While there are many causes for this increased demand, few are within the control of the health system. Organizational strategies offer most to control increasing demand Within the health system, the interface between primary and secondary care is the most crucial area to control increasing demand for acute inpatient admissions.
Organizational strategies that focus on care delivery systems rather than individual patient care have most to offer. Such strategies act at three levels, which overlap to some extent. Successful strategies to modify external demand include financial incentives designed to limit transfers from primary to secondary care; alternatives to inpatient admission; and reduction of ‘inappropriate’ admissions. Strategies to improve inpatient efficiency include process redesign and provision of senior and/or specialized staff in emergency departments; general observation units; pre-admission clinics and enhanced day surgery programs.
Strategies to improve inpatient throughput focus on various forms of improved discharge planning. Patient level strategies have less certain effects on demand for acute inpatient beds. Chronic disease management programs and home visits may reduce length of stay and readmission but case management programs alone do not. While specialized treatment programs for particular diagnoses (e. G. Chest pain observation units) may offer improved efficiencies for these patients their impact on overall acute inpatient demand is unclear.
The review did not identify any particular innovative or effective practices that ere not already familiar in Some form within the Victorian health system. However, to our knowledge, the strategies are not universally or consistently applied locally. Commitment and planning are important Changing the patterns of health service delivery is difficult. Studies that achieved successful outcomes repeatedly mentioned the importance of the commitment of care delivery organizations and individual clinicians to achieve practice change.
Careful planning and the use of formal quality improvement processes also appeared important. Similarly, the value of multidisciplinary involvement and coordination across care delivery sectors was evident. While this kind of review cannot quantify the influence of these factors they were mentioned sufficiently frequently to deserve comment. The available evidence has limitations The studies identified for this review had several limitations. While the majority of the Reese rich identified was descriptive surprisingly few studies used formal qualitative research methods.
Process outcome measures, such as inpatient occupancy rate, length of stay or readmission rate, were often not the primary outcomes of interest analyses by the researchers. Relatively few studies used comparison groups to control for potential biases or confounding factors. Unequivocal results from rigorous research were rare. The available economic analyses were small in number, limited in scope, rarely considered indirect costs, and were Often Of uncertain relevance to the health funding environment in Australia. Iterate Review on Integrated Bed and Patient Management CHAPTER ONE: MANAGING HOSPITAL ADMISSIONS Why is demand increasing?
Reports of “increased hospital admissions”, and “winter peaks” have appeared in the press and medical literature over the past decade, adjacent o articles forecasting increased demand 1-5 pressure as the size of the elderly population increases Throughout this period there has been a decline in bed numbers, and an acknowledged increase in efficiency of bed utilization. There are many views on the causes of the increase in demand and hospital admissions, ranging from socio- demographic factors to tech analogical advances, risk management and patient expectation and an increased ability to treat. A recent paper summarizes 740 published articles on the rise in medical admissions. The authors conclude that the increase in admissions is due to here types of factors: patient mediated, gatekeeper related and health care organization related. The main factors are an increasing number of elderly people, a reduction in socio-economic status for some groups, and changing patterns of societal care, notably a decreasing ability of families to provide residential care for elderly family members. These factors are largely outside the control of health services.
Economic incentives for organizations to increase admissions and iatrogenic causes are also important factors in the increase. Changing incentives will change organizational behavior. Factors thin the control of health services include rate of re-admissions, elective waiting times, and changes in the number and behavior of General Practitioners (Gaps) and Emergency 4 Department (DE) staff. Hobbs states that the referring behavior of Gaps is not a factor in admissions, as it is ultimately the hospital doctors who make the decision to admit. A recent review provides further light on the observed increase in admissions They are predominantly in the elderly age group, and primarily involve hospitalizing for respiratory and cardiac conditions. In the period 1989-1994 New Zealand had a 1. % pa increase in admissions, and the United Kingdom, 2%pa. Scotland had an average annual increase of 4% pa during the period 1981-1994. During the same period there have been simultaneous decreases in bed stock and length Of Stay.
The reviewers conclude that the increase is real rather than apparent, and that causes of the increase are multiple, complex and interrelated. 6 Hider et al make the point that as emergency admissions are more expensive than elective admissions they make larger demands on hospital budgets, and reduce the ability of health services to meet non-urgent demand. While the Roth in acute admissions is largely a medical 4 rather than a surgical issue the result is a reduced capacity of surgeons to work through elective waiting lists.
The proliferation of day surgery may free up existing hospital surgical beds for medical admissions. Hobbs asks whether the observed increase in hospitalizing reflects health gain and improved access to care, or deteriorating health due to an over-reliance on secondary care and poorly performing primary and preventative care. Strategies to manage demand With varying degrees of success, health care organizations have introduced a anger of strategies to manage demand and admissions, and control costs.
These include: forecasting peaks and troughs in demand, allocating capacity based upon the forecasted elective and emergency demand, reducing bed supply, increasing waiting lists, decreasing consumer expectation, reducing “inappropriate” admissions, and increasing use of non-acute inpatient alternatives. Currently there is concern about the appropriateness of acute hospital care for certain conditions, and increasing interest in providing care in settings that may better meet 6 patient needs, and perhaps be cheaper . Literature Review on Integrated Bed and Patient Management 4 “Substitute care” is receiving increasing attention.
Such substitutes include substitution for a hospital admission (egg. Home care) and substitution for hospital stay (egg early discharge, including the use of intermediate care for patients in acute hospital beds who no longer require intensive care). The organizational purpose of such strategies must be clear. Fifth aim is to treat a constant level of demand at lower cost, then the introduction of “substitutes” must be accompanied by closure of acute capacity, otherwise there will be increased supply and increased costs.
If alternatively, the aim is to treat increased demand, then “substitutes services” 8 may do this more efficiently than opening more acute beds . The focus of demand management strategies is on the acute admission threshold. Edwards and 8 Henries present a model (shown below) Of the relationship between disease severity and management thresholds over time. Initially, a patient’s condition may be managed in the primary’ care sector, but with increasing care needs specialist ambulatory services are required.
As the condition worsens hospital admission occurs, followed by return to the community and primary sectors, and more hospitalizing. The central part of their model is the level of secondary threshold and our ability to manage both sides of the boundary. The opportunities for reduced admissions and earlier discharges are discussed in this review. Fig 1. Relationship between disease severity and management thresholds over time 8 7 New Zealand Health Technology Assessment published a comprehensive review in which they assessed the effectiveness of interventions to reduce acute medical admission rates.
They concluded that the most effective interventions are at the macro-management or organization level, targeting the interface between primary and secondary care. Such interventions include hospital closures, changing from hospital reimbursement on admission rates to prospective DRY payments, foundling, public health interventions, the provision of hospital in the home (HIT) for acute episodes, to assist early discharge and for palliative care, high technology’ at home, community hospitals, GPO beds, and patient hotels. These interventions have been used in the K, USA and NZ.
There is good evidence from randomized controlled trials that some of these 5 strategies (egg. HIT and comprehensive geriatric care) reduce acute admissions. The provision of prospective funding has also been proven to reduce admissions. There is some evidence that other strategies are probably effective in reducing admissions. Examples in this category include closure of hospitals, public health preventative interventions, community hospitals and GPO beds, home alarms, and alternative and improved options for the long term care of the elderly.
In response to changing patient needs, hospitals in he UK are redesigning their bed and service 9 provision to manage the emergency and elective demands (National Bed Inquiry) . With limited research on forecasting demand for health services, changes in service delivery such as opening or closing acute beds and early discharge programs rarely produce long term benefits. 8 Edwards and Henries stress the need for demand management strategies to focus on hospital care and substitutes for hospital. There is also a need to understand pathways to admission, and the relationship between the diversity of primary providers and continuity of care.
Patient level strategies Patient level or micro-management interventions have received some attention but few consistent results. They include primary care, hospital outpatient-based interventions, emergency department strategies such as observation units and chest pain evaluation units, maximizing bed utilization; programs to reduce admissions of the elderly, utilization review to reduce “inappropriate” admissions, use of guidelines, interventions to reduce medication related 7 admissions, changing the number or behavior of Gaps, and community based interventions .
There is good evidence from randomized controlled trials that placement Of Gaps in emergency departments reduces acute admissions. There is also evidence that more senior staff, and observation and chest pain evaluation units in emergency departments, probably reduce admissions. There is some evidence that drug education for patients and Gaps and hospital outreach services reduce admissions . Some of the new technologies have been shown to be effective in reducing acute admissions .
These include use of low molecular weight heparin for anti coagulation therapy, Etc-m-Humph for the diagnosis of appendicitis, trooping T levels as a rapid indicator for myocardial damage and plasma D-dimmer for the diagnosis of thermoelectric disease. Some patient level interventions have no demonstrable positive effect on admissions, although they may improve patient well being. These include out- patient based education, increased 6 outpatient services, utilization review and case management Hider et al .
There is some interest in whether primary care can improve patient outcomes and reduce hospital admissions for people with chronic disease. This is the basis of the coordinated care trial program in Australia, which aims o improve health outcomes for people with chronic disease, within existing resources, through fund pooling and care coordination and the substitution of cheaper contain souse community care for expensive episodic acute care (unpublished). A number of studies have found that the provision of home visits by health 10-12 professionals is effective in reducing admissions .
The authors of a meta-analysis of the 13 impact of home care on hospital days concluded that home care reduces acute hospital days significantly in the period of time most proximal to active reception of care. Home care was defined as the delivery of either nursing, medical or support services in patients’ homes. While the effect sizes reported are not overwhelmingly large, the consistent reduction in number of hospital days across studies suggests that home care had a significant impact on an important and costly outcome, and that home care for the terminally ill, in particular, has an unambiguous impact on this outcome.
CHAPTER TWO: PREPARE-ADMISSION PROCESSES Pre-admission clinics, admission on day of surgery and day surgery In the past decade, admission on day Of surgery, day surgery centers and pre- admission programs have become routine at major hospitals throughout the USA KICK, Canada, New Zealand and Australia. Their purpose is to increase efficiency of resource utilization, that is beds, operating theatres and staff time, and also to provide a better service to patients, through timely and appropriate admissions.
Pre-admission clinics DEFINITION The use of pre-admission programs to assess patient readiness for surgery and identify higher risk elective patients was introduced in the early sass. Pre-admission assessment of patients 14 one to two weeks before surgery is becoming standard practice in ASSAI, Canada , UK and Australia. There are a number of models of permission, but the essence is an outpatient attendance one to four weeks prior to surgery.
This generally includes some or all of the following: initial screening by a trained assessment nurse, anesthetic assessment, completion of consent process, any required pre-operative assessment and diagnostic and screening tests. It may also include discharge planning patient education and support. It is an established alternative to the traditional approach of admitting patients one or more days prior to surgery to ensure readiness for urges. Pre-admission requires some form of preliminary screening to identify those patients requiring additional tests or assessment prior to surgery.
A number Of techniques are used including personal interviews during a hospital or consultant visit, mailed questionnaires, telephone 15 interviews and computer assisted questionnaires. Patella and Hannibal, , using a cohort design, collected pre-admission information via telephone for 5031 pediatric patients, and supplemented this with anesthetic consultation as required. The group receiving this screening showed significantly lower rates f theatre cancellation than those not screened.
BENEFITS Pre admission programs offer opportunities to reduce operating theatre delays and cancellations 17 , reduce hospital costs and improve bed utilization, ward workload, diagnostic facilities management, patient satisfaction and quality of care. When Ottawa Civic Hospital introduced pre-admission and day of surgery admissions in 1993-4 and 1994-5, surgical volume remained constant, despite a reduction in bed numbers, operative hours increased each year, and there were no day of admission cancellations due to lack of beds or incomplete pre-operative 14 reparation.
In addition over 3000 bed days were saved in each year . Pre- admission is currently used for most areas of surgery (ophthalmology, tautology’s, neurosurgery, thoracic surgery, vascular surgery, dental procedures, general surgery, campanology, orthopedic surgery, 14 urology, plastic, .NET and renal) . 16 PATIENT TTS Permission clinics have increased importance for day of admission patients, as there is less time to deliver necessary information to the patient, ensure that consent procedures have been 18 completed, and that test results are in order .
Studies of the timing of pre- operative patient 19 mound that there was no difference in pre-operative anxiety or knowledge between education patients receiving the information up to a week before surgery or the day before surgery. RESOURCES While cost effective in terms of maximizing theatre utilization, pre-admission is resource intensive, and sometimes inefficient, as not all patients require assessment. The use of permission questionnaires leads to improved targeting of those who will benefit and improves 20 21 resource utilization .
A randomized controlled trial (McPherson in el Nagger et al found that pre-admission reduced pre-operative hospitalizing from a mean of 2. 9 to 1. 6 days in the group attending a pre-admission clinic. While pre-admission is valuable in making efficient use of 21 theatre lists, it requires significant nursing, clerical and medical staff time . Epsom General Hospital uses nurses rather than junior doctors for pre- admission assessment. This has been possible with the development of a protocol for assessment.
Obtaining consent and physical examination are still performed by medical staff. A retrospective audit over 4 separate months of 127 patients attending pre-admission found that nurses were as effective as deiced staff in 22 preventing cancellations . Pre-admission results in changes in work flow for nursing, clerical and medical staff. While less preparation is required at ward level on day of surgery, permission clinics require additional staff.
There is also the risk of over-ordering or repeat 23 ordering of diagnostic tests . There is some debate regarding appropriate staffing for pre-admission clinics, and the cost 24 examined groups Of surgery patients who had implications of this. A study by Stannic et al their pre-admission evaluation performed by surgeons or anesthetists. They ere compared for number of tests ordered and number of theatre cancellations. Anesthetist assessment was found to be more cost effective in terms of cost of test performed.
ADMISSION ON DAY OF SURGERY Another approach to improving bed utilization is admission on day of surgery, either to the day surgery facility or surgical ward. Such admissions are increasing, although rates vary between hospitals for reasons including staff practices, procedure complexity and available facilities. Reported rates of admission on day of surgery were as high as 90% for a 295-bed hospital in 25 New Hampshire . The rate at Liverpool Hospital, Sydney, increased from 6% to 35% between 26 July 1 992 and December 1 994 .
Admission on day of surgery generally reduces overall length 27 of stay by at least one day . There is no evidence that admitting people on day of surgery 28 delays discharge, or increases morbidity or mortality.