[Housekeeping service in the hospital: your motivation for team work with other hospital services. Housekeeping employee in the hospital].
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Hospital Departments↗
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The effects of multi-hospital systems on hospital prices.
US hospital prices are rising again after years of limited growth. We analyze trends in hospital prices during a period of significant price growth (1999-2003) to assess whether hospitals that are part of multi-hospital systems were able to increase their prices faster than non-system hospitals. We find hospitals that were members of multi-hospital systems were able to increase their prices substantially more than comparable non-systems hospitals (34% for large systems and 17% for small systems). Further, we find that the systems effect is not confined to hospitals that have other system member hospitals in their local markets. One possible explanation is that hospitals belonging to non-local multi-hospital systems have improved their bargaining position vis-à-vis health plans.
California↗
Major differences in 1-month survival between hospitals in Sweden among initial survivors of out-of-hospital cardiac arrest.
AIM: To explore the rate of survival to hospital discharge among patients who were brought to hospital alive after an out-of-hospital cardiac arrest in different hospitals in Sweden. PATIENTS AND METHODS: All patients who had suffered an out-of-hospital cardiac arrest which was not witnessed by the ambulance crew, in whom cardiopulmonary resuscitation (CPR) was started and who had a palpable pulse on admission to hospital were evaluated for inclusion. Each participating ambulance organisation and its corresponding hospital(s) required at least 50 patients fulfilling these criteria. RESULTS: Three thousand eight hundred and fifty three patients who were brought to hospital by 21 different ambulance organisations fulfilled the inclusion criteria. The number of patients rescued by each ambulance organisation varied between 55 and 900. The survival rate, defined as alive 1 month after cardiac arrest, varied from 14% to 42%. When correcting for dissimilarities in characteristics and factors of the resuscitation, the adjusted odds ratio for survival to 1 month among patients brought to hospital alive in the three ambulance organisations with the highest survival versus the three with the lowest survival was 2.63 (95% CI: 1.77-3.88). CONCLUSION: There is a marked variability between hospitals in the rate of 1-month survival among patients who were alive on hospital admission after an out-of-hospital cardiac arrest. One possible contributory factor is the standard of post-resuscitation care.
Aged↗
In-hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway.
INTRODUCTION: While pre-hospital factors related to outcome after out-of-hospital cardiac arrest (OHCA) are well known, little is known about possible in-hospitals factors related to outcome. HYPOTHESIS: Some in-hospital factors are associated with outcome in terms of survival. MATERIAL AND METHODS: An historical cohort observational study of all patients admitted to hospital with a spontaneous circulation after OHCA due to a cardiac cause in four different regions in Norway 1995-1999: Oslo, Akershus, Østfold and Stavanger. RESULTS: In Oslo, Akershus, Østfold and Stavanger 98, 84, 91 and 186 patients were included, respectively. Hospital mortality was higher in Oslo (66%) and Akershus (64%) than in Østfold (56%) and Stavanger (44%), P=0.002. By multivariate analysis the following pre-arrest and pre-hospital factors were associated with in-hospital survival: age -3.5 mmol l(-1), body temperature <or=37.8 degrees C, and serum glucose <or=10.6 mmol l(-1) 1-24 h after admittance with OR (95% CI) 2.72 (1.09-8.82, P=0.033), 1.12 (1.02-1.23, P=0.016), 2.67 (1.17-6.20, P=0.019) and 2.50 (1.11-5.65, P=0.028), respectively. Pre-arrest overall function, whether adrenaline was used, body temperature, the occurrence of hypotensive episodes, and the degree of metabolic acidosis differed between the four regions in parallel with the in-hospital survival rates. CONCLUSION: Both pre-arrest, pre- and in-hospital factors were associated with in-hospital survival after OCHA. It seems important also to report in-hospital factors in outcome studies of OCHA. The design of the study precludes a conclusion on causability.
Aged↗
In-hospital versus out-of-hospital presentation of life-threatening ventricular arrhythmias predicts survival: results from the AVID Registry. Antiarrhythmics Versus Implantable Defibrillators.
OBJECTIVES: This study describes the outcomes of patients from the Antiarrhythmics Versus Implantable Defibrillators (AVID) Study Registry to determine how the location of ventricular arrhythmia presentation influences survival. BACKGROUND: Most studies of cardiac arrest report outcome following out-of-hospital resuscitation. In contrast, there are minimal data on long-term outcome following in-hospital cardiac arrest. METHODS: The AVID Study was a multicenter, randomized comparison of drug and defibrillator strategies to treat life-threatening ventricular arrhythmias. A Registry was maintained of all patients with sustained ventricular arrhythmias at each study site. The present study includes patients who had AVID-eligible arrhythmias, both randomized and not randomized. Patients with in-hospital and out-of-hospital presentations are compared. Data on long-term mortality were obtained through the National Death Index. RESULTS: The unadjusted mortality rates at one- and two-year follow-ups were 23% and 31.1% for patients with in-hospital presentations, and 10.5% and 16.8% for those with out-of-hospital presentations (p < 0.001), respectively. The adjusted mortality rates at one- and two-year follow-ups were 14.8% and 20.9% for patients with in-hospital presentations, and 8.4% and 14.1% for those with out-of-hospital presentations (p < 0.001), respectively. The adjusted long-term relative risk for in-hospital versus out-of-hospital presentation was 1.6 (95% confidence interval [CI] 1.3-1.9). CONCLUSIONS: Compared with patients with out-of-hospital presentations of life-threatening ventricular arrhythmias not due to a reversible cause, patients with in-hospital presentations have a worse long-term prognosis. Because location of ventricular arrhythmia presentation is an independent predictor of long-term outcome, it should be considered as an element of risk stratification and when planning clinical trials.
Aged↗
Device-related sources of bacteraemia in English hospitals--opportunities for the prevention of hospital-acquired bacteraemia.
Between 1997 and 2001, 17 teaching and 56 non-teaching acute English hospitals conducted hospital-wide surveillance of hospital-acquired bacteraemia (HAB) using a standard protocol drawn up by the Nosocomial Infection National Surveillance Scheme (NINSS). The sources of organisms, the incidence of device-related HAB, and the distribution of HABs from individual device-related sources by specialty and type of hospital were determined for 6,956 HABs in order to identify where resources should best be targeted to reduce these infections. The overall incidence of HAB was higher in teaching than in non-teaching hospitals: 5.39 and 2.83 HABs per 1,000 patients at risk, respectively (P<0.001). Device-related sources were responsible for 52.4 and 43.2% of all HABs in teaching and non-teaching hospitals, respectively (P<0.001), and central lines were the commonest source, causing 38.3% of HABs in teaching versus 22.3% in non-teaching hospitals (P<0.001). In teaching hospitals, general intensive care units (ICUs), haematology, special care baby units (SCBUs), nephrology, and oncology accounted for only 6.1% of the population surveyed, but had the highest incidence of HAB, and contributed 47.8% of 2091 HABs and 56.9% of 1,095 device-related bacteraemias. Of 623 device-related bacteraemias in these high-risk specialties, 554 (88.9%) were from central lines. Thus, in teaching hospitals, resources should be targeted primarily at the prevention of central line-related bacteraemia in these five high-risk specialties, and the surveillance should include data on central line use. In non-teaching hospitals, nearly two thirds (63.3%) of 4,865 HABs and 60.7% of 2,103 device-related bacteraemias were from a few specialties with a low incidence of bacteraemia, but large numbers of patients, namely general medicine, general surgery, geriatric medicine and urology. These specialties accounted for 50.5% of the population surveyed. Central lines were the most common source of bacteraemia in general medicine and surgery, and together accounted for 23.3% of all device-related bacteraemias. However, in geriatric medicine and urology, central line sources were infrequent, accounting for only 1.7% of all device-related bacteraemias. On the other hand, bacteraemia from catheter-associated UTI were common in all these four specialties accounting for 20.9% of all device-related bacteraemias. Thus, in non-teaching hospitals, resources should be targeted primarily at these low-risk specialties and surveillance should include, at least, bacteraemia from central lines and from catheter-associated UTI. Further benefit can be obtained by including central line-related bacteraemias from general ICU and haematology patients, as they contributed 17.0% of all device-related bacteraemias in non-teaching hospitals.
Bacteremia↗
Environmental cultures and hospital-acquired Legionnaires' disease: a 5-year prospective study in 20 hospitals in Catalonia, Spain.
OBJECTIVE: To determine whether environmental cultures for Legionella increase the index of suspicion for legionnaires' disease (LD). DESIGN: Five-year prospective study. SETTING: Twenty hospitals in Catalonia, Spain. METHODS: From 1994 to 1996, the potable water systems of 20 hospitals in Catalonia were tested for Legionella. Cases of hospital-acquired LD and availability of an "in-house" Legionella test in the previous 4 years were assessed. After the hospitals were informed of the results of their water cultures, a prospective 5-year-study was conducted focusing on the detection of new cases of nosocomial legionellosis and the availability and use of Legionella testing. RESULTS: Before environmental cultures were started, only one hospital had conducted active surveillance of hospital-acquired pneumonia and used Legionella tests including Legionella urinary antigen in all pneumonia cases. Only one other hospital had used the latter test at all. In six hospitals, Legionella tests had been completely unavailable. Cases of nosocomial LD had been diagnosed in the previous 4 years in only two hospitals. During prospective surveillance, 12 hospitals (60%) used Legionella urinary antigen testing in house and 11 (55%) found cases of nosocomial legionellosis, representing 64.7% (11 of 17) of those with positive water cultures. Hospitals with negative water cultures did not find nosocomial LD. CONCLUSIONS: The environmental study increased the index of suspicion for nosocomial LD. The number of cases of nosocomial LD increased significantly during the prospective follow-up period, and most hospitals began using the Legionella urinary antigen test in their laboratories.
Antigens, Bacterial↗
Patient and hospital characteristics associated with patient assessments of hospital obstetrical care.
OBJECTIVES: The goals of this study were to examine the relationship of patient assessments of hospital care with patient and hospital characteristics. In addition, the authors sought to assess relationships between patient assessments and other patient-derived measures of care (eg, how much they were helped by the hospitalization and amount of pain experienced). METHODS: The authors surveyed 16,051 women (response rate, 58%) discharged after labor and delivery from 18 hospitals during the study period of 1992 to 1994. Patient assessments were obtained using a previously validated survey instrument, Patient Judgment of Hospital Quality, that includes eight scales assessing different aspects of the process of care (eg, physician care, discharge procedures) and other single item assessments (eg, overall quality). For this study, we utilized five of the scales (physician care, nursing care, information, discharge preparation, global assessments [willingness to brag, recommend or return to the hospital]). For analysis, items were rated on a five-point ordinal scale from poor to excellent. For scoring purposes, responses were transformed to linear ratings, ranging from 0 to 100 (eg, 0 = poor care, 100 = excellent care). RESULTS: In multivariable analyses, the authors found that patients who were older, white, not married, uninsured or had commercial insurance, and in better health status were significantly more likely to give higher assessments (P < 0.01), although very little of the variance in assessment scores was explained by these characteristics (2%-3%). In bivariate analyses, patient assessments were higher in nonteaching hospitals and those with fewer beds, fewer deliveries, lower cesarean-section (C-section) rates, fewer patients with Medicaid, and higher rates of vaginal births after C-section deliveries. When these variables were utilized as independent predictors in multivariable analyses using adjusted nested linear regression (to account for clustering of patients), few of the hospital characteristics reached a level of statistical significance. Finally, correlations between the five scales and other patient assessments of quality, such as how much they were helped by the hospitalization, were statistically significant (P < 0.01) and high in magnitude, ranging from 0.47 to 0.61. CONCLUSIONS: Although hospital scores differed according to several patient and hospital characteristics, the magnitude of the associations was relatively small. The findings suggest that, with respect to obstetric care, patient assessments may represent a robust measure that can be applied to diverse hospitals and patient casemix.
Adolescent↗
Direct hospital costs for patients with inflammatory bowel disease in a Canadian tertiary care university hospital.
OBJECTIVE: We set out to determine the direct costs of hospitalizations of patients with Crohn's disease and ulcerative colitis admitted to a university-affiliated tertiary care hospital and to contrast the costs of medical versus surgical inpatient care, Crohn's disease versus ulcerative colitis, and to identify dominant components of inpatient costs. METHODS: We used a patient-specific case costing system at Saint Boniface General Hospital, Winnipeg, Manitoba, for fiscal years 1994 and 1995. We extracted all inpatients whose hospital discharge abstracts included ICD-9-CM codes 555 (Crohn's disease) and 556 (ulcerative colitis) among the top eight discharge diagnoses, and performed a chart review on all cases to ensure that the hospitalization was for inflammatory bowel disease and the diagnoses were accurate. We analyzed cases based on their disease diagnosis, primary mode of therapy associated with the hospitalization (medical vs surgical), and their major diagnosis-related group (DRG). This study evaluated direct patient care costs only and costs are expressed in Canadian dollars. RESULTS: Of 362 hospital admissions, 325 were eligible and of these admissions 275 belonged to the digestive system DRGs. Seventy-one (37%) were admitted more than once during the 2 yr of the study, accounting for 202 (62%) of the total number of admissions. The mean cost per admission of all cases of Crohn's disease was $3,149 (95% confidence interval [CI], $2,665-$3,634) and for ulcerative colitis was $3,726 (95% CI $3,008-$4,445). Surgical therapy cases accounted for 49.8% of all admissions, 57.8% of all hospital days, and 60.5% of all costs. Patients treated surgically had more costly hospitalizations than those treated medically, particularly when analyzing only nontotal parenteral nutrition (TPN) cases. Surgical treatment admissions were significantly more costly for ulcerative colitis digestive DRG admissions than Crohn's disease. The nondigestive DRG admissions were more costly than the digestive DRGs in all categories although this was only statistically different among medically treated Crohn's disease. Patients treated medically were similarly costly whether they had Crohn's disease or ulcerative colitis. There was no significant difference in cost per admission among cases admitted multiple times, compared with those admitted only once. TPN cases accounted for 9.5% of cases but 27.1% of costs. TPN-associated hospitalizations were more costly than non-TPN-use hospitalizations but these costs were primarily driven by duration of stay rather than TPN use itself. For all cases, the top five cost categories in descending order were nursing unit bed-days, drugs and pharmacy, diagnostic lab tests, operating room, and diagnostic imaging and endoscopy. CONCLUSIONS: Using our system we could determine direct costs for inpatients with inflammatory bowel disease and the factors that determined increased costs. Medical therapy admissions were similarly costly between Crohn's disease and ulcerative colitis; however, surgical therapy admissions were costlier among ulcerative colitis patients. Admissions for nondigestive DRGs were more costly than those for digestive DRGs. TPN use identified a sicker group of patients who remained in the hospital longer than nonusers and, not surprisingly, these were the costliest patients.
Adolescent↗
Critical access hospitals: how many rural hospitals will meet the requirements?
Although the Medicare Rural Hospital Flexibility Program (MRHFP), which establishes a new designation for limited-service hospitals called critical access hospitals (CAH), intends to assist small rural hospitals having financial difficulty, it is unclear how many hospitals will qualify for the program. Potential CAHs are identified and the strategic issues that will impact actual participation in the program are discussed. Potential CAHs are identified by applying the legislative criteria for designation to a data set created from both the 1992-1995 Medicare Hospital Cost Report Information System and the 1993 and 1995 Prospective Payment System's Impact files. Descriptive analyses are used to identify potential CAHs by three parameters: distance to nearest hospital, average daily census and operating margin. Results indicate that the majority of potential CAHs have low volume and report poorer operating margins than other rural hospitals. Findings also show that the mileage requirements significantly impact the number of potential CAHs. There is more than a ninefold difference between the 93 hospitals that meet the mileage criterion and the 864 hospitals that might be eligible if certified by the state as "necessary providers," regardless of distance to the nearest hospital. The MRHFP is designed to prevent small, isolated hospitals from closing and thus to ensure continued access to care for rural residents. However, the number of potential CAHs that participate will clearly hinge on the flexibility of the program and the ability of states to determine "necessary providers."
Bed Occupancy↗
Achieving equity in Medicare disproportionate share payments to rural hospitals: an assessment of the financial impact of recent and proposed changes to the disproportionate share hospital payment formula.
Historically, the Medicare Disproportionate Share Hospital (DSH) payment program has been less favorable to rural hospitals: eligibility thresholds were higher and the payment adjustment was smaller for rural than for urban hospitals. Although the Medicare, Medicaid, and SCHIP Benefit Improvement and Protection Act (BIPA) of 2000 established a uniform low-income threshold and increased the magnitude of the adjustment for certain small and rural hospitals as a means to promote payment equity, the DSH distribution formula continues to vary by location. This study examines how the DSH revisions mandated under BIPA are likely to affect rural hospitals' financial performance and simulates the financial impact of implementing a uniform DSH payment adjustment. Using data from the 1998 Medicare cost report and impact files, this study found that two-thirds of both rural and urban hospitals would have qualified for DSH payments following BIPA compared with only one-fifth of rural hospitals and one-half of urban hospitals prior to BIPA. Although the impact of BIPA revisions on rural hospitals' total margins were found to be modest, the financial impact of a uniform payment adjustment would be somewhat greater: rural hospitals' average total margins would have increased by 1.6 percentage points. Importantly, 20% of rural hospitals with negative total margins would have been "in the black" if rural and urban hospitals were reimbursed using the same DSH formula. These findings suggest that elimination of rural and urban disparities in DSH payment could strengthen the rural health care safety net.
Fee-for-Service Plans↗
Economic study in surgical patients of a new model of nutrition therapy integrating hospital and home vs the conventional hospital model.
BACKGROUND: Dehospitalization is a trend in the health sector justified by humanitarian and socials aspects for the patient and relatives. From the financing institutions' perspective, whether government or third party, the positive results arise from an optimization of hospital bed use and favorable cost-benefit ratio. The "integrated home-hospital" model was created with the purpose of optimization of resources without detriment to the patients' nutritional care. The objective of this study was an economic evaluation regarding nutrition therapy of the integrated hospital-home model in comparison with an exclusively hospital model. METHODS: A retrospective controlled study, paired (age, sex, disease, and surgical procedure), was performed on 56 digestive surgery patients divided into 2 groups: study (SG; n = 30) and control (CG; n = 26). The data collected included total expenses with hospitalization, nutritional benefits, minimization cost analysis, cost-effectiveness ratio analysis, cost-benefit ratio analysis, hospital length of stay, and hospital-bed optimization. RESULTS: The patients from the SG achieved the same nutritional benefits as those in the CG, but with expenses 3 times lower (median Brazil Reals (R)$3237.18 vs R$8647.93; p < .05). The new model resulted in economic benefit to the institution, as shown by the cost-effectiveness ratio, mainly resulting from the savings of the days of hospitalization avoided. The cost-benefit ratio showed an important savings per patient for the institution (US $3100). CONCLUSIONS: The home-hospital model also reduced length of hospital stay 2.7 times and optimized the hospital bed usage, as it promoted higher hospital-bed rotation (3 times greater).
Cost-Benefit Analysis↗
[Analysis of hospital morbidity by motor vehicle accidents in public hospitals in Rio de Janeiro, Brazil].
INTRODUCTION: Morbidity due to motor vehicle accidents was analysed in a descriptive study based on reports of hospitals with the objective to characterize their victims, types of injuries, and the health care provided. METHODS: The study was carried out in two municipal hospitals of Rio de Janeiro, Brazil. Motor vehicle accidents were defined as a run over, a collision, and "other traffic accidents". Data was collected from cases seen in May (Hospital 1) and June (Hospital 2) of 1996 by 7 teams that alternated in shifts of 12 hours, covering the collection 24 hours per day. The events were classified according to the victim or, when it was impossible, to the person who helped them or accompanied them to the hospital. RESULTS: In the study period, 320 cases were seen in Hospital 1 and 290 in Hospital 2. Most of the victims were men (69.3%) in both of hospitals and the most affected group was young adults between 20 to 39 years (60.5% in Hospital 1 and 47.5% in Hospital 2). Of all 610 cases, the main cause of injury was being run over (49.3%), followed by collisions (35.6%), and "other traffic accidents" (15.1%). CONCLUSIONS: The analysis of the cases distributions and the type of care required corroborates with the need of a better organization of hospital care teams, more completeness of hospital reports and emphasis on some aspects in prevention campaigns.
Accidents, Traffic↗
[Some problems of psychiatric care unit in a general hospital I: Concerning decision of admission to hospital (author's transl)].
Over a thousand patients a year request hospitalization at the Psychiatric Admission Unit of the Region General Hospital of Santa Maria Nuova in Florence. About five hundred are actually hospitalized, less than half. Decision to hospitalize depends on several factors: a) factors relating to the patient (the psychopathological picture, the severity of his condition, his family background etc.); b) factors relating to the doctor on duty (degree of experience, attitude toward the patients, theoretical view toward hospitalization etc.); c) practical and administrative factors (service situation, day of the week, time of the day etc.). On the other hand the doctor's attitude may be that of undertaking care of the patient's psychiatric needs or not. This behaviour is largely independent from the decision to hospitaliz or not. Hospitalization does not necessarily mean taking care of the patient from a psychiatric point of view (hospital seen as a parking place, for example) and, vice versa, treatment can be planned without hospitalizing the patient who asks for it. Thus, there are four possibilities in a Psychiatric Admission Unit: a) hospitalization and care of the patient; b) no hospitalization but care of the patient; c) hospitalization without care of the patient; d) no hospitalization and no care of the patient. These four situations discussed with appropriate examples. The emotional attitude of the psychiatrist in his relationship with the patients who request admission is viewed as the most important factor for a correct decision.
Humans↗
The need for acute, subacute and nonacute care at 105 general hospital sites in Ontario. Joint Policy and Planning Committee Non-Acute Hospitalization Project Working Group.
BACKGROUND: Previous studies of hospital utilization have not taken into account the use of acute care beds for subacute care. The authors determined the proportion of patients who required acute, subacute and nonacute care on admission and during their hospital stay in general hospitals in Ontario. From this analysis, they identified areas where the efficiency of care delivery might be improved. METHODS: Ninety-eight of 189 acute care hospitals in Ontario, at 105 sites, participated in a review that used explicit criteria for rating acuity developed by Inter-Qual Inc., Marlborough, Mass. The records of 13,242 patients who were discharged over a 9-month period in 1995 after hospital care for 1 of 8 high-volume, high-variability diagnoses or procedures were randomly selected for review. Patients were categorized on the basis of the level of care (acute, subacute or nonacute) they required on admission and during subsequent days of hospital care. RESULTS: Of all admissions, 62.2% were acute, 19.7% subacute and 18.1% nonacute. The patients most likely to require acute care on admission were those with acute myocardial infarction (96.2% of 1826 patients) or cerebrovascular accident (84.0% of 1596 patients) and those admitted for elective surgery on the day of their procedure (73.4% of 3993 patients). However, 41.1% of patients awaiting hip or knee replacement were admitted the day before surgery so did not require acute care on admission. The proportion of patients who required acute care on admission and during the subsequent hospital stay declined with age; the proportion of patients needing nonacute care did not vary with age. After admission, acute care was needed on 27.5% of subsequent days, subacute care on 40.2% and nonacute care on 32.3%. The need for acute care on admission was a predictor of need for acute care during subsequent hospital stay among patients with medical conditions. The proportion of patients requiring subacute care during the subsequent hospital stay increased with age, decreased with the number of inpatient beds in each hospital and was highest among patients with congestive heart failure, chronic obstructive pulmonary disease and pneumonia. INTERPRETATION: In 1995, inpatients requiring subacute care accounted for a substantial proportion of nonacute care days in Ontario's general hospitals. These findings suggest a need to evaluate the efficiencies that might be achieved by introducing a subacute category of care into the Canadian health care system. Generally, efforts are needed to reduce the proportion of admissions for nonacute care and of in-hospital days for other than acute care.
Acute Disease↗
The effect of hospital volume on the in-hospital complication rate in knee replacement patients.
OBJECTIVE: To examine the effect of hospital volume on in-hospital surgical outcomes for knee replacement using six years of Medicare claims data. DATA SOURCES/STUDY SETTING: The data include inpatient claims for a 100 percent sample of Medicare patients who underwent primary knee replacement during 1985-1990. We supplemented these data with information from HCFA's denominator files, the Area Resource File, and the American Hospital Association survey files. STUDY DESIGN: We estimated the probability that a patient has an in-hospital complication in the initial hospitalization for the first primary knee replacement, using a Logit model, for three definitions of complication. The models controlled for hospital volume, other hospital characteristics, patient demographics, and patient health status. We tested for the endogeneity of hospital volume. DATA COLLECTION/EXTRACTION METHODS: A panel of two orthopaedic surgeons and two internists reviewed diagnosis codes to determine whether a complication was likely, possible, or due to anemia. After removing the few observations with bad or missing data, the final population has 295,473 observations. PRINCIPAL FINDINGS: The probability of a likely in-hospital complication declines rapidly from 53 through 107 operations per year, then levels off. Statistical tests imply that hospital volume is exogenous in this patient-level data. Complication rates increased steadily through the study period. Although obesity appeared to lower the probability of a complication, a counterintuitive result, further investigation revealed this to be an artifact of the claims data limit of listing no more than five diagnoses. Controlling for this restriction reversed the effect of obesity. CONCLUSIONS: Rather than uncontrolled expansion of knee surgery to small hospitals, decentralization to regional centers where at least about 50, and preferably about 100, operations per year are assured appears to be the optimal policy to reduce in-hospital complications.
Arthroplasty, Replacement, Knee↗
Nosocomial infection indicators in Australian hospitals: assessment according to hospital characteristics.
The relationship of bed size and hospital type (private or public) was studied using Hospital-Wide Medical Indicator data on nosocomial infections submitted to the Australian Council on Healthcare Standards Care Evaluation Program by hospitals presenting voluntarily for accreditation in 1993. The aim was to determine if this process could simplify the establishment of hospital peer groups for comparison of risk in the absence of knowledge of patient illness severity indices. After adjusting for potential confounders in a logistic model, hospital type was found to be a significant predictor for the occurrence of infection in clean and contaminated wounds. Bed size was a significant predictor for the occurrence of hospital-acquired bacteraemia in private and public hospitals. The increase in the risk of developing hospital acquired bacteraemia with increasing number of beds was significant as a trend (P < 0.0001) in private as well as public hospitals. The results suggest that hospital type and bed size are initial indices for 'flagging' peer group variation and prompting a more detailed internal review.
Australia↗
Yersinia enterocolitica infections in hospitalized patients: the problem of hospital-acquired infections.
OBJECTIVE: To study the epidemiology of Yersinia enterocolitica infections in hospitalized patients and to determine the frequency of hospital-acquired infection and the modes of transmission within the hospital. DESIGN: Descriptive study in which the clinical microbiology laboratory reported all positive Yersinia cultures to the infection control department; each case was investigated to determine the source of infection. SETTING: A 700-bed university teaching hospital. PARTICIPANTS: All patients who were culture-positive for Y enterocolitica after admission to the University of Cincinnati Hospital during the 4-year period between 1987 and 1990. RESULTS: Of 18 patients who were diagnosed with Yersinia infections, 8 (44%) were community-acquired. These patients were admitted with gastrointestinal symptoms and had their first positive cultures between days 1 and 5 of their hospitalizations. Five patients (28%) had hospital-acquired infections, having developed diarrhea after admission for unrelated problems, and became culture-positive between days 18 and 66. The remaining 5 patients could not be classified as either community- or hospital-acquired. These patients had gastrointestinal symptoms at the time of admission, but these could have been explained by other diseases. Their first positive stool cultures were not obtained until the second week or later during hospitalization, and 3 of these patients had negative stool cultures prior to a positive culture. CONCLUSIONS: Although Y enterocolitica has not previously been recognized as a common hospital problem, at least 28% of our patients acquired their Yersinia infections in the hospital. In some cases, cross infections, transmitted by healthcare workers, occurred between patients. Four of the 18 infections occurred in patients with acquired immunodeficiency syndrome.
Cross Infection↗