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The utilization of acute care medical beds in Prince Edward Island Wright, Charles J.; Cardiff, K. (Karen), 1953- Nov 30, 1998

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Centre for Health Servicesand Policy ResearchTHE UTILIZATION OF ACUTE CARE MEDICAL BEDSIN PRINCE EDWARD ISLANDCharles J. WrightKaren CardiffHPRU 98:14D November, 1998Health Policy Research UnitDiscussion Paper SeriesTHE UNIVERSITY OF BRITISH COLUMBIAThe Utilization of Acute Care MedicalBeds in Prince Edward IslandA study conducted for the Ministry of Health of the Province of Prince Edward Island by:Charles J. Wright, MB, MSc, FRCSC]Karen Cardiff, RN, BSc, MHSc2] Director, Clinical Epidemiology and Evaluation, Vancouver Hospital & Health Sciences Centre2 Research Associate, Centre for Health Services and Policy Research, Vancouver, British ColumbiaThe Centre for Health Services and Policy Research was established by the Board ofGovernors of the University of British Columbia in December 1990. It was officiallyopened in July 1991. The Centre's primary objective is to co-ordinate, facilitate, andundertake multidisciplinary research in the areas of health policy, health services research,population health, and health human resources. It brings together researchers in a varietyof disciplines who are committed to a multidisciplinary approach to research, and topromoting wide dissemination and discussion of research results, in these areas. TheCentre aims to contribute to the improvement of population health by being responsive tothe research needs of those responsible for health policy. To this end, it provides aresearch resource for graduate students; develops and facilitates access to health andhealth care databases; sponsors seminars, workshops, conferences and policyconsultations; and distributes Discussion Papers, Research Reports and publicationreprints resulting from the research programs of Centre faculty.The Centre's Health Policy Research Unit Discussion Paper series provides a vehicle forthe circulation of (pre-publication) work of Centre faculty, staff and associates. It isintended to promote discussion and to elicit comments and suggestions that might beincorporated within revised versions of these papers. The analyses and interpretations, andany errors in the papers, are those of the listed authors. The Centre does not review oredit the papers before they are released.A complete list of available Health Policy Research Unit Discussion Papers and Reprints,along with an address to which requests for copies should be sent, appears at the back ofeach paper.TABLE OF CONTENTSPageAcknowledgments 1Executive Summary 11Introduction 1Ongoing Health Care Reform in Canada 1Recent Bed Utilization Studies in Canada 2Hospital Resources in Prince Edward Island 3Objectives of the Project 4Methodology 6Study Design 6Measurement Tool..... 6Sampling Strategy 7Sample Size 8Description of Study Sample 9Data Collection 10Analysis 11Presentation of Findings 12Admission Review 12Alternate Levels of Care 12Length of Stay 13Demographic and Clinical Variables 14Continued Days of Stay Review 14Proportion of Patients Who Met Criteria 14Observations and Implications of the Results . 16Why Undertake this Project? 16PageChoice of the InterQual ISD Instrument 18Limitations of this Study 19Efficiency, Appropriateness and Opportunity Cost - AllQuality Issues 19Medical Admissions Not Matching the Criteria 20Alternate Levels of Care 22Comparison of Studies across Canada 23Influence of Age and Route of Admission 24Matching Criteria with Continued Days of Stay 24Are Any Patients Discharged Too Early? 25Implications for Utilization Management in Hospitalsand Regions 25Implications for Health Care System Planning 27Recommendations 30For consideration by the Ministry of Health 30For consideration by the Regional Authorities, hospitalmanagers and health care providers 31References 32Tables 33Table I: Description of Sample Size 34Table 2: Description of Study Sample 35Table 3: Description of Location From Which Patient WasAdmitted 36Table 4: Description of Patient Entry to Hospital 37Table 5: Patients Matching Criteria at the Time of Admission .. 38Table 6: Patients Not Meeting Criteria at the Time of Admission:Description of Severity of Illness (SI) and Intensity ofService (SI) Criteria 39PageTable 7: Alternate Levels of Care Assigned to Patients Who DidNot Meet Criteria at the Time of Admission 40Table 8: Alternate Levels of Care Assigned to Patients WhoDid Not Meet Criteria at the Time ofAdmission:Detailed Description of 'Outpatient Care ' . . . . . . . . . . . . . . .. 41Table 9: Average Length of Stay (LOS) Described byCriteria Match at the Time of Admissicn 42Table 10: Patients Matching Criteria at the Time of Admission:Described by Age Group and Route of Admission .. .. . 43Figures 44Figure 1: Diagnostic Categories Based on "Most Responsible"D ' , 45lagnosls ,Figure 2: Diagnostic Categories Based on "Most Responsible"D' , 45lagnosls .Figure 3: Proportion of Patients Meeting Criteria at Time ofAdmission: Described by "Most Responsible"Diagnostic Category 46Figure 4: Proportion of Patients Who Met Criteria forContinued Hospitalization "Post Admission" Review .. 46Figure 5: Proportion of Patients Who Meet Criteria forContinued Hospitalization "Post Admission"Review: Described by Size of Hospital 47Appendix A 48InterQual Criteria Development Revision Process 48Development Process 48Revision Process 48PageAppendix B 49Comparison of Study Population with Study Sample (Mean Lengthof Stay & Gender) 49Appendix C 50Reliability Testing 50Appendix D 51Alternate Levels of Care (adapted from the ISD criteria) 51No Immediate Care :. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 51Outpatient Services .. 51Home-Based Care (Professional Services) 51Home-Based Care (Support Services) .. 51Non-Acute Institutional Care 51Hospice ' " 52Addiction Services 52Mental Health Services . 52Rehabilitation 52Observation 52Local Accommodation 53Convalescent 53Special Program 53Appendix E 54ISD Criteria: Example from Respiratory System.... ... .................. 54Appendix F 56Examples of Patients Meeting Criteria . .... .. . . . . .. . .... . . ..... .. . .. .. . .. . 56Appendix G 59Examples of Patients Not Meeting Criteria..................... .... ...... 59- 1 -ACKNOWLEDGMENTSThe authors would like to acknowledge the willing assistance and cooperation offered bythe following individuals in the planning and conduct of this study:• Mary Hughes Power, Director, Acute & Continuing Care Division, Health and SocialServices, PEl• Dr. Don Ling, Director ofMedical Services, Health & Social Services, PEl• The physicians of the hospitals who met with the consultants in the preparations forthe project• The regional board members who also met with the consultants• The administrative and health record staff ofthe seven hospitals- 11 -Executive SummaryIn the processes of health care management and reform the issue of efficiency hasalways received much attention, but recently more questions are being askedabout the appropriateness of services and the current configuration of the healthcare system in general. Recent studies in British Columbia, Alberta,Saskatchewan, Manitoba, and Ontario examining the appropriateness of acutecare bed utilization have shown that a proportion of these beds are occupied bypatients whose care requirements could be provided in alternative settings. Thisstudy was commissioned by the Ministry ofHealth ofPrince Edward Island toexamine hospital bed utilization in the province using similar methodology to thatused in the other Canadian studies.The major objectives were to assess the proportion of patients in acute carehospital beds that meet standard criteria for requiring acute care services and todocument the alternative type or level ofcare that would be more appropriate forthose patients not meeting the criteria. A structured sample of general adultmedical inpatients in all seven Prince Edward Island hospitals in 1997 wasexamined using the InterQual ISD criteria. Surgical patients and those inpsychiatric, rehabilitation, coronary care or intensive care units were excluded inorder to focus on the general medical group that are often found to present thegreatest opportunities for better resource utilization.For the provincial sample as a whole, 27% of the patients met all the ISD criteriajustifying admission to an acute care hospital bed. In the large hospital group theproportion meeting criteria was 29% and in the small hospital group 25%, with arange of 13-51% across all individual hospitals. This can be put in perspective- III -with the other similar studies across Canada that have shown a range from only10-61% of patients meeting acuity criteria. It appears that the same issues aboutappropriate bed utilization confront health care boards; managers and providersfrom coast to coast.Analysis of the potential alternate levels of care that could satisfy the needs ofthose patients not requiring acute hospital care reveals that the most frequentrequirement was for outpatient services. A large proportion required some lesseracuity type of nursing care, observation only, or home based care. A muchsmaller number required the alternatives of hospice care, long-term care,rehabilitation services, or only convalescence. All patients in all hospitals werefound to require some type of care and attention but not necessarily at the level ofacute hospital care. Patients who did not meet admission criteria had a tendencytowards a shorter average length of stay, but this was not significant, suggestingthat once admission has occurred there are delays in appropriate discharge. Thisemphasizes that the crucial decision point is at the time that hospital admission isbeing considered.For those patients that did match criteria at the time of admission the continueddays of stay remained appropriate in the large majority. No significantrelationship was found between the likelihood of matching criteria and thepatient's age or the route of admission (from physician's office or EmergencyDepartment).It is concluded from this study that a substantial proportion of hospital beds inPrince Edward Island are currently being used for patients who could be cared foradequately and safely in alternative settings. The potentially appropriatealternative settings are detailed and discussed in the report. The recommendationsthat arise from the findings in this report are directed to the Ministry of Health,- IV-regional authorities, hospital managers and health care providers. In summary,they address the following major issues:• The need for better system wide planning and resource reallocation to achievea more appropriately balanced configuration of hospital, outpatient, homebased and other care services• The public perception that only acute care hospitals can provide the healthcare services they need requires the development of a public educationprogram about the features of a modem quality health care system• The importance of developing a structured incentivized comprehensiveutilization management program in all acute care hospitals- 1 -The Utilization of Acute Care Medical Beds inPrince Edward IslandINTRODUCTIONOngoing Health Care Reform in CanadaCanada's publicly funded health care system is faced with responding to thecontinuous and progressive changes in health care knowledge and care,technology and public expectations. In most Canadian jurisdictions, health carereform over the last five years has led to consolidation of resources, elimination ofduplication of services and redefinition of provider roles in some cases, all with amajor emphasis on the issue of efficiency, that is maximal health care serviceprovision with optimal resource use. The pattern of reform has also usuallyincluded elimination ofmultiple separate authorities for various aspects of thehealth care system in favor of regionalization. These changes offer the potential,for the first time, for regional authorities to examine and manage the biggerpicture including all the many and different services and types of care that arerequired in looking after the health of the population.With this changing focus, questions are inevitably asked about theappropriateness of current resource utilization within each of the health caresectors and especially about the appropriateness of the current utilization of acutecare hospital beds. It must be recognized that we work in a largely unevaluatedsystem but with increasing clamour for evaluation activities and accountability for- 2 -the very large expenditures. It is noted that serious questions are also now beingraised concerning the appropriateness of prescribing patterns, diagnostic tests andprocedures of all kinds but these questions are outside the scope ofthis project.Recent Bed Utilization Studies in CanadaThere has been a progressive fall in the number of bed days per thousandpopulation used by Canadians over the last 30 years. The number of hospital beds(1996 data), counting only general, acute med/surg, rehab, pediatric andpsychiatric beds per 1,000 population is 2.7 in Ontario and British Columbia, 3.4in Nova Scotia, 4.3 in Manitoba and 4.9 in Prince Edward Island, with an averageof3.0 in Canada as a whole ref 1-2. In many areas of the country the number ofbeds used has fallen to about 1/3 of the number used in the 1960's at the sametime as the scope and intensity of health care services has increased enormously.This has been achieved by a progressive reduction in emphasis of acute inpatientcare in exchange for increasing programs of outpatient care, day surgery, same­day-admit surgery programs and domiciliary care. Throughout all these changesthere has been constant pressure on hospital beds with apparent difficulties ofaccess, and it is particularly interesting to note that these pressures were no lesswhen three times the number of beds were being used than they are today.It has long been observed in the Canadian health care system that acute carehospitals tend to be all health care things to all people and that many patientscurrently in hospital could have the ir health care requirements adequately met if(and this 'if is of crucial importance) the more appropriate level of care wereavailable. Different levels ofcare intensity are required for different patientproblems, but the Canadian system has been slow to respond to the growingevidence on this issue.- 3 -These observations and opinions have been tested in several jurisdictions inCanada over the last few years. Province-wide studies examining appropriatenessof acute bed utilization and designating preferred alternatives where relevant havenow been conducted in Saskatchewan, 1994 ref3, Manitoba, 1996 ref4, BritishColumbia, 1997 refS and Ontario, 1997. ref6 Further individual hospital studieshave been reported from various settings, for example in Alberta,ref7 and inBritish Columbia ref8. All of these projects used the same tools and basicmethodology as in the current study in PEl, although there are importantdifferences in detail. All of their results confirm the observation that a substantialproportion ofpatients in hospitals in these provinces could be adequately or betterserved in alternative care settings.Hospital Resources in Prince Edward IslandThe acute care resources in PEl consist of seven hospitals:HOSPITAL NUMBER OF ACUTE BEDS (1998)Western (Alberton) 27Community (O'Leary) 10Prince County (Summerside) 112Stewart Memorial (Tyne Valley) 4Queen Elizabeth (Charlottetown) 274Kings County (Montague) 30Souris 17TOTAL 474- 4-The bed occupancy rate in these hospitals ranges from 78 to 98% and there iscurrently a perception in some regions of severe pressure on hospital beds withinadequate patient access to in-hospital services.The provincial health care system includes also an array of community and long­term care resources which were not examined in this study.Objectives of the ProjectThe objectives were designed in consultation among the consultants, Ministry ofHealth personnel and hospital staff. The general objective was to evaluate thecurrent pattern of acute care medical bed utilization in the hospitals of theprovmce.The specific objectives were:• To assess the proportion ofpatients in acute care beds that do not meetstandard criteria for requiring acute care services.• For those patients not matching the criteria, to document the alternative typeor level of care that would have been more appropriate to meet the patientsneeds.• For those patients meeting criteria at the time of admission, to assess theappropriateness of continued hospitalization (and potential alternatives).• To provide the Ministry of Health, the Regional Authorities and the hospitalsof PEl with information that will assist in planning the future configuration ofhealth care services.• To provide regional authorities and hospitals with information that will assistin the design of ongoing utilization management programs.- 5 -In the design of the study it was decided to focus on acute medical beds ratherthan any specialized unit or surgery because experience has shown that this is thearea of acute care hospitalization with the greatest potential for improvements inappropriateness and utilization. The indications for medical admission andcontinuing stay in medical beds are often more judgmental and less influenced bythe incentives for rapid turnover experienced in surgery.It was agreed that the published report would include the overall results for thehospitals in the province and further the results for the groups of large and smallhospitals respectively. The large hospital group was deemed to include the QueenElizabeth and Prince County hospitals and the small hospital group included theCommunity, Kings County, Souris, Stewart Memorial and Western hospitals. Itwas also agreed that each hospital would receive its own detailed results and theRegional Authority would receive the detailed results for each hospital in theregion,- 6-MethodologyStudy DesignThe major objective of this study was to examine how acute medical beds in theProvince ofPrince Edward Island (PEl) are used. To do this, data were collectedretrospectively using a chart review process. If data are collected concurrently,there may be a tendency for providers and/or administrators to change previouspractices related to admitting and discharging patients with the realization thatpatient acuity and service delivery are under investigation. For this kind of studythe "Hawthorne Effect!" requires a design involving retrospective data collection.Measurement ToolA number of tools have been developed for objective assessment of patients inacute-care. Each instrument consists of sets of objective criteria for determiningthe medical necessity ofhospital admissions and days of care. The instrumentsdiffer from each other in their organization and in the number and content of thecriteria included. This study used the ISD instrument.2Initially developed by InterQual in 1978, the ISD consists of a set of explicit,diagnosis-independent criteria (InterQual, 1978). The criteria are used to evaluatewhether inpatient acute-care hospital services are justified, based on both theclinical characteristics of the patient (severity of illness criteria) and the specificservices received by the patient (intensity of service criteria). Discharge screensevaluate the patient's readiness for discharge and consider two key elements-theclinical stability of the patient and the necessity for continuing care at the acute-1 The Hawthorne Effect (ref 9) refers to the influence on subjects of awareness that they arc part of astudy with the consequent tendency to alter their behaviour to obtain better results . (Shortell ,Richardson , William, 1978).2 The acronym "ISO" stands for "Intensity of Service," "Severity of Illness" and "Disch argeScreens."- 7 -care level as explicitly defined. The ISD criteria are updated on a regular basis byInterQual, in an attempt to keep pace with advances in health technology whichaffect not only the type of care that is delivered, but also the location in whichcare can be safely provided. This study used the 1997 version of the ISD criteria.Details about the InterQual Criteria Development/Revision Process are describedin Appendix A.The ISD criteria can be applied to 1) assess the need for admission, and 2) assessthe need for continued days of stay in hospital.The ISD criteria are designed for review by a non-physician. The informationused in the review comes from the patient's hospital chart, i.e. admission historyand physical, progress notes, consult notes, nurse's notes, and the notes of otherhealth care providers (e.g. rehabilitation therapy, social work), the laboratory,medication and clinical record. The criteria can be applied on either a concurrentbasis or retrospective basis. The criteria can also be used to assess patients priorto hospital admission, with the intention of avoiding inpatient stays for patientswho might otherwise be considered for management in a less service-intensivesetting, such as an outpatient department or home-based care.While the ISD protocol allows for a designated physician who is familiar with theISD review process to review a patient record (when it is deemed necessary to doso) and override the judgement of the ISD criteria, this study did not use thesystem ofphysician override.Sampling StrategyThe study population was based on data routinely collected by all hospitals inPEl and compiled by the MoH and included all separations from adult medicine.'In order to achieve a sample of routine medical separations the following groupsof patients were excluded:• patients whose stay in hospital included admission to:3 Adult was defined as any individual 14 years of age or older.- 8 -an intensive cafe unita coronary care unita rehabilitation unita psychiatric unit• patients who underwent a surgical procedure, other than minordiagnostic procedures (e.g. endosco py, co lonoscopy) .The time frame encompassed the period irom January 1997 through December1997. During th is period of time there were 9,709 "el igib le" (no t excluded) adultmedical separations from acute-care hospitals in the province of PEl.The hospitals were catego rized by size, based on the number of adu lt med icalseparations during the time period from Janu ary 1997 through Janu ary 1997.Large HospitalsSmall HospitalsAdult Medical Separa tions fromAcute-care Hospita l In pa tient Beds1,500 +less than 1.500The seven hospitals included in the study are listed in Table 1. There are 2hospitals in the "large hospital" group (Queen Elizabeth and Prince County). andthe other 5 hospitals in the "small hospital" gro up (Community, Kin g's County,Souris, Stewart Memorial and Western).Sample SizeThe sample size is described. in Table 1. The sample of records from eachhospital was j udged to be adequate to accurately determin e the proportion ofpatients who met criteria at the time ofadmi ssio n and on continued days of stay .In order to achieve adequate representation of eac h patient population , a higherproportion of the tota l number of admissions must, of co urse, be sampled in thesmall hospitals than in the large hospitals.- 9 -Description of Study SampleThe study sample was representative of the study population (Appendix Bprovides a comparison between the study population and the study sample forage, gender and mean length of stay).A detailed description ofthe study sample is provided in Tables 2 and 3. Therewere 515 patients represented in the sample," of whom 56% were female. Fifty­six percent of the patients were under 70 years of age at the time of admission.Ninety-two percent of the patients were living in their own home at the time ofadmission. The majority ofpatients who were discharged returned to their ownhome; 11% were discharged to another level of institutional care. Six percent ofthe patients died in hospital.The route of admission to hospital (whether directly from a physician's office orthrough the emergency department) is displayed in Table 4 for the 2 largehospitals. This information was not recorded frequently enough to justify analysisfor the smaller hospitals.4 Although the estimated sample size was 520 the actual study sample consisted of 515 patient records. Thereason for this is that it was necessary to eliminate a few data collection forms because of missinginformation (n=5).- 10 -Figure 1 shows the patient sample broken down into "most responsible"diagnostic categories - those which best described the main cause for admission ofthe patient. The majority of the patients (81%) in this study fell within thefollowing 7 diagnostic categories :Diagnostic ICD-9 %of No. ofCategory Codes Patients PatientsRespiratory System 460 - 519 18% 88Circulatory System 390 - 459 19% 92"Symptoms"S 14% 27Digestive System 520 - 579 11 % 56Mental Health 290-319 7% 33Neoplasms 140-239 6% 30Injury or Poison 800 - 999 6% 68Figure 2 provides a description of the "most responsible" diagnostic categoriesfor the "large" and "small" hospitals respectively.Data CollectionTwo registered nurses, experienced in the application ofISD criteria collected thedata. Prior to beginning data collection, reliability testing was done to measure theextent to which the nurses were applying the ISD criteria in a uniform manner.The inter-rater reliability ofthe nurse reviewers ranged from kappa 0.70-0.90. 65 This category includes symptoms, signs, abnormal results of laboratory or other investigative procedures,and ill-defined conditions regarding which no diagnosis classifiable elsewhere in the ICD-9-CMClassification ofDiseases is recorded .6 The kappa statistic measures the level of agreement between two independent reviewers and corrects forchance agreement. If there is perfect agreement the kappa= I; if there is no agreement (i.e. equal to chanceagreement) the kappa=O. The kappa scores obtained in this study indicate a "very good" level of agreementbetween reviewers.- 11 -Additional details about the reliability testing can be found in Appendix C andreference 10.From mid-July 1998 through mid-August 1998, the two nurse reviewersabstracted data from patients' charts at the respective hospital sites. Each patientchart was evaluated to determine if the patient met the ISD criteria at the time ofadmission. Although the ISD protocol specifies that the patient must meetcriteria within 4 hours of admission (InterQual ISD Workshop Series, 1996)patients in this study were given 48 hours from the time of their admission tomeet the criteria. If the patient met the ISD criteria at the time of admission thenurse reviewer would apply the criteria to the continued days of stay until thepatient no longer met the criteria, was discharged or died (to a maximum of 12days "post admission" review). If the ISD criteria were not met at the time ofadmission the criteria would not be applied beyond 48 hours.The nurse reviewers excluded the hospital charts of patients who were:• admitted to hospital for less than 12 hours• admitted to a designated palliative care bedAnalysisThe analysis involved several steps. First, the data were examined to determinethe proportion of patients who met the ISD criteria within 48 hours of admission.Next, for those patients who did not meet ISD criteria at the time of admission,the specific levels of care that these patients might have required , as an alternativeto the inpatient care that they received, were identified.The data were further analyzed by demographic (e.g. age and gender ofthepatient) and clinical characteristics (e.g. "most responsible" diagnostic category).- 12 -Presentation of FindingsAdmission ReviewTable 5 shows that 27% of the total provincial sample of492 patients met both ofthe 2 groups ofISD criteria (for severity of illness and intensity of service) within48 hours of admission. The proportion of patients meeting these criteria at thetime of admission ranged from 13% to 51% in different hospitals.Although the majority of the patients did not meet both groups of the ISD criteriaat the time of admission, Table 6 shows that 37% of these did meet the "severityof illness" criteria.Table 7 shows that for those patients who did not meet criteria at the time ofadmission, all of them required some further care (i.e. none of the patients wereready to go home without the necessity for any further "immediate" follow-upcare).Alternate Levels of CarePatients who did not meet the criteria at the time of admission were classified asrequiring various combinations of care. There were one or more levels of careassigned to each patient as follows:• Eighty-six percent of the patients were considered to require some form ofoutpatient services• Forty-five percent of the patients were considered to require some form ofobservation care• Sixteen percent of the patients were considered to require some form ofhome-based care- 13 -• Six percent were considered to require mental health services and 2%were considered to require addiction services• Five percent of the patients were considered to require hospice care• Two percent of the patients were considered to require convalescent careThese results are outlined in Table 7. For those patients deemed to requireoutpatient services as the appropriate alternate level of care, Table 8 displaysfurther detail of what particular outpatient service was required. A description ofthe alternate levels of care that were used can be found in Appendix D.Although there was considerable variation amongst the hospital categories withrespect to the alternate levels of care that were identified, similar patterns didemerge. For example, all patients were judged to require some form of"immediate" care. Outpatient services, home-care and observation were the mostcommon services cited.Length of StayThe mean length of stay (LOS) for the entire sample of patients was 9 days andthe median was 5 days.i With a few exceptions, the distribution of average LOSfor the individual hospitals displayed a similar pattern.Table 9 describes the average length of stay (LOS) for patients, with a breakdownby those who met criteria and those who did not. The mean LOS was similar forboth groups . With respect to the median, LOS was lower for the group of patientswho did not meet criteria.7 Because the distribution of LOS is generally not symmetrical (meaning that there are usually a fewpatients with very long lengths of stay), and because the arithmetic mean is sensitive to extreme values(meaning that the extreme values of LOS, although only a few in number, would nonetheless increasethe mean value for LOS), median LOS is often considered a more appropriate measure to use.- 14 -Demographic and Clinical VariablesData were examined to determine if there was any correlation between "meeting"and "not meeting" criteria at the time of admission and selected variables.When the proportion of patients who met criteria at the time of admission wereexamined by age group (Table 10) it was found that there was no significantcorrelation between meeting criteria and the age group of the patient (p = 0.45).Table 10 also shows that patients who were admitted to hospital via theemergency department (n=115) were no more likely to meet criteria at the time ofadmission than patients who entered the hospital via a physician's office (n=36)(p = 0.4).8Figure 3 shows that patients admitted with problems related to the circulatorysystem, respiratory system, or gastrointestinal system were more likely to meetcriteria at the time of admission compared to patients whose primary diagnosisfell within one of the other diagnostic categories.Continued Days of Stay ReviewProportion of Patients Who Met CriteriaThe continued stay review data" showed that 77% (n=146) of the patients whohad met criteria on admission (and had not yet been discharged from hospital)continued to meet criteria on the first day "post admission". On the second day"post admission" 80% (n=112) of the patients who met the criteria on theprevious day (and had not yet been discharged from hospital) continued to meet8 Information about route of admission to hospital was not collected from the "small" hospitals becausein most instances the hospital record did not clearly indicate the route of admission.9 If the patient met the ISD criteria at the time of admission (i.e. within 48 hours of admission) the nursereviewer would apply the criteria to the patient's continued days of stay and would continue to reviewthe continued days of stay until the patient no longer met criteria, was discharged or died, to amaximum of 12 days .- 15 -the criteria. By the fifth day "post admission" 92% (n=48) of the patients werestill meeting criteria. These results are displayed in Figure 4. The results forthe "large" and "small" hospitals respectively are displayed in Figure 5. Afterthe 6th post-admission day, the number ofpatients who had met criteria onadmission and who were still in hospital became too small to permit validanalysis.- 16 -OBSERVATIONS, AND IMPLICATIONS OF THERESULTSWhy Undertake this Project?The Canadian health care system has always relied heavily on acute care hospitalsfor the provision of a wide variety ofhealth care services. Alternative settings forthe provision of care when appropriate, for example outpatient services, homebased care, subacute care, convalescent care and observation care have onlyrecently received more intense attention in Canada. Specific units and settings for"subacute care", "skilled nursing care", and patient observation are widely used inthe United States but are virtually absent in the Canadian system where the acutecare hospital has provided all these different levels of care without actuallyrecognizing them as distinct.Physicians admit patients to acute hospital beds for the professional services anddiagnostic treatment and care facilities that the hospital provides and that thepatient requires. In many instances the only facility available to the physician toensure that the patient receives the required care is the acute care hospital becausethe alternative level of care that may be more appropriate is simply not available.The way that acute care hospital beds are used has not, until recently, beensubjected to much scrutiny although there is growing evidence that at least aproportion of patients currently occupying acute hospital beds could be cared forsafely and appropriately in alternate ways.The progressive fall in hospital bed numbers per thousand population over the last30 years has many causes:- 17 -• More effective treatment programs causing more rapid resolution ofillness episodes.• Improved technology, for example, minimally invasive surgeryrequiring very short hospital visits instead of many days of hospitalconvalescence.• Preadmission clinics to ensure that all necessary tests and patienteducation in preparation for surgery are complete ahead of time.• Same-day-admit surgery, that is the elimination of any days in hospitalsimply waiting for the procedure. Preadmission clinics and same-day­admit programs for elective surgery are now widely used except, ofcourse, for patients who have other medical conditions requiring atleast some hospital preparation for the procedure.• Progressive improvement in community support mechanisms.• Major expansion of outpatient facilities and capacity to handle avariety of problems that used to require inpatient hospitalization.• Day surgery units for increasingly complex procedures that used torequire hospitalization.• Recognition that immobilization in bed poses serious health risks andis only indicated when absolutely necessary because of the patient'scondition. Groin hernia surgery is now done in day surgery unitswhereas 30 years ago the patient was kept in bed for a week."Confinement" used to mean just that, namely a prolonged period ofbed rest following childbirth.These changes have affected surgical services to a much greater extent thanmedical services, as surgery has a large volume of elective practice. In contrast,there are very few truly elective admissions to medical beds and it is for thisreason that the study (and most of the other similar Canadian studies) hasconcentrated on the evaluation of general medical bed use.- 18 -The results demonstrate that the patients do need care, but the major questionexplored here is whether the acute hospital bed is best suited for the patientrequirements or whether an alternative setting (if it were available) would bepreferable. Medical beds represent the area of inpatient hospital services wherethe greatest opportunity for using alternatives is likely to be found.Choice of the InterQual ISD InstrumentSeveral criteria based decision support instruments are available, and for thisstudy it was necessary to use one that was focused on the criteria forhospitalization and continuing stay in acute medical beds. The lnterQual lSDinstrument was chosen because of its credible, professionally designed andregularly updated criteria, its wide acceptance throughout North America, and itsprevious use in similar studies in Canada, in Ontario, Manitoba, Saskatchewan,Alberta, and British Columbia. The 1997 version of the InterQual lSD criteriawas used for application to the sample of patients in PEl hospitalized during 1997.The decisions concerning patient exclusions from the study were made because ofthe focus on medical patients and the need to ensure comparable results across theprovince. The objective was to examine the use of acute adult medical beds,particularly in the areas where decisions may be most subject to individualjudgement. Therefore, patients in any critical care area, rehabilitation, maternityor psychiatric unit, pediatric patients and those having any surgical procedurewere excluded. The group sample was then chosen from the remainder in anattempt to capture the general medical adult hospitalized population wherequestions concerning the utilization of acute patient days most frequently arise.- 19 -Limitations of this StudyAll studies of this kind have some limitations which need to be understood in theinterpretation of the results. As a retrospective study, the reviewers must rely onthe hospital chart contents for all information. When using the InterQual ISD toolconcurrently the decisions may be subjected to physician review which alwaystends to increase the proportion ofpatients matching criteria by a smallpercentage. The sample of patients chosen for the study excluded certain groupsthat would obviously have a higher level of acuity and treatment, for example insurgical, psychiatric and intensive care units, because the major objective was toidentify the best opportunities for reconfiguring patterns of care. It is known that'general medical' patients best fit this requirement.Efficiency, Appropriateness and Opportunity Cost - All Quality IssuesThe continuous improvement oftreatment programs, better management practicesand above all the constraints of resource limits have caused progressiveefficiencies in the provision of health services, that is achieving the greatest outputpossible for the least cost. However, to ensure that resources are well directed inthe first place there are crucial issues about the criteria for access to health careservices and about the appropriate level at which the care is provided. It iscertainly possible to provide highly efficient services that are either of doubtfulbenefit or not ideally matched to the patients needs.This realization has led to the application of various decision support tools forphysicians and other health care professionals including preadmissionappropriateness screening of patients booked for elective procedures, concurrentreview of the need for hospitalization, clinical practice guidelines for variousprofessional groups and care paths.- 20-Although this current study focuses on medical admissions, there are other similartools that can be applied to evaluate the appropriateness of surgical admissions,operations and procedures, home care, long-term care, consultations and imagingstudies. A comprehensive utilization management program within a region, forexample, would include the application of at least some of these available tools inaddition to the more traditional activities ofdischarge planning programs,antibiotic reserve programs (and similar programs for other drugs), guidelines andcare paths.The opportunity cost of inappropriate resource use is certainly a major qualityissue. There is no question that the total resource pool available to the health caresystem is finite and any dollar spent providing an inappropriate service, orproviding care in an expensive setting where a less expensive setting would beadequate, is not available for a patient or program with greater need.Medical Admissions Not Matching the CriteriaThe results must be viewed in the context of the study methodology and thelimitations described above. The overall proportion ofpatients meeting thecriteria (27 %) and the converse, those not meeting the criteria (73%) doesindicate that there is significant opportunity for reconfiguration of health careservices in Prince Edward Island.It is important to note that no patient was deemed not to require care andattention. The issue is the appropriateness of the acute care hospital setting ratherthan the potential alternatives. These findings in PEl are very similar to thefindings in the other similar studies across the country (see below) although theexact proportions differ.- 21 -There is an inconsistent trend towards higher appropriateness rates in the largerhospitals but this is not statistically significant. As mentioned previously, thedecision was made at the outset that these results would be compiled for theprovincial aggregate and for the two larger hospitals and the five smaller ones. Inaddition each individual hospital and regional authority will receive its own dataon the proportion criteria match, potential alternate levels of care, average lengthof stay, and criteria status by patient age grouping (the equivalent of tables 5-12 inthis report).For those patients not meeting the overall criteria at the time of admission, theanalysis of the severity of illness versus the intensity of service reveals (table 6)that a substantial proportion of them (37%) did meet the severity of illnesscriteria only, with no significant difference in this finding between the larger andthe smaller hospital groups.The average length of stay (ALOS) of the patients who met and did not meet thecriteria respectively are displayed in Table 9 in the three groupings, namely theprovincial aggregate and the larger and smaller hospitals respectively. Both themeans and medians are recorded for interest. The results do show a small butconsistent trend for the median ALOS to be shorter when admission criteria werenot met, as would be expected.The proportions of patients matching criteria in relation to the "most responsiblediagnosis" are displayed in Figure 3. Figures 1 and 2 reveal the spread of "mostresponsible" diagnoses as coded by the hospitals for the patients reviewed. Asusual for samples of this particular patient population, cardiovascular, respiratory,and gastrointestinal problems dominate the causes for admission.- 22-Several typical examples ofpatients who were assessed in this study to be entirelyappropriate for hospitalization (that is they met the InterQual criteria) aredescribed in appendix F. Conversely, examples of patients who did not meet thecriteria are described in appendix G. These actual case descriptions help to placethe measurement instrument in perspective and to recognize that the criteria arebased on well accepted concepts likely to be approved by most physicians.Alternate Levels of CareThe most frequently required alternate level care in this study was "outpatientservices" (86% ofpatients not matching criteria), followed by "observation"(45%) and "home-based care" (16%), and more than one alternate care level wasoften designated. For many patients in hospital the only major requirement was adiagnostic test or special imaging procedure that could have been provided as anoutpatient if sufficient capacity existed. It is not unusual for physicians to admitto hospital knowing that in the patient's best interest the only way for rapid accessto a CT Scan, for example, is through hospital admission. Other reasons includethe unavailability of laboratory or imaging services at the time the patientpresents, unavailability of appropriate outpatient services, location of the patient'sresidence requiring long distance travel for service, and patient and providerconvenience. Within outpatient services, the most frequent requirement was forlaboratory services, followed by imaging studies and then OP visits to a physician(Table 8).In the present system it is obvious that the level of care that may be mostappropriate is often not available. The acute hospital has always been there forreferrals, drop-ins, triage, in addition to the provision of the more intense medicaland surgical services for which there is clearly no alternative. Physicians areoften put in the situation of having to admit a patient to an acute hospital bedbecause it is the only available route for care at the time it is required.- 23 -Comparison of Studies across CanadaThe result from this study that only 27% of the patients surveyed in hospitals inPEl matched the InterQual criteria for requiring acute care hospitalization iswithin the range reported in similar studies across Canada. Many of thequantitative differences among these studies are due to the different details ofstudy methodology. The 1994 Saskatchewan study ref J showed anappropriateness level for adult medical admissions ranging from 50% for smallcommunity hospitals to 61% for base hospitals. It must be noted that in theSaskatchewan study the patient sample was of all adult medical admissions withno exceptions. In Manitoba, 1996, ref 4 the proportion of appropriately "acute"admissions ranged from 27% in small rural hospitals to 55% in major urbancentres, with exclusion from the study of patients in certain groups known to beless acute.The British Columbia study "Acute Medical Beds: How are they used in BritishColumbia?" in 1997 is the one most similar to the PEl study in terms of themethodology and in particular the sampling frame. The BC study refS found thatthe proportion of adult medical patients matching the InterQual criteria rangedfrom only 10% in the smallest rural hospitals to 32% in the large hospitals. Theprovince wide Ontario study in 1997 ref 6 found higher rates of appropriateness(around 80%) but it must be noted that there were very significant differences inthe methodology used in Ontario. The major difference which is undoubtedlyresponsible for the high rates of criteria match is that selected patient diagnosticgroups likely to be more acute were studied rather than random adult medicaladmissions. These included acute myocardial infarction, congestive heart failure,chronic obstructive lung disease, cerebral vascular accident, and pneumonia. Inaddition elective surgical patients were included in orthopaedics, urology andgynaecology.- 24-The differences in design, methodology, and in particular sampling strategy fromstudy to study make direct comparisons impossible, but it is clear that the findingsare qualitatively similar across the country. The exact proportion of patientsfound to be suitable for alternate care levels varies from study to study but theproportion is highly significant in every case. The present study in PEl can echothe conclusions of the other studies namely that planning the health care systemdoes require acknowledgement of the changing role of acute hospital beds inrelation to all the resources and services that could be provided to meet patientshealth care needs.Influence of Age and Route of AdmissionIt is often assumed that older patients are more likely to be admittedinappropriately than younger patients and this question was examined with theresults displayed in Table 10. It is noted that the proportion of patients meetingcriteria on admission did not change significantly from age group to age group.Questions are often raised about the desirability of "double checking" the patientsneed for admission by ensuring that all patients are routed through the EmergencyDepartment rather than admitted directly from physicians' offices. In otherstudies the proportion of inappropriate admissions has been higher for patientsadmitted directly from a physician's office than for those admitted through theemergency room. Table 10 also demonstrates that in this study in PEl , this had noapparent influence on the proportion of patients meeting criteria or not.Matching Criteria with Continued Days of StayFor patients who met criteria at time of admission, Figure 4 displays theproportion continuing to match criteria day by day of the hospital stay. The sameinformation is conveyed in Figure 5 separating out the results for the large and- 25 -smaller hospitals respectively. These figures demonstrate that a large proportionof the patients who match the criteria at the time of admission continue to do sothroughout the hospital stay. This finding emphasizes the critical nature of theinitial decision to admit to hospital. Monitoring lengths of stay is important, buteven more important is monitoring the indications for admission in the first place.Are Any Patients Discharged Too Early?In the preparatory discussions with physicians when planning this project, theconverse issue to inappropriate hospitalization was raised, namely patients whomay be discharged inappropriately. Among the 492 patients reviewed in thisstudy, there were 12 patients who did not "pass" the InterQual discharge screenon the day of discharge. The most frequent reasons for this were potentiallyunstable lab results (for example patients on anti-coagulants and not yet fullycontrolled) and patients admitted with respiratory problems who were stillexperiencing some shortness of breath in the 12 hour period prior to discharge.This study did not investigate any of the issues surrounding patient outcomes withearly discharge or alternate levels of care, but there is no doubt that individualinstances of inappropriate discharge do occur and this can be viewed as a positiveindication for using formal appropriateness monitoring and discharge screeningtools. It may be noted from the Manitoba study ref 4 that no relationship wasfound between early discharge and subsequent increase in readmission rates orother adverse events. Decision support tools can address physicians' concernsabout inappropriate early discharge in addition to the issue of inappropriatehospitalization.Implications for Utilization Management in Hospitals and RegionsThe limitations of this study have been clearly stated above, but even accepting amargin of error and large variations across the province it must be accepted that- 26-there is a problem here that needs to be addressed. The exact proportion ofinappropriate hospital admissions is debatable but there can be no question that asignificant proportion of such patients exists . In other words there are patientscurrently using acute hospital resources that would be better served either in analternate facility and outpatient setting or at home with the necessary support.A more detailed analysis of the available health care services in each region willbe necessary to assess the availability of the alternate levels of care suggested inthis study. The results certainly suggest that, rather than more acute hospital beds ,what is required is a more coordinated planning approach to the provision of allthe various types of care that patients require. It is unlikely, at least in the shortterm, that any major cost savings can occur. There are likely to be capitalinvestment needs in providing the adequate outpatient, home based and revisedinstitutional services that would fit the patients' needs better.In redefining care settings, there is also likely to be difficulty with traditionalprofessional roles and with patient acceptance. The message that "hospitals donot equal health care" ref 11 is not yet well understood by the public or indeedmany health care professionals, who may react to any attempt to transferresources from the hospital sector to any other part of the system with warnings ofdire danger to patients. The provision of adequate and quality health care servicesand programs must be emphasized rather than the maintenance of acute carehospital beds as a goal in itself.There are many components to an effective utilization management program forhospitals but one of the most important is the evaluation of admissions andlengths of stay. There are now several proprietary tools available for thisincluding the InterQual ISD instrument (appendix A, the instrument used in thisstudy), the medical care appropriateness protocol (MCAP), and guidelines- 27 -produced and marketed by several other groups. It is also possible to custom­build decision support tools of this type locally, but this is enormously expensivein time and resources and requires skills in critical appraisal, facilitation andanalysis that may not be available in every local setting. The ideal admissionreview is carried out prospectively, for example in the Emergency room and in thebed booking office, but a concurrent process also enables physicians and hospitalmanagers to work on the areas requiring most attention. Within a trulyregionalized system which is currently developing in Prince Edward Island, thiskind of analysis becomes especially important in view of the potential, whichnever existed before, for regional authorities to make decisions about moreappropriate resource allocation across the whole spectrum of health care services.The findings of this and all the other similar studies tend to cause high levels ofanxiety among health care providers because of the potential implications forreconfiguration of resources within the health care system. This is fullyunderstandable in human terms and there are very legitimate concerns about thepossible consequences of transferring the responsibility for care from the acutehospital sector to other alternatives without careful detailed and stepwise planningto ensure that patients are well served. However, these studies demonstrate thatthe emphasis must be on health care services and programs rather than hospitalbeds. This presents a major public relations challenge as the news media, thepublic, and the health care professions still tend to react very negatively to anyhospital bed restrictions even if equivalent programs to match patientsrequirement are provided.Implications for Health Care System PlanningAll of the patients reviewed in this study required health care. The question iswhere and in what kind of setting the most appropriate health care for thepatient's needs can be provided. The findings carry important implications for the- 28-planning of health care services, facilities, and programs. Acute hospitals arestaffed and resourced for a relatively high level of service and it is clear that thesefacilities are currently being used in many cases for patients that could be safely,adequately, and probably less expensively managed in alternative settings. Someof the potentially useful alternative settings do not presently exist in the Canadiansystem. For example, the "subacute" care level, the "skilled nursing facility"level and facilities especially designed for simple professional observation do notcurrently exist. All of these levels are currently absorbed within the acute hospitalsetting, whereas more specific designations ofthese other levels permit lowerlevels of staffing and resources to be specifically planned.Examination of Tables 5, 6 and 9 enables a calculation of the total number ofhospital bed days in acute hospitals at present that could potentially be transferredto alternate settings.Assuming around 9,000 "eligible" patients for this study with a mean length ofstay of 9 days, then even if one half of the potentially transferrable days could berealized there would be 0.5 x 0.73 x 9,000 x 9 = 29,565 bed days (equivalent toabout 90 hospital beds with 90% occupancy) that could be redirected for moreappropriate care levels. These bed days represent a large pool of resources thatare not currently used in the most appropriate way possible.This study strongly suggest that the acute care hospital facilities availablethroughout Prince Edward Island are no longer ideally matched to actual patientneeds with all the recent changes that have occurred in technology, diagnosticfacilities, outpatient treatment programs and home care. Regional governingsystems permit all of these options to be regarded as a whole for the first time inour health care history. This in turn encourages ministries of health and- 29-governing authorities to move towards integration of patient's health carerequirements with more appropriate use of all the available resources.- 30 -• RecommendationsThe results of this study suggest that steps could be taken in Prince Edward Islandto reconfigure some of the available resources in the health care system. Therecommendations that arise can be considered in two main categories, namelysuggestions for utilization management initiatives and suggestions related toplanning the system as a whole. In view of the Ministry of Health's role and thedevolving authority to regional boards, some recommendations will be of priorityinterest to the Ministry of Health and others to the Regional Authority's hospitalmanagers and care providers, although they are intended for all those involved inhealth care in the province.For consideration by the Ministry of Health1. It is recommended that provincial health care planning address the need forenhanced access to alternate levels of care as a priority rather than acutehospital beds. More rigorous health care system wide planning is requiredmore urgently than any increase in in-hospital resources.2. It is recommended that planning for the future configuration of health careresources address the need for ambulatory care facilities and diagnosticservices, home based care, and institutional levels of care such as observationand lower acuity nursing in designated units.3. It is recommended that the Ministry and Governing Authorities ensure thatadequate alternate means of care are available before making decisions thatwould affect current access to acute hospital facilities.4. It is recommended that the Ministry in collaboration with the RegionalAuthorities initiate a province wide process for the increased development ofutilization management activities.- 31 -5. It is recommended that utilization review and management be encouragedthroughout the hospital sector by the application of appropriate financialincentives and targets for activities and outcomes.6. It is recommended that the Ministry ofHealth develop a public education planto inform the public about the full spectrum of services and programs thatconstitute modern quality health care in order to deal with the publicperception that many of the health care services currently provided inhospitals cannot be safely reconfigured.For consideration by the Regional Authorities, hospital managers and healthcare providers7. It is recommended that utilization review and management activities bestrongly encouraged and incentivized in the region's hospitals.8. It is recommended that plans be developed for the application of validutilization management tools on a concurrent basis for in-hospital patients.9. It is recommended that formal discharge planning processes be developed (orenhanced if already in place) in all hospitals.10. It is recommended that consideration be given to the appointment of medicalunit managers and emergency triage officers who would have theresponsibility for monitoring hospital admissions and recommending reviewwhere appropriate.11. It is recommended that the availability of appropriate alternate levels of carelocally be examined and that regional planning groups be established withMinistry ofHealth collaboration to recommend what changes should be made.12. It is recommended that the availability of outpatient diagnostic services beexamined in detail to assess how greater capacity there could provide thenecessary services required by many patients currently occupying hospitalbeds.- 32-REFERENCES1. Statistics Canada, 19972. Guide to Canadian Health Care Facilities, 1997-1998, Canadian Health CareAssociation, Ottawa3. Health Services Utilization & Research Commission of Saskatchewan. Barriers tocommunity care final report, November 1994.4. DeCoster C, Peterson S, Kasian P. Alternatives to acute care. Manitoba centre forhealth policy and evaluation report, July 1996.5. Wright C.J., CardiffK, Kilshaw M. Acute Medical Beds: How are they used inBritish Columbia? Centre for health services and policy research, University ofBritish Columbia 1997, HPRU 97:7D.6. Joint Policy and Planning Committee (Ontario). Non-acute hospitalization project(adult) final report, 1997. Ref: RD6-3.7. Calgary Regional Health Authority. Concurrent review project-Rockyview Hospitalproject progress report, May 1998.8. CardiffK, Sheps S, Thompson D. "To be or not to be" in hospital: a new approach toan old problem. Centre for Health Services and Policy Research, University ofBritish Columbia, 1996: HPRU 96: lID9. Shortell SM, Richardson WC. Health Program Evaluation, 1978, CV Mosby Co.10. Strumwasser I, Paranjpe DL, Ronis D et al. Reliability and validity of utilizationreview criteria. Medical Care 1990; 28:95-11111. Editorial. Globe and Mail, February 26, 1997, page A22Tables- 33 -Table 1: Description of Sample SizeTable 2: Description of Study SampleTable 3: Description ofLocation From Which Patient Was AdmittedTable 4: Description ofPatient Entry to HospitalTable 5: Patients Matching Criteria at the Time ofAdmissionTable 6: Patients Not Meeting Criteria at the Time ofAdmission:Description of Severity of Illness (SI) and Intensity of Service (IS)CriteriaTable 7: Alternate Levels of Care Assigned to Patients Who Did Not MeetCriteria at the Time of AdmissionTable 8: Alternate Levels of Care Assigned to Patients Who Did Not MeetCriteria at the Time of Admission: Detailed Description of'Outpatient Care'Table 9: Average Length of Stay (LOS) Described by Criteria Match at theTime ofAdmissionTable 10: Patients Matching Criteria at the Time of Admission: Described byAge Group and Route of Admission- 34 -The Utilization of Acute Care Medical Beds in Prince Edward IslandTable 1: Description of Sample SizeHospital SitesAcute CareBed Numbers(1997)Adult MedicalSeparations (1997) Sample SizeProportion of TotalNumber of AdultMedical Separations(1997)Queen Elizabeth Hospital 274 4,189 120 3%Prince County Hospital 112 2,279 100 4%Western Hospital 27 859 70 6%Kings County Memorial 30 1,031 70 7%HospitalCommunity Hospital 10 460 50 11%Souris Hospital 17 692 70 7%Stewart Memorial 4 199 40 20%HospitalTotal 474 9,709 520 NA- 35 -The Utilization of Acute Care Medical Beds in Prince Edward IslandTable 2: Description of Study SampleAge Group (years) (%) Gender (%)Hospital SitesAll Hospitals in Study SampleSampleSize51315-6040%61-7016%71-7512%76-8012%81-8511%86+9%Male Female44% 56%Queen Elizabeth Hospital 119 41% 15% 16% 7% 8% 13% 35% 65%Prince County Hospital 100 35% 20% 5% 13% 17% 10% 44% 56%Western Hospital 69 41% 9% 12% 19% 14% 5% 44% 56%Kings County Memorial 69 43% 18% 12% 10% 13% 4% 55% 45%HospitalCommunity Hospital 48 34% 21% 15% 9% 8% 13% 33% 67%Souris Hospital 70 44% 13% 11% 16% 7% 9% 51% 49%Stewart Memorial Hospital 40 43% 20% 12% 8% 5% 12% 45% 55%Total 515- 36 -The Utilization of Acute Care Medical Beds in Prince Edward IslandTable 3: Description of Location From Which Patient Was Admitted(number ofvalid cases=507)Location From WhichPatient Was AdmittedLocation To WhichPatient Was Discharged*All HospitalsLarge HospitalsSmall HospitalsHome Setting92%94%90%InstitutionalSetting8%6%10%Home Setting89%93%86%InstitutionalSetting11%7%14%Hospital 1 94% 6% 95% 5%Hospital 3 94% 6% 91% 9%Hospital 4 93% 7% 86% 14%Hospital 5 91% 9% 86% 14%Hospital 6 92% 8% 91% 9%Hospital 7 89% 11% 86% 14%Hospital 8 88% 12% 85% 15%* 6% ofpatients died in hospital and were not included in the analysis a/this variable- 37 -The Utilization of Acute Care Medical Beds in Prince Edward IslandTable 4: Description of Patient Entry to Hospital(number ofvalid cases=152)Route of Admission to HospitalPhysician's Office Emergency DepartmentAll Large HospitalsHospitallHospital 324%28%19%76%72%81%- 38 -The Utilization of Acute Care Medical Beds in Prince Edward IslandTable 5. Patients Matching Criteria at the Time of Admission(number ofvalid cases=492)Admission ReviewHospitalsAll HospitalsLarge HospitalsSmall HospitalsSample Size492214278Proportion of PatientsMeeting Criteria27%29%25%Proportion of PatientsNot Meeting Criteria73%71%75%- 39 -The Utilization of Acute Care Medical Beds in Prince Edward IslandTable 6: Patients Not Meeting Criteria at the Time of Admission:Description of Severity of Illness (SI) and Intensity of Service (IS) CriteriaAll HospitalsCriteria MetCriteria Not MetLarge HospitalsCriteria MetCriteria Not MetSmall HospitalsCriteria MetCriteria Not MetCriteria MetSI & IS met (0%)SI not met & IS met (4%)Criteria MetSI & IS met (0%)SI not met & IS met (5%)Criteria MetSI & IS met (0%)SI not met & IS met (3%)Criteria Not MetSI met & IS not met (37%)SI not met and IS not met (59%)Criteria Not MetSI met & IS not met (37%)SI not met and IS not met (58%)Criteria Not MetSI met & IS not met (37%)SI not met and IS not met (60%)- 40-The Utilization of Acute Care Medical Beds in Prince Edward IslandTable 7: Alternate Levels of Care Assigned to PatientsWho Did Not Meet Criteria at the Time of Admission(number ofvalid cases = 361)All Hospitals Large Hospitals Small HospitalsNo Care 0% 0% 0%Outpatient 86% 93% 81%Home-Based Care 16% 14% 17%Non-Acute Institutional Care 2% 1% 2%Hospice 5% 9% 3%Addiction Services 2% 0% 3%Mental Health Services 6% 3% 8%Rehabilitation Services 2% 3% 2%Observation 45% 50% 42%Local Accommodation 0% 0% 0%Convalescent 2% 1% 3%Special Units 1% 1% 0%- 41 -The Utilization of Acute Care Medical Beds in Prince Edward IslandTable 8: Alternate Levels of Care Assigned to Patients Who Did not Meet Criteriaat the Time of Admission: Detailed Description of 'Outpatient Care'CombinationIV Physician of OutpatientLaboratory Imaging EKG Medications Consult Care(n) (n) (n) (n) (n) (n)All HospitalsLargeHospitalsSmallHospitals22198123170967423518411427109416814113- 42-The Utilization of Acute Care Medical Beds in Prince Edward IslandTable 9: Average Length of Stay (LOS) Described by Criteria Match at the Time of Admission(number ofvalid cases=490)Met Criteria (n=130) Criteria Not Met (n=360)Mean LOS Median LOS Mean LOS Median LOS(days) (days) (days) (days)Ali Hospitals 9 6 9 5Large Hospitals 10 7 9 5Small Hospitals 7 5 8 4Small Hospitals(n=275)- 43 -The Utilization of Acute Care Medical Beds in Prince Edward IslandTable 10: Patients Matching Criteria at the Time of Admission:Described by Age Group and Route of Admission(number ofvalid cases=489)All Hospitals Large Hospitals(n=489) (n=214)Age GroupMet Criteria 15-60 yrs 26% 27% 26%61-70 yrs 33% 39% 27%71-75 yrs 26% 36% 19%76-80 yrs 16% 10% 20%81-85 yrs 28% 30% 26%86+yrs 28% 36% 18%Criteria Not Met 15-60 yrs 74% 73% 74%61-70yrs 67% 61% 73%71-75 yrs 74% 64% 81%76-80 yrs 84% 90% 80%81-85 yrs 72% 70% 74%86+yrs 72% 64% 82%Route ofAdmissionMet Criteria DirectIndirectnJanJa30%30%nJanJaCriteria Not Met DirectIndirectn1anJa70%70%n1anJa- 44-FiguresFigure 1: Diagnostic Categories Based on "Most Responsible" DiagnosisFigure 2: Diagnostic Categories Based on "Most Responsible" DiagnosisFigure 3: Proportion ofPatients Meeting Criteria at Time ofAdmission:Described by "Most Responsible" Diagnostic CategoryFigure 4: Proportion ofPatients Who Met Criteria for ContinuedHospitalization "Post Admission" ReviewFigure 5: Proportion ofPatients Who Met Criteria for ContinuedHospitalization "Post Admission" Review: Described by Size ofHospital- 45 -Figure 1: Diagnostic Categories Based on "Most Responsible" Diagnosis(number ofvalid cases=493)~'3 !t ~ 0:; ] .., 00- ! .~ r::0 ~U ~ r~i:l s.9:l; U ~'"w,£; g E E Ii g. ~ f ~~ ~ N' £ ~"~ ~~~ 60 ~'t ~ »'" » ~~ i '" " r.n ~ "':!)'il !!. a ~ ~e 3'5 !-S ::> "OJ '" C u o - W se~O ~ t " is '2OJ *- <3Diagnostic Categories100 .,-- - - - - - - - - - - - - - - - - - - - - - - - ---- - - - - - - ---,9O-t--- --- - ------ - - - - - - - - - - - ------------t80 -j--- - - - - - - - - - - - - - - - - ------- - - - - - - ------f70 -t-- - - - - - - ---- - - - - - - - - - - - - - - - --- - - - ---t6O +--- ------- - - - - - - - - - - - - -------------j% 50 +--- - - - ------ - - - - - - - - - - - --------------j4O +-- - - - - - - - - - - - ------ - - - - - - - - - - - - - ----t30 +-- - - - - - - - - - - - - - - - - - - ----------------t20 -1-- - - - - - - - - - - - - - ­10 -1- - - - - - - - - - - - - - - -O -l---J=~-=~+___£=_+_-'"_<~~_+_.=~-I:=-_t_=l_.+_Figure 2: Diagnostic Categories Based on "Most Responsible" Diagnosis(number ofvalid cases=493)EILarge fus pitats• Small Hospitals100,-- -------------------========~-_____,9O -t-- - - - - - - - - - - - - - - - - - - - - - - - - ---------180 -1---- - - --- ----- - - - - - - - ----- - - --- - - -470 -1-- - - - - - - - - - - - - - - - - ------- - - --------16O -t--------- - - - - - - - - - - - - - - - - - - - - - - - - --1% 50 +-- - - - - - - - - - - - - - - - - - ---- - - - - - ------ ----i4O -t-- - - - - - - - - - - - - - - - - - - - ------ - - - - - - --130 -1- -- --- - --- - - - - - - - - - - - - - - - - - -------120 -j--- --------- - - - ­1O -t-- -o-!-'"--L..<-~ ~ L ,£; ! ! E E E ~ ~ u ~ 0~ " t £ ~ 'g 0 s1 <l: :; '" ~ '" ~ ... ~ ~ i~ g ~ ; ~ 0. ii ::> 18 '"z 6 o s s~ ~ .s '2 .9iii z <3Diagnostic Categories- 46-Figure 3: Proportion of Patients Meeting Criteria at Time of Admission: Described by"Most Responsible" Diagnostic Category• CriteriaNotMet1:::1 MelCriteria10090807060% 50403020100.j-Jt=l-t--=::i-+-J:=L-+--'=:l-t-l::=1...-t-I:1 s r -s I ~ a a ~ a 01 ~ ~ a:il ~~ 1l !:. It It !i!. ., li !.d :z: <II '" '" .,0 <II <II .,iil5' ~ ~ . ~ '" li J )a jz I ~ .~ <II;g ~ u a"'eDiagnostic CategoryFigure 4: Proportion of Patients Who Met Criteria for Continued Hospitalization'post admission' Review• CriteriaNotMetEIMel Criteria10090807060% 5040302010o1 2 3 (n=84) 4 (n=64) 5 (n=48) 6 (n=42) 7 (11=26) 8 (11=15) 9 (n=13) 10 (11=9) II (n=7) 12 (n=6)(n=I46) (0=112)Day 'post admission'- 47-Figure 5 Proportion of Patients Who Meet Criteria for Continued Hospitalization'post admission' Review: Described by Size of Hospital"Small" Hospital Group• Criteria Not MetIilII Met Criteria123 456(0=63) (0=49) (0=32) (0=23) (0=13) (0=11)1009080~7060--%_. ],50 - < -- r403020100Day 1 2 3 4 5 6(0=60) (0=55) (0=47) (0=39) (0=33) (0=29)"Large" Hospital Group- 48-Appendix AInterQual Criteria Development Revision ProcessDevelopment ProcessISD criteria development begins with a Clinical Product Development Team. This teamconsists of a physician or nurse Project Manager, InterQual's staff physicians and nurses,and a network of physician consultants in the field. These consultants include bothgeneralists and specialists and represent a national panel of experts from both academicand community-based practice. When InterQual identifies an area for which the marketneeds objective, clinical criteria, the product development team prepares an initial draft ofthe criteria based upon input from the generalist and specialist consultants, as well asfrom review of existing guidelines and medical literature. These versions are thenreviewed, revised to incorporate validated feedback, and re-reviewed in an iterative,consensus-building process . Areas where agreement cannot be reached areacknowledged, and an explanation is provided for the stance that has been chosen.Detailed notes and references provide the clinical rationale for criteria decisions. We alsocite all relevant literature references in the "notes" section of the criteria, which makethem an educational tool for the nurse and physician reviewer.Revision ProcessThe clinical development team remains in place and immediately begins to update thecriteria based on clinical advances and medical text references. Medical literature isreviewed on an ongoing basis and the references in the criteria are updated. The need forstructural and/or functional improvements is addressed as well. InterQual continuallysolicits feedback and input from customers, as well as consultants. The process ofcriteria revision is ongoing.- 49-Appendix BComparison of Study Population with Study Sample (Mean Length of Stay & Gender)Hospital Mean LOS (days)Population SampleGenderPopulationMale FemaleSampleMale FemaleQueen Elizabeth Hospital 11 11 45% 55% 35% 65%Prince County Hospital 9 8 48% 52% 44% 56%Western Hospital 7 8 42% 55% 44% 56%Kings County Memorial Hospital 10 10 46% 54% 55% 45%Community Hospital 9 8 36% 64% 33% 67%Souris Hospital 8 8 45% 55% 51% 49%Stewart Memorial Hospital 11 9 44% 56% 45% 55%- 50 -Appendix CReliability TestingDesigned to be used by non-physician reviewers, the ISD tool is straightforward and easyto use, and when applied by well trained reviewers, has been shown to be reliable andvalid (Strumwasser, Parnjpe, Ronis, Share and Sell, 1990).The two registered nurses collecting the data were trained in the application of the ISDcriteria. One of the nurse reviewers had substantial involvement in other similar studiesconducted throughout the country (Health Services and Utilization Review Commissionstudy; British Columbia Ministry of Health study and numerous small-scale studiesundertaken by the Centre For Health Services and Policy Research, at the University ofBC). This reviewer took responsibility for monitoring the data collected by the othernurse. In particular spot-checks were undertaken (every 5th record was checked) to ensurethat the data collection remained consistent and complete.In addition, considerable attention was given to establishing inter-rater reliability, prior tobeginning the data collection for this study. The kappa scores obtained indicated "verygood" agreement between the two nurse reviewers. The inter-rater reliability of the nursereviewers ranged from kappa 0.70-0.90. 1I The kappa statistic measures the level of agreement between two independent reviewers and corrects forchance agreement. If there is perfect agreement the kappa=l ; ifthere is no agreement (i.e. equal to chanceagreement) the kappa=O. The kappa scores obtained in this study indicate a "very good" level ofagreement between reviewers .- 51 -Appendix DAlternate Levels of Care (adapted from the ISD criteria)No Immediate Careassigned to patients who could be at home without the need for care within the next 48hours or who have refused treatmentOutpatient Servicesassigned to patients receiving therapeutic or diagnostic tests or procedures that could beaccomplished on an outpatient basis and to those requiring IV medications or"immediate" follow-up with a physicianHome-Based Care (Professional Services)assigned to patients who require home care including at least one of the following:• nursmg care• physical, occupational, respiratory services, or speech therapy• social servicesHome-Based Care (Support Services)assigned to patients who require home care including at least one of the following:• homemaker/home health aide• nutritional support servicesNon-Acute Institutional Careassigned to patients who require care in one of the following settings:• personal care home• intermediate care facility• extended care facility51- 52-Hospiceassigned to patients who are terminally ill (life expectancy less than 6 months) andrequire palliative/supportive management of the primary illness and related conditionsprovided by an interdisciplinary team including:• physician• registered nurse• physical, occupational, or speech therapist• social worker• pastor or bereavement counselorAddiction Servicesassigned to patients who require treatment for substance abuseMental Health Servicesassigned to patients who require treatment for mental health problemsRehabilitationassigned to patients who require a multidisciplinary, formalized rehabilitation programObservationassigned to patients who require close observation for a limited period of time, such asthose who:• require short term observation to determine if admission is necessary• require observation to "play it safe" following emergency departmentevaluation(the level of observation required would depend on a host of factors, including thepatient's age, co-morbidities, the quality of social support structures available in thepatient's home and proximity to hospital)52- 53 -Local Accommodationassigned to patients who require lodging close to hospital but do not require admission,such as those who:• receive daily outpatient therapies• require frequent transportation and who live long distances from thehospital, and for whom transportation is not available• receive daily chemotherapy or radiation therapy and do not requireprofessional observation• require therapeutic or diagnostic tests or procedures that could beaccomplished on an outpatient basis, but where the travel time from thepatient's residence to the hospital is significantConvalescentassigned to patients who require care following an illness or have been transferred froman acute care facility (at a higher level)Special Programassigned to patients who require monitoring related to adjustment of medications (e.g.,management of headaches, seizure disorder, movement disorder; chronic pain)53- 54-Appendix EISO Criteria: Example from Respiratory SystemRespiratory/ChestSeverity of IllnessRuleONE:Elective Surgery/Invasive procedure, both:Scheduled same day as admissionDesignated inpatient setting2:ONE SI2:..THREE marginal SIClinical Findings(Recent Onset)Dyspnea and three:Change in mental status/consciousnessRaleslRhonchilWheezinglStridorAccessory muscle breathingRespiratory rate 2:24/minDistended neck veinsHeart rate ~ 100/minSputum smear/culture (+) for bacteria/fungi/protozoaDisseminated malignant disease and one :Renal dysfunction (BUN> 25 mg/dL (8.9 mmoUUCreatinine> l.5mgldL (133 umol/L)CHF/Liver diseaseDebilitationAdverse effects of chemotherapy anticipated, 2: one :Hemmorrhagic cystitisAcute renal failureDisseminated intravascular coagulationTumor lysisT2:40.0 CT 2:38.9 C and one:WBC 2: 18,OOO/cu.mrn (l8x109/L)WBC 2: l5,000/cu.mrn (l5xl09/L) with ~ 7% (0.07)bandsT z 38.1 C and one:Absolute neutrophil count 5 500/cu .mm (5.00x 106/L)WBC 5 l,500/cu.mrn (1.5xI09/L)Imaging Findings(Newly Discovered)HemothoraxPneumothorax ~ 15% (0.15)Pulmonary edema/Heart failureFree air in mediastinumPulmonary infiltrates ~ 2 lobesPulmonary infiltrate and one :Absolute neutrophil count 5 500/cu.mm (500XI06/L)O2SAT 589% (0.89)Pulmonary embolus/infarctLaboratory Findings(Newly Discovered)Blood GasesO2SAT 589% (0.89) with dyspneaArterial p02 5 59 mmHg (7.9 kPa)Arterial pC02~ 51 mmHg (6.8kPa)Arterial pH 5 7.30Arterial pH 2:7.50HematologyHct518% (0.18)Hct 5 30% (0.30) and one:DyspneaPostural systolic BP drop 2:30Platelets 5 60,OOOcu.mm (60xI09/L) and one:ThrombosisPulmonary BleedingPT ~ 1.5x ULN (INR 2.0-3.0) and bleedingAPTT 2: 1.5x ULN and bleedingMicrobiologyBlood smear/culture (+) for bacteria/fungi/protozoaIntensity of Service(see Treatments/MedicationsRuleONE:~ONEIS~THREE *ISTreatments/Medications(At Least Daily)Post surgery/procedure care ~ 3d and ~ two:IV fluids ~ 100mUhIV/1M analgesicsIV/1M antiemeticsPost lung transplant care ~ 4dIV chemotherapy (cyclic) and ~ two:High dose/Multiple agentsIV fluid hydration ~ 3U24hIV/1M antiemetics s 4x124hChest tube to suctionIV anticoagulantsO2> 60% (0.60)*BIoodIBlood products*Cbest tube*IV fluids> lOOmLIb*Respiratory therapy, one:Medical gas managementNebulizerlMist!AerosolNon-rebreather mask*Medical gas management*Ventilator assistance*IV/Aerosol broncbodilators*IV11Mcorticosteroids> 3x124h*IVIIM diuretics> 2x124h*IVIIM analgesics> 4x124h*IVIIM antiemetics > 4x /24b*IV11M anti-infectives >3x124b- 55 -Respiratory/ChestDischarge Screens(see Discharge Indicators)RuleONE:Acute episode (SI) resolving/stabilized (apply relateddischarge indicators)End stage diseaseandONE:Care needs (*15) could be met at alternate levelTreatment refusedDiscbarge IndicatorsVital signs stable last 8hDyspnea relieved last 12h and all:WBC < 15,000/cu .mm (15x109/L)T < 38.ICHeart rate ~ 100/minRespiratory rate ~ 24/minO2 SAT> 89% (0.89)Ventilator dependent and blood gases/O, SATimproved/unchanged last 12hBlood gases/O, SAT w/in acceptable ranges last 12hVomiting controlledHematology values stable last 24h andbleeding controlledPneumothorax resolvingChest tube suction D/C'dInfection (signs, symptoms, labs) improvingPain controlled/manageableTheoph ylline level w/in acceptable rangePost surgery/procedure, all:Vital signs stable last 8hFluids toleratedVomiting controlledPain controlled/manageablePassing flatus/stoolVoiding/Passing urine- 56-Appendix FExamples of Patients Meeting CriteriaAge: 71 yearsGender: femaleAdmitted from homeDischarged to homeLength of stay: 5 daysDiagnosis: pneumonia; history of asthma, deafness and visual lossHistory: shortness of breath, productive cough yellow sputum and wheezeOlE : P 128; Resp 40; T378; dyspneic with wheezeOn admission received nebulized respiratory medications , O2 + oximetry monitoring, IV antibiotics Q8HAge: 74 yearsGender: femaleAdmitted from homeDischarged to homeLength of stay: 13 daysDiagnosis: hyponatremiaHistory: short of breath and weakOlE : dyspneicLabwork: Na 119; paz 56On admission received IV@ 100thour, O2 + oximetry monitoring, IV lasix BIDAge: 68 yearsGender: maleAdmitted from homeDischarged to homeLength of stay: 5 daysDiagnosis: epistaxis; history of hypertension and chronic lymphatic leukemiaHistory : history of surgery (nasal septop1asty) one week ago; was discharged six days ago and experiencedintermittent nose bleed after discharge 7 nasal packing + cautery performed; however, onset of brisk nosebleed three days later 7 came to OPD 7 balloon catheter inserted with anterior nasal packingOlE: brisk epistaxis in OPDOn admission received N antibiotics; IV ranitidine ; IV morphine (given x 4 within 24 hours) and 1Mgravo1 (given x 1 in 24 hours) ; IV @ 75thour; po meds (adalat)Age: 84 yearsGender: maleAdmitted from intermediate careDischarge Status : DeadLength of stay: 6 daysDiagnosis: influenza, pneumoniaHistory: shortness of breath with productive coughOlE: P 92; Resp 36; T398; dyspneic; distended abdomenImaging/Labwork: x-ray confirms consolidation LLL; blood culture -ve; sputum +ve growthOn admission received IV @100thour; IV zantac; IV lasix; IV gravol pm (not given); Oz + oximetrymonitoring; respiratory meds via nebulizer- 57-Age: 70 yearsGender: femaleAdmitted from homeDischarged to homeLength of stay: 13 daysDiagnosis: seizure; ?? CVA; history of previous CVAHistory: complain of weakness in face, arm and leg; patient seizuringOlE : seizure on admission to emergency room; toes up-goingImaging: CT brain shows subdural hematoma (uncertainty re age oflesion)On admission: IV TKVO; IV valium xl; respiratory meds via nebulizer; morphine ordered (but notgiven); gravol ordered (but not given); post-CVA stabilizationAge : 71 yearsGender: femaleAdmitted from homeDischarged to homeLength of stay: 9 daysDiagnosis: acute exacerbation COPD; history of IHD and emphysemaHistory: complain shortness of breathOlE: P 62; Resp 28; T 38; dyspneic; wheezingLabwork: P02 47; PC02 42; electrolytes normalOn admission received O2 + oximetry monitoring; IV medications; respiratory meds via nebulizerAge: 83 yearsGender: femaleAdmitted from homeDischarged to homeLength of stay: 8 daysDiagnosis: pancreatitisHistory: sudden onset of abdominal pain , nausea and vomitingOlE: abdomen tender; no rebound tendernessLabwork: electrolytes normal; amylase 1605On admission received IV @ 125/hour; 1M demerol given x 4 (within 24 hours); 1M gravol given x 4(within 24 hours); NPOAge: 66 yearsGender: maleAdmitted from homeDischarged to homeLength of stay 14 daysDiagnosis: alcoholic DT's; hypomagnesia; history of hypertensionHistory: agitated, confused, drinking +++ for several days then stoppedOlE : patient agitated and confused; neuro vital signs within normallirnits; cardiovascular/respiratorysystem normal; BP 154/90Imaging/Labwork; Mg = .25; electrolytes normal; EKG: some changesOn admission received IV @ 50/hour; 1M thiamine x 3 days; 1M haldolAge: 62 yearsGender: femaleAdmitted from homeDischarged to homeLength of stay: 6 daysDiagnosis: pyelonephritisHistory: history of urinary tract infection -7 ran out of medications and developed chills, rigors, headacheOlE: T 39 1; Labwork: blood culture +veOn admission received IV @ 100/hour; IV ampicillin Q6H; IV gentamycin OD; 1M stemetil Q6H- 58 -Age: 94 yearsGender: femaleAdmitted from personal care homeDischarged to personal care homeLength of stay: 9 daysDiagnosis: respiratory infection; congestive heart failure; history of IHDHistory: flu-like illness -) was treated with antibiotics but is deteriorating with increasing shortness ofbreath and complains of epigastric painOlE: P 72; Resp 28; wheezing; chest - decreased air entry to bases with ralesOn admission received O2 + pulse oximetry monitoring; respiratory meds via nebulizer; IV antibiotics Q6HAge : 57 yearsGender: femaleAdmitted from homeDischarged to homeLength of stay: 2 daysDiagnosis: chest pain NYD; history of hypertensionHistory: sudden onset chest pain with palpitations; sweaty and short of breathOlE: P 68; Resp 24; afebrile; BP 200/110; pulse later decreased to 30-68Imaging/Labwork; EKG - occasional PVC with increased PR interval; WBC normal; electrolytes normalOn admission put on cardiac monitor; O2 with pulse oximetry; IV morphine; nitro ; ASA; 'rule-out MI'protocolAge: 20 yearsGender: femaleAdmitted from homeDischarged to homeLength of stay : 2 daysDiagnosis: acute pharyngitis; pneumonitis; tachycardia NYDHistory: complain right sided chest pain and sore throat; history of palpitationsOlE : P 116; Resp 20; T 382; BP 90/60; pharynx red; cervical nodes enlarged and tender; chest - no rales orrhonchi; abdomen NADImaging/Labwork: CBC normal; EKG: abnormal sinus tachycardia with evidence of inferior infarcts(newly discovered)On admission received IV @ 1251hour; IV antibiotics Q6H; 1M analgesia; patient on cardiac monitorAge: 68Gender: femaleAdmitted from homeDischarged to homeLength of stay : 5 daysDiagnosis: acute exacerbation COPD; history of Ca lungHistory: patient deteriorating; coughing ++ -- has been on oral antibiotics @ homeOlE: debilitated; scattered rales and rhonchi; Resp 30; P 128; BP 120170; abdomen normalOn admission received IV @ 1001hour; respiratory meds via nebulizer; IVantibiotics Q8H- 59-Appendix GExamples of Patients Not Meeting CriteriaPatient did not meet 51 or IS criteriaAge: 31 yearsGender: femaleAdmitted from homeDischarged to homeLength of stay: 4 daysDiagnosis: herpes simplex virus; urinary retentionHistory: rash in perineal area x several days 7 herpes simplex infection of genitalia; painful voiding andsome urinary retentionOlE: herpes simplex infection genitalia; vital signs normalOn admission: foley catheterization pm; treated with zovirax cremeRecommended alternate levels of care:Physician consultHome-Based CarePatient did not meet 51 or IS criteriaAge: 52 yearsGender: maleAdmitted from homeDischarged to homeLength of stay: 10 daysDiagnosis: MVA with # ribsHistory: MVAOlE: P 68; Resp 20; BP 144/92; hematoma legImaging/Labwork: EKG normal; C-spine x-ray normal ; chest x-ray -- no evidence of pneumothorax but #ribs; urinalysis normal ; electrolytes normal, CBC normal, Hgb normal, O2 gases normalOn admission received IV TKVO; ice packs; physio ; DAT; AAT; IV morphine x 3 then tylenol #3Recommended alternate levels of care:ObservationOutpatients (imaging , labwork, physician follow-up)Patient did not meet 51 or IS criteriaAge: 54 yearsGender: femaleAdmitted from homeDischarged to homeLength of stay: 5 daysDiagnosis: burns to right hip and leg; history of cerebral palsyHistory: burns to hip and right legOlE: 2° burn involving 5-7% of right leg and hip area; vital signs normalOther comments: 'admitted because patient is wheelchair bound and lives alone' (history cerebral palsy)On admission received DAT; AAT; daily dressing changes with flamazine ungt; medications PORecommended alternate levels of care:Outpatients (physician consult)Home-Based Care- 60-Patient did not meet SI or IS criteriaAge: 77 yearsGender: femaleAdmitted from homeDischarged to homeLength of Stay: 8 daysDiagnosis: gastroenteritis; history of arthritisHistory: 'flu-like' illness for two days with complaints of fever, chills , nausea and some diarrheaOlE: Pulse 58; Temp 366; Resp 20Imaging/Labwork: x-ray no evidence of heart failure or consolidation; electrolytes normal; hct .305Other comments: 'because of her age and infirmity she was kept for a number of days' (lives at home withelderly husband and handicapped child)On admission received IV @ l25lhour and IV antibiotics Q6H; gravol was ordered but not givenRecommended alternate levels of care:ObservationOutpatient CareHome-Based CarePatient did not meet SI or IS criteriaAge : 23 yearsGender: maleAdmitted from homeDischarged to homeLength of stay: 5 daysDiagnosis: migraine headacheHistory: persistent headache x 10 days with vomiting; history of migraines and history of seizuresOlE : Pulse 70; BP 122/56; Temp 36Imaging/Labwork: MRI normal; electrolytes normal, CBC normalOther Comments: 'because of his severe pain, patient was admitted'On admission received IV @ l50lhour; Decadron IV TID ; demerol and gravol ordered but not givenRecommended alternate levels of care :ObservationOutpatients (labwork and imaging)Patient did not meet SI or IS criteriaAge: 25 yearsGender: femaleAdmitted from homeDischarged homeLength of stay: 9 daysDiagnosis: irritable bowel disease, crohns diseaseHistory: history of crohns disease, some recent weight lossOlE: P 85; Resp 18; T 374 ; BP 127/50 ; bowel sounds normal; no rebound tendernessLabwork: WBC 17.69; electrolytes normalOther comments: 'symptoms today seems more like irritable bowel or spastic bowel, but patient is unableto cope at home and needs to be admitted for further evaluation and treatment.. ...she loves narcotics and onthis occasion it was no different'On admission received 1M demerol x 4 (within 24 hours) and 1M gravol x 4 (within 24 hours)Recommended alternate levels of care :Outpatients (labwork, imaging, physician consult)- 61 -Patient did not meet 51 or IS criteriaAge: 61 yearsGender: maleAdmitted from homeDischarged to homeLength of stay: 28 daysDiagnosis: acute pneumonitis; history of COPD; chronic alcoholicHistory: complain of cough and shortness of breathOlE: Chest (decreased air entry) with some rhonchi; no cyanosis; P 100; Resp 22; BP 100/80;cardiovascular system NAD; abdomen NADImaging: chest x-ray - no acute disease observedOn admission received IV @ 75/hour; IVantibiotics Q6H; respiratory meds via nebulizer; patient up andabout the ward with no limitation of activity and diet taken wellRecommended alternate levels of care:Outpatients (imaging; physician consult; IV medications)Patient did not meet SI or IS criteriaAge: 50 yearsGender: femaleAdmitted from homeDischarged to homeLength of stay: 6 daysDiagnosis: acute bronchitis; gastric motility disorderHistory: complain of cold symptoms; nausea and decreased oral intakeOlE: pale, slightly dehydrated, P 96; Resp 16; BP 90/62; T 37; chest - some decreased air entry to bothbases with rhonchi; abdomen normal; cardiovascular system normalLabwork: electrolytes normal; WBC normalOn admission received IV fluids; patient eating and drinking well at the time of admission to hospitalRecommended alternate levels of care:Outpatients (lab; physician consult)Patient met SI criteria but did not meet IS criteriaAge: 17 yearsGender: femaleAdmitted from homeDischarged to homeLength of stay: 4 daysDiagnosis: pyleonephritisHistory: left flank pain with fever and malaiseOlE: left flank pain; Temp 389Labwork: electrolytes normal; WBC 12.07On admission received IV @ 100/hour; IVampicillin Q6H; analgesia PORecommended alternate levels of care:Outpatients (Iabwork, physician consult, IV medications)- 62-Patient met SI criteria but did not meet IS criteriaAge: 62 years of ageGender: femaleAdmitted from homeDischarged to homeLength of stay: 7 daysDiagnosis: COPDHistory: increasing shortness of breath x 3 days; abdominal pain with diarrhea, wheezingOlE: P 105; Resp 28; T374; wheezing; dyspneic; mild abdominal tenderness (RUQ)Labwork: electrolytes normal; CBC normal; urinalysis normalOn admission received IV TKVO; DAT; AAT; nebulizer respiratory medications; 1M gravol given x 4(within 24 hours)Recommended alternate levels of care:ObservationOutpatients (imaging; labwork)Patient met SI criteria but did not meet IS criteriaAge: 71 yearsGender: femaleAdmitted from homeDischarged to homeLength of stay: 6 daysDiagnosis: wound infectionHistory: history of surgery (in situ composite graft involving his leg) two weeks ago - discharged fromhospital 6 days ago and has returned with wound infection; feels ill with chills; was not being treated athome with outpatient antibioticsOlE: P 68; Resp 18; T 36; Chest clear; abdomen NADLabwork: WBC 16; K 6On admission received IV cloxacillin QID; IVgentamycin OD; IV flagyl Q8HRecommended alternate level of care:Convalescent carePatient did not meet SI criteria but met IS* criteriaAge: 53 yearsGender: femaleAdmitted from homeDischarged to homeLength of stay: 10 daysDiagnosis: tic doulereauxHistory: complain of severe pain from her tic doulereaux; pain makes her nauseated and she has beenvomitingOlE : P 76; Resp 18; BP 138/79; Temp 366On admission received 1M demerol QID; 1M antiemetic QID; IV fluids @ 150/hourRecommended alternate levels of care:ObservationOutpatients

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