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PubMed2002

A test-and-treat policy does not save endoscopy workload in a non-referral hospital.

AIM: To assess the impact that a test-and-treat policy with open-access urea breath testing (UBT) has had on the referral rates for endoscopy in a district hospital. Additionally, we examined for any change in the proportion of serious pathology detected endoscopically after adopting the policy. METHODS: Analysis of data on all open-access endoscopy referrals in a 12-month period before (October 1994 to September 1995) and 2 years after (October 1997 to September 1998) the introduction of the UBT service. This was compared with the same service in our sister hospital, which had not provided a UBT service. Results of patients attending the UBT service during the period of study were also examined. RESULTS: A total of 798 patients attended for endoscopy (18% aged < 40 years, 82% aged > 40 years) in the pre-UBT year compared with 1905 patients (16% aged < 40 years, 84% aged > 40 years) in the post-UBT year. The standardized referral ratios were significantly higher for both age groups in the post-UBT year: 210 in the < 40 years group (95% CI 187 to 235) and 244 in the > 40 years group (95% CI 233 to 257). Six per cent of the < 40 years group in the post-UBT year had serious pathology compared with 7% pre-UBT (P < 0.1). However, the proportion of serious pathology decreased from 37 to 27% in the > 40 years group (P < 0.01). The total number of open-access endoscopies had increased steadily over the 3 years, despite the introduction of the UBT service. This trend was mirrored in our sister hospital. A total of 457 patients attended the UBT service during the 12 months. Of these, 24.5% were Helicobacter pylori positive, with a 66.3% eradication rate. CONCLUSIONS: A test-and-treat policy has not saved endoscopy workload in this non-referral hospital. We feel that results from centres with an H. pylori interest cannot be generalized for the vast majority.

Adult↗

PubMed1998

The effect of heavy maternal workload on fetal growth retardation and preterm delivery. A study among southern Thai women.

Heavy maternal workloads are considered to be hazardous to the fetus. The effects of physical activity during pregnancy on low birth weight (LBW), small for gestational age (SGA), and prematurity were assessed from a sample of 1797 women in a follow-up study at the antenatal clinic of two hospitals in southern Thailand. The women were interviewed twice, at 17 and 32 gestational weeks. Outcome data were obtained from medical records and the newborn gestational age determined using Dubowitz's score. The risk of SGA was elevated for women working > 50 hours/week, squatting in work, commuting > 1 hour/day, and having high psychological job demands; the risk of preterm delivery was increased with obstetrical complications. Women who worked long hours and had demanding work conditions had an elevated risk of giving birth to SGA infants but not of preterm delivery.

Adult↗

PubMed2001

Associations between workload and diseases rarely occurring in sickness absence data.

This study provides rate ratios for sickness absence in relation to workload, which was accessed by means of a job exposure matrix. Emphasis is given to diseases that are seldom studied by sickness absence data either because the incidence is low or because medical treatment is not supplemented by rest from work. A total of 42,508 employees from the metal processing and retail trade were followed for 3 years. Sick leave related to hypertension, ischemic heart diseases, ulcer, neurotic disorders, or work accidents was most frequent in employees exposed to physical demands and low control. In contrast, an inverse relation was observed for psychological demands, for which rate ratios decreased with increasing exposure. This finding might be an expression of work commitment or pressure to attend rather than of coping behavior, because both hard and soft diagnoses were considered.

Absenteeism↗

PubMed2004

Workload and case-mix in a Greek emergency department.

The objective of the present study was to evaluate the workload and case-mix of the Emergency Department of a referral hospital, with the aim of determining the causes of overcrowding. The study was of a descriptive prospective design and was carried out in a 700-bed university hospital covering a population of approximately 200,000 inhabitants. The total number of patient visits to the Emergency Department and hospital admissions were recorded during one year, whereas the case-mix of patients visiting the department was evaluated during 11 consecutive on-call days using a triage scale with four categories of patient severity. During the year of the study 81,110 patients (a mean of 443 visits per on-call day) visited the department, with a hospital admission rate of 14.5%. The case-mix analysis of 3389 patients who visited the department during the 11 consecutive on-call days studied revealed that 5.7% were critically ill patients, 53.8% were patients with urgent but non-critical health problems, 30% were patients with non-urgent problems and 10.5% were miscellaneous cases, probably inappropriately visiting the department. In conclusion, the Emergency Department studied is severely overcrowded in relation to the population that it covers. A great part of this overload was directly related to non-urgent cases and inappropriate visits.

Diagnosis-Related Groups↗

PubMedDate not supplied

Quantifying case management workloads: Development of the PACE tool.

In 1999, the Clinical Resource Management (CRM) group at Saint Alphonsus Regional Medical Center in Boise, Idaho, implemented a specialty-based nursing case management model for individual caseload assignment of all inpatient admissions. This model assigns caseloads by proportion determined by physician specialty type. This model does not consider patient acuity and may have weaknesses associated with self-report. In addition, time requirements for effective case management outcomes are not always reflected in admission volumes alone. This article describes the development and pilot testing of the Patient Acuity Case management Evaluation (PACE) measurement tool. Five phases of methodological development are discussed: (1) conceptualization phase, (2) content development, (3) Delphi technique using expert opinion and critique, (4) inter (intrarater reliability testing, and (5) pilot testing of acuity tool. Examples of instrument development throughout these phases are included. This instrument is expected to provide verifiable measurement of individual and group case management workload.

Attitude of Health Personnel↗

PubMed2005

Workload redistribution: a new approach to the 80-hour workweek.

BACKGROUND: The new Accreditation Council for Graduate Medical Education-mandated 80-hour resident work week has resulted in busy trauma services struggling to meet these strict guidelines, or face loss of accreditation. METHODS: Beginning in July 2003, our Level I trauma service began a policy of direct admission of isolated neurosurgical or orthopedic injuries to the specific subspecialty service after complete evaluation by the trauma service in the emergency department for associated injuries. Complications, missed injuries, delayed diagnoses, and admission rates were compared in two 6-month periods: PRE, before the policy change; and POST, after the new policy had been instituted. Resident work hours were likewise compared over the two time periods. RESULTS: Selected single-system injury admission to subspecialty services resulted in a 15% reduction in admissions to the trauma service. There were no significant differences in the overall complication rate, delayed diagnoses, or missed diagnoses between the PRE and POST time periods. Overall, there was a 9.7% reduction in resident work hours (p = 0.45; analysis of variance) between the PRE and POST periods, which allowed them, on average, to meet the Accreditation Council for Graduate Medical Education 80-hour workweek mandate. CONCLUSION: Direct admission of patients with isolated injuries to subspecialty services is safe and decreases the workload of residents on busy trauma services.

Age Distribution↗

PubMed1990

A study of the effect of introducing a restrictive cervical screening policy on laboratory workload and cervical cancer detection rates.

This study examines the effect of a change in screening policy on the detection rate of severe dyskaryosis. During 1987 a total of 423 cases of severe dyskaryosis were identified by the Avon Screening Programme. Eleven per cent of these abnormal smears were repeat smears taken without clinical indication within the recommended 5 year recall period (interval smears). In a comparable control group of negative smears 31% were interval smears. Twenty-five per cent of the dyskaryotic interval smears (3% of the total severely dyskaryotic smears) were taken within 3 years of the previous negative smear, compared with 50% of the control group. By discouraging opportunistic smears within 5 years of the previous smear, the laboratory workload could be reduced by 30%, or within 3 years of the previous smear by 15%. There is, however, a risk of 11% and 3% respectively of missing a significant lesion (severe dyskaryosis).

Cell Nucleus↗

PubMed2004

Implementing computerised workload data collection in rural primary health care.

OBJECTIVE: Describes the implementation of a computerised information system to collect workload data and discusses feedback from staff evaluation of use and value. DESIGN: Feedback interviews following service implementation. SETTING: Remote rural primary health care, Scotland. SUBJECTS: Thirty-three primary health care staff. MAIN OUTCOME MEASURES: Not relevant, as the study was service development with qualitative evaluation. RESULTS: Findings of evaluation interviews indicate a number of themes common to remote rural practice that make implementing a computerised information system problematical. These include: logistical problems caused by small practice teams and wide areas covered; inadequate allowance for recording of blurred roles and the wide range of non-clinical duties carried out; lack of local contextual and cultural information, which is necessary to make sense of data collected. Remote rural health professionals found reports from the system of limited value as they felt they already had good knowledge of local activities and had few opportunities, due to small teams, to use data for service redesign. CONCLUSION: Remote rural primary care is underpinned by a number of organisational and philosophical features that require understanding when considering the implementation of initiatives developed in an urban working environment.

Attitude of Health Personnel↗

PubMed2004

The Surgical Acute Care Unit (SACU): effects on surgical workload and mortality.

BACKGROUND: A surgical acute care unit (SACU) is designed to provide level 1 care for surgical patients. The aim of the present study was to audit the effects of the introduction of a SACU in a teaching hospital surgical department. METHODS: A retrospective case-note audit of all admissions to the newly established SACU over the first 6 months was performed. Expected mortality and morbidity was calculated using POSSUM (physiological and operative severity score for the enumeration of mortality and morbidity) scores. Critical care data for the same period and the 6 months prior to the SACU opening was examined to determine any effect on critical care workload. RESULTS: The SACU admitted 131 patients during the audit period. There was no significant difference between predicted and observed mortality or morbidity. There was no effect on critical care length of stay after the SACU opened. Many patients who would have needed critical care beds before the SACU opened were admitted directly to the SACU after it opened. CONCLUSIONS: This audit demonstrates that the provision of a surgical acute care unit allows many patients who would normally need to be admitted to the critical care unit for postoperative care to be safely admitted to level 1 care beds.

Adult↗

PubMed2004

A European perspective on intravascular catheter-related infections: report on the microbiology workload, aetiology and antimicrobial susceptibility (ESGNI-005 Study).

The laboratory workload, microbiological techniques and aetiology of catheter-related infections in European hospitals are mostly unknown. The present study (ESGNI-005) comprised a 1-day (22 October 2001), laboratory-based, point-prevalence survey based on a questionnaire completed by microbiology laboratories in European (European Union (EU) and non-EU) hospitals. Also included were questions requesting retrospective information for the year 2000. In total, 151 hospitals from 26 European countries participated, of which 78.1% were teaching institutions. Overall, the estimated population served by these institutions was 121,363,800, and the estimated number of admissions during 2000 was 6,712,050. The total number of catheter tips processed during 2000 was 142,727, or 21/1,000 admissions, of which 23.7% were considered to be positive in the institutions using semiquantitative or quantitative techniques. Overall, EU centres received significantly more catheter tip samples/1,000 admissions and had a significantly higher rate of 'positivity' (p < 0.0001) than non-EU centres. Of the institutions surveyed, 11.4% (7.2% in EU countries and 23.7% in non-EU countries; p 0.04) used only qualitative techniques for catheter tip sample processing. On the day of the study, 167 microorganisms were recovered from significant catheter tip cultures (122 patients), of which Gram-positive bacteria represented 70.7%, Gram-negative bacteria 22.2%, and yeasts 7.2%. The five most common microorganisms were coagulase-negative staphylococci, Staphylococcus aureus, Candida spp., Enterococcus spp. and Pseudomonas spp. Overall, 19% of catheter tip cultures were polymicrobial. In the case of S. aureus, 40% of isolates were resistant to oxacillin, as were 63.4% of coagulase-negative staphylococcus isolates. Of 37 Gram-negative isolates, 35% were resistant to cefotaxime, 31% to ceftazidime, and 27% to ciprofloxacin. Imipenem and cefepime had the lowest reported rates of resistance (11%).

Anti-Bacterial Agents↗

PubMed1997

Meeting the challenges of workload and building a practice: the perspectives of 10 rural physicians.

This qualitative study used in-depth interviews to identify and describe factors regarding the retention of rural physicians. A purposeful sample of 10 established rural physicians from counties of fewer than 10,000 people participated in the study. Analysis of the interview transcripts identified the increased workload involved in building a rural practice to be a major concern of the physicians. The physicians expressed this difficulty in the form of two challenging dilemmas: (1) Towns with only a few physicians presented excellent opportunities for a building practice, but the lack of physicians resulted in more difficult working conditions; and (2) building a practice was described as primarily competitive, but staying in rural practice involved working cooperatively with various competitors. The demands of family, practice, and community interact in a complex fashion. The smallest health systems, those in counties with populations of fewer than 10,000, one hospital, and fewer than five physicians, may represent situations where it is difficult to find a workable solution.

Economic Competition↗

PubMed1992

Deprivation and general practitioner workload.

OBJECTIVES: To examine general practitioner consultations by demographic and socioeconomic variables and to derive a method of measuring the impact of relative deprivation on general practitioner workload. DESIGN: The study was based on general practitioner consultations reported in the general household surveys of 1983-7, covering a sample of 129,987 individuals in Great Britain. Odds ratios for general practitioner consultations were obtained for selected variables among children (0-15 years), men (16-64), women (16-64), and elderly people (greater than or equal to 65). These were then used to derive deprivation indices specific to electoral wards for use in general practice. SETTING: Great Britain, with particular findings illustrated by English electoral wards and the conurbations of London, Manchester, Merseyside, and the West Midlands. RESULTS: Council tenure increased the likelihood of consultation significantly in all four groups. Odds ratios were raised in children, men, and women with no access to a car. Birth in the New Commonwealth or Pakistan yielded high odds ratios in men, women, and elderly people but not in children. Marginally increased consultation rates were evident in the manual socioeconomic groups in women, elderly people, and children with a single parent mother. The deprivation indices for general practice derived using these odds ratios varied substantially among English electoral wards with, for example, anticipated general practitioner consultations in the electoral ward of Hulme, Manchester, being 24% higher than the average ward in England as a result of local attributes, and consultations in the Cheam South ward of Sutton, London, 11% lower than average. CONCLUSION: This deprivation index for general practice overcomes several shortcomings expressed about the underprivileged area score, which has been adopted in the 1990 contract as a basis for allocating deprivation supplements to general practitioners. The proposed index can be applied nationwide.

Adolescent↗

PubMed1993

Minor surgery by general practitioners under the 1990 contract: effects on hospital workload.

OBJECTIVE: To determine the extent to which minor surgery undertaken by general practitioners after the introduction of the 1990 contract substituted for hospital outpatient workload. DESIGN: Before and after observational study. SETTING: Four English family health services authorities. SUBJECTS: Patients in 22 practice populations who were operated on by their general practitioner or referred to hospital for minor surgery during April to June 1990 or April to June 1991. MAIN OUTCOME MEASURES: Numbers of minor surgical procedures undertaken in general practice and in hospital, numbers of referrals to hospitals for conditions treatable by a minor surgical procedure, and the mix of diagnoses and procedures undertaken in each setting. RESULTS: General practitioners claimed reimbursement for 600 minor surgical procedures during April to June 1990 and for 847 during April to June 1991, an increase of 41%. Referrals to hospital for comparable conditions showed no compensatory decrease (385 during April to June 1990 and 388 during April to June 1991, 95% confidence interval for change in referrals -51 to 57), and the number of hospital procedures resulting from those referrals also remained constant (187 in the first period, 189 in the second, 95% confidence interval for change in procedures -36 to 40). The mix of procedures did not change significantly from one study period to the next in either setting. CONCLUSIONS: Many or all of the additional patients receiving minor surgery under the terms of the 1990 contract may not have previously been referred to hospital. General practitioners seem not to have systematically shifted towards treating the more trivial cases. The overall increase in minor surgical activity may reflect an improvement in accessibility of care or changes in patients' perceptions and attitudes.

Contract Services↗

PubMed1999

Influence of hospital and clinician workload on survival from colorectal cancer: cohort study.

OBJECTIVE: To determine whether clinician or hospital caseload affects mortality from colorectal cancer. DESIGN: Cohort study of cases ascertained between 1990 and 1994 by a region-wide colorectal cancer register. OUTCOME MEASURES: Mortality within a median follow up period of 54 months after diagnosis. RESULTS: Of the 3217 new patients registered over the period, 1512 (48%) died before 31 December 1996. Strong predictors of survival both in a logistic regression (fixed follow up) and in a Cox's proportional hazards model (variable follow up) were Duke's stage, the degree of tumour differentiation, whether the liver was deemed clear of cancer by the surgeon at operation, and the type of intervention (elective or emergency and curative or palliative intent). In a multilevel model, surgeon's caseload had no significant effect on mortality at 2 years. Hospital workload, however, had a significant impact on survival. The odds ratio for death within 2 years for cases managed in a hospital with a caseload of between 33 and 46 cases per year, 47 and 54 cases per year, and >/=55 cases per year (compared to one with </=23 cases per year) were respectively 1.48 (95% confidence interval 1.03 to 2.13), 1.52 (1.08 to 2.13), and 1.18 (0.83 to 1.68). CONCLUSIONS: There was no detectable caseload effect for surgeons managing colorectal cancer, but survival of patients treated in hospitals with caseloads above 33 cases per year was slightly worse than for those treated in hospitals with fewer caseloads. Imprecise measurement of clinician specific "events rates" and the lack of routinely collected case mix data present major challenges for clinical audit and governance in the years ahead.

Adult↗

PubMed2002

Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs.

OBJECTIVE: To compare the workloads of general practitioners and nurses and costs of patient care for nurse telephone triage and standard management of requests for same day appointments in routine primary care. DESIGN: Multiple interrupted time series using sequential introduction of experimental triage system in different sites with repeated measures taken one week in every month for 12 months. SETTING: Three primary care sites in York. PARTICIPANTS: 4685 patients: 1233 in standard management, 3452 in the triage system. All patients requesting same day appointments during study weeks were included in the trial. MAIN OUTCOME MEASURES: Type of consultation (telephone, appointment, or visit), time taken for consultation, presenting complaints, use of services during the month after same day contact, and costs of drugs and same day, follow up, and emergency care. RESULTS: The triage system reduced appointments with general practitioner by 29-44%. Compared with standard management, the triage system had a relative risk (95% confidence interval) of 0.85 (0.72 to 1.00) for home visits, 2.41 (2.08 to 2.80) for telephone care, and 3.79 (3.21 to 4.48) for nurse care. Mean overall time in the triage system was 1.70 minutes longer, but mean general practitioner time was reduced by 2.45 minutes. Routine appointments and nursing time increased, as did out of hours and accident and emergency attendance. Costs did not differ significantly between standard management and triage: mean difference pound 1.48 more per patient for triage (95% confidence interval -0.19 to 3.15). CONCLUSIONS: Triage reduced the number of same day appointments with general practitioners but resulted in busier routine surgeries, increased nursing time, and a small but significant increase in out of hours and accident and emergency attendance. Consequently, triage does not reduce overall costs per patient for managing same day appointments.

Appointments and Schedules↗

PubMed2003

Impact of NHS walk-in centres on the workload of other local healthcare providers: time series analysis.

OBJECTIVES: To assess the impact of NHS walk-in centres on the workload of local accident and emergency departments, general practices, and out of hours services. DESIGN: Time series analysis in walk-in centre sites with no-treatment control series in matched sites. SETTING: Walk-in centres and matched control towns without walk-in centres in England. PARTICIPANTS: 20 accident and emergency departments, 40 general practices, and 14 out of hours services within 3 km of a walk-in centre or the centre of a control town. MAIN OUTCOME MEASURES: Mean number (accident and emergency departments) or rate (general practices and out of hours services) of consultations per month in the 12 month periods before and after an index date. RESULTS: A reduction in consultations at emergency departments (-175 (95% confidence interval -387 to 36) consultations per department per month) and general practices (-19.8 (-53.3 to 13.8) consultations per 1000 patients per month) close to walk-in centres became apparent, although these reductions were not statistically significant. Walk-in centres did not have any impact on consultations on out of hours services. CONCLUSION: It will be necessary to assess the impact of walk-in centres in a larger number of sites and over a prolonged period, to determine whether they reduce the demand on other local NHS providers.

After-Hours Care↗

PubMed2005

Changes in the emergency workload of the London Ambulance Service between 1989 and 1999.

OBJECTIVES: To examine changes in the emergency workload of the London Ambulance Service (LAS) between 1989 and 1999. METHODS: All emergency responses by the LAS during week 16 in each of 1989, 1996, and 1999 were studied. For each week, 999 call responses were analysed by time and day of call, and age/sex of the patient. Call response rates were calculated using age/sex census population estimates for London. Changes in call rates over time were calculated as rate ratios. RESULTS: Emergency responses increased from 6624 to 13 178 in the index weeks of 1989-1999. The ratio of response rates (1999/1989) was 1.91 (95% CI: 1.85 to 1.96). The proportion of out of hours calls increased significantly, from 68.8% in 1989 to 71.3% in 1999 (p = 0.0003). Response rates rose significantly more steeply for male patients than female patients from 1989 to 1999: rate ratio (95% CI); male patients 2.00 (1.91 to 2.08), female patients 1.69 (1.62 to 1.77), p<0.0001. Response rates varied by age in each of the three years investigated. Rates were consistently highest for patients aged 75 and above, and lowest for those aged 5-14. However, there was no evidence that call rates had increased disproportionately in any particular age group (p = 0.79). CONCLUSIONS: Demand for emergency ambulance services in London has doubled in a decade. This increase is similar for all age groups, with no evidence of a greater rise in demand among older people. Call rates have increased more steeply in men than in women. Demographic changes do not explain the observed increases in demand.

Adolescent↗

PubMed1998

Increasing workload and changing referral patterns in paediatric cardiology outreach clinics: implications for consultant staffing.

OBJECTIVE: To assess the workload of, and referral patterns to, paediatric cardiology outreach clinics to provide data for future planning. DESIGN: Descriptive study of outpatient attendance during 1991 and 1996. SETTING: Five district general hospitals with unchanged local demographics and referral patterns during the study period. METHODS: Postal, telephone, and on site survey of clinic records and case notes. RESULTS: The number of outpatients increased by 61%, with a consequent increase in the number of clinics held and patients seen in each clinic. The number of patients aged between 10 and 15 years doubled. CONCLUSION: These data confirm the impression that demands for paediatric cardiology services are increasing. The increased need for attendance at outreach clinics has inevitable consequences for the clinical, teaching, and research activities of specialists in tertiary centres. An increase in the number of paediatric cardiologists, or development of local expertise (general paediatricians with an interest in cardiology), will be required. Furthermore, the increasingly large cohort of older teenagers and young adults with congenital heart disease underscores the need for the development of specialist facilities.

Adolescent↗