Assessing the necessity of hospital stay by means of the appropriateness evaluation protocol: a different perspective

Factors associated with low-acuity hospital admissions in a public safety-net setting: a cross-sectional study

Background

Given system-level focus on avoidance of unnecessary hospitalizations, better understanding admission decision-making is of utility. Our study sought to identify factors associated with hospital admission versus discharge from the Emergency Department (ED) for a population of patients who were assessed as having low medical acuity at time of decision.

Methods

Using an institutional database, we identified ED admission requests received from March 1, 2018 to Feb 28, 2019 that were assessed by a physician at the time of request as potentially inappropriate based on lack of medical acuity. Focused chart review was performed to extract data related to patient demographics, socioeconomic information, measures of illness, and system-level factors such as previous healthcare utilization and day/time of presentation. A binary logistic regression model was constructed to correlate patient and system factors with disposition outcome of admission to the hospital versus discharge from the ED. Physician-reported contributors to admission decision-making and chief complaint/reason for admission were summarized.

Results

A total of 349 (77.2%) of 452 calls resulted in admission to the hospital and 103 (22.8%) resulted in discharge from the ED. Predictors of admission included age over 65 (OR 3.5 [95%CI 1.1–11.6], p = 0.039), homelessness (OR 3.3 [95% CI 1.7–6.4], p=0.001), and night/weekend presentation (OR 2.0 [95%CI 1.1–3.5], p = 0.020). The most common contributing factors to the decision to admit reported by the responding physician included: lack of outpatient social support (35.8% of admissions), homelessness (33.0% of admissions), and substance use disorder (23.5% of admissions).

Conclusions

Physician medical decision-making regarding the need for hospitalization incorporates consideration of individual patient characteristics, social setting, and system-level barriers. Interventions aimed at reducing unnecessary hospitalizations, especially those involving patients with low medical acuity, should focus on underlying unmet needs and involve a broad set of perspectives.

Improving performances of the knee replacement surgery process by applying DMAIC principles

RATIONALE, AIMS, AND OBJECTIVES

The work is a part of a project about the application of the Lean Six Sigma to improve health care processes. A previously published work regarding the hip replacement surgery has shown promising results. Here, we propose an application of the DMAIC (Define, Measure, Analyse, Improve, and Control) cycle to improve quality and reduce costs related to the prosthetic knee replacement surgery by decreasing patients' length of hospital stay (LOS) METHODS: The DMAIC cycle has been adopted to decrease the patients' LOS. The University Hospital "Federico II" of Naples, one of the most important university hospitals in Southern Italy, participated in this study. Data on 148 patients who underwent prosthetic knee replacement between 2010 and 2013 were used. Process mapping, statistical measures, brainstorming activities, and comparative analysis were performed to identify factors influencing LOS and improvement strategies.

RESULTS

The study allowed the identification of variables influencing the prolongation of the LOS and the implementation of corrective actions to improve the process of care. The adopted actions reduced the LOS by 42%, from a mean value of 14.2 to 8.3 days (standard deviation also decreased from 5.2 to 2.3 days).

CONCLUSIONS

The DMAIC approach has proven to be a helpful strategy ensuring a significant decreasing of the LOS. Furthermore, through its implementation, a significant reduction of the average costs of hospital stay can be achieved. Such a versatile approach could be applied to improve a wide range of health care processes.

Impacto de una intervención de autoevaluación clínica sobre la adecuación de la estancia hospitalaria

AIM

To assess the impact of an intervention on inappropriate hospital stays (IHS) in acute-care hospitals in Catalonia (Spain) with the aim of testing the hypothesis that a simple intervention (adeQhos) reduces the proportion of IHS.

METHODS

A pre-test/post-test study was performed through the <<adeQhos>> questionnaire. Two intervention groups (internal medicine and general surgery) and 2 control groups (other medical specialities, orthopedics) were compared in 10 acute-care hospitals in Catalonia. The same evaluators assessed appropriateness of hospital stays before and after the intervention, using the Appropriateness Evaluation Protocol.

RESULTS

A total of 1,594 pre-test stays and 1,495 post-test stays were reviewed. Of all the stays reviewed (day before discharge), 41.1% were inappropriate. The intervention was applied to 4,613 stays. There was a significant increase of IHS in the medicine control group (from 39.7 to 48.6%), and no decrease in the intervention groups (internal medicine [from 46.7 to 50.6%] or general surgery [from 27.2 to 31.2%]). The correlation between the intensity of the intervention and the difference in IHS before and after the intervention was r = -0.373 (p = 0.106). The intensity of intervention differed among the hospitals. In hospitals with an intensity of intervention > 60%, the proportion of IHS decreased by 10.7 points in internal medicine and by 4.8 points in general surgery, while the proportion of IHS increased in the control groups.

CONCLUSIONS

The prevalanece of IHS the day before discharge in the hospitals studied was high (41.1%). No significant decrease in IHS was observed after a low-intensity intervention.

Appropriateness of admission and length of stay in a Turkish Military Hospital

The purpose of this study was to determine the extent of inappropriate days of stay in a Turkish military hospital, and to explore the variables correlated with these. A review was made of the medical records of surgery patients admitted to the hospital of Gülhane Military Medical Academy. To determine the appropriateness of lengths of hospitalization, a Turkish version of the Appropriateness Evaluation Protocol (AEP) was applied retrospectively. A total of 375 patients'files were reviewed; and 21.3% of the hospital admissions were evaluated as inappropriate. Multiple logistic regression analysis showed that inappropriate length of stay was significantly increased with relation to age, emergency status, military rank, and distance from the hospital to the patient's home. The results of the study suggest that changes in physicians' behavior and in the organization of hospital activities may be effective in improving the quality and efficiency of hospital care.