly (foretaksmote).1 The “enterprise” concept is, of course, borrowed from private business, modelled on companies of limited liability. The choice of this organizational model must be understood at least partly within the context of a general politico-administrative reform, inspired by the worldwide New Public Management movement. Each enterprise is a separate economic entity with a clear responsibility for balancing its budgets. Privatization (or part-privatization) and bankruptcy, however, are out of the question, as the state in the end retains full economic responsibility. The objective of this article is to contribute towards an understanding of this pattern of reform. I will suggest three explanations. First, ownership and organization in the hospital sector falls nicely into a long line of development in the creation of the Norwegian welfare state—with the emphasis on “state”. This can be described as the development from “welfare localism” to central direction with the aim of equalizing welfare provisions nationally. The desire to secure equal rights, care and benefits nationwide has always been a concern of the state, but I will argue that this concern has greatly increased over the last few decades. From this perspective, the two reforms in 1970 and 2002 could even be considered as two steps in one and the same process. This theme of centralization versus decentralization is, of course, a general and common one in international hospital history,2 and in the on-going reform debate on hospital organization in several countries in the western world. It is also an important theme in ongoing social science research on current hospital reform. A central question in this respect, which calls for a broader comparative approach than is possible within the scope of this article, is whether developments in Norway—from a decentralized towards a centralized system of hospital organization—run counter to a general trend towards decentralization of hospital management and direction, and if this is the case, why?3 Secondly, both the reorganization of the 1970s and that of 2002 fall neatly into a broader picture of fundamental Norwegian political and administrative government reform. Important factors behind both hospital reforms are thus at least as much connected to the problems of reorganization of government and administration in general, as they are specific to hospital politics. Thirdly, the fundamental problems and tensions that inspired reform at the beginning of the new millennium were basically the same as those that made reform necessary thirty years earlier. Several problems in hospital politics were probably greater at the end of the three decades of county ownership than at the beginning. I will therefore argue that it is possible to see the phase of general county ownership as an interlude in a hundred-year-long search for the “right” way of organizing Norwegian hospitals. Circumstances and what are considered good and appropriate organizational solutions probably change more than the fundamental problems of hospital politics, which have turned out to be surprisingly consistent and recalcitrant. State regional enterprise is just as much the hegemonic politico-administrative “solution of today” as county ownership was in the 1960s and 1970s.

Prevalence of eating disorders in Norwegian general hospitals 1990-1994: admissions per year and seasonality.

To study the occurrence of eating disorders in patients admitted to somatic hospitals. For all, approximately 3.3 million, admissions to Norwegian general hospitals in the period 1990-1994, admissions with the primary diagnoses for the eating disorders anorexia nervosa (AN) and bulimia nervosa (BN) were selected. Data on gender, age groups, emergency admission, different hospital types, length of stay, seasonal differences, and differences along the latitudes were related to the primary diagnosis. A small number of men with eating disorders were admitted; 9-17 times more women were admitted (140-183 female and 11-15 male admissions per year). The male/female ratio was on the mean 8% for the period. About two thirds to three fourths were emergency admissions. The mean length of stay was 12-19 days, and the median stay was 6-8 days. A significant (p = .03) season of admission was found. A significant number of admissions occurred in the beginning of March and a minimum in June. The best model was two harmonics without trend. There are few reports on eating disorders in somatic inpatients in the literature, but our results indicate that it is important to consider the general hospital in this connection. Bulimia nervosa was rather unusual in the present study, while anorexia nervosa was prevalent, specifically for women. Seasonality has rarely been reported in relation to hospitalization.

Mezlocillin treatment of septicemia in general hospitals.

Gramnegative septicemia in 23 patients from different Norwegian departments of general medicine or surgery was treated with mezlocillin. Most of the patients were old, and 14 patients were considered compromised due to underlying disease. In the majority of cases the septicemia originated from urinary tract infections. Uneventful recovery was accomplished in 16 patients (70%) and another 5 cases improved. In 2 patients no clinical effects were observed within 3 days of treatment. Apart from diarrhoea in 5 of the cases, no side-effects occurred. Mezlocillin proved to be a safe and efficient drug for the treatment of gramnegative septicemias of the type that is most commonly encountered in Norwegian general hospitals.