Operating a Monitoring Unit in the Geriatric Department: Effects on Outcomes

Effect of a geriatric unit in the outcomes of hospitalized older Mexican adults with cancer: A case-control study

INTRODUCTION

Geriatric interventions may improve the care of hospitalized older adults with cancer, but information regarding their effect on geriatric-specific outcomes is lacking. We studied the effect of a specialized geriatrician-led inpatient geriatric management unit compared with a conventional internal medicine ward on the outcomes of hospitalized older adults with cancer in Mexico.

MATERIALS AND METHODS

Case-control study including persons aged ≥65 years with solid malignancies who had a cancer-related hospitalization at a university-affiliated hospital in Mexico City. Patients hospitalized in a geriatric unit (cases) were paired 1:2 with those in internal medicine wards (controls). Matching criteria included: age (+/- five years), tumor type (according to International Classification of Diseases [ICD]-10 code), and admission date (+/- three months). The association between being hospitalized in the geriatric unit on various outcomes was determined using conditional logistic regression models.

RESULTS

One hundred cases and 200 controls were included. Mean age was 75.3 years (standard deviation 6.4 years) and 53% had gastrointestinal tumors. No difference in median length-of-stay was found between cases and controls (9.0 days, vs. 9.5 days, p = 0.34). Hospitalization in the geriatric unit was associated with a reduced risk of delirium (odds ratio [OR] 0.18, 95% confidence interval [CI] 0.04-0.80). Being hospitalized in the geriatric unit was not associated with an effect on hospital-acquired complications (OR 0.83, 95% CI 0.47-1.45) or in-hospital mortality (OR 1.82, 95% CI 0.32-10.18).

DISCUSSION

Among older Mexican adults hospitalized for a cancer-related diagnosis, receiving care in a geriatric management unit was associated to a decreased risk of delirium, without influencing other outcomes.

Mechanical ventilation in medical departments: a necessary evil, or a blessing in bad disguise?

In most countries there is a mismatch between demand for intensive care unit (ICU) beds and ICU bed availability. Because of a policy of low ICU-bed reimbursement this mismatch is much more profound in Israel, which arguably has the lowest number of ICU beds/1000 population of OECD countries. Increasing demand for mechanical ventilation has led to an ever-rising presence of ventilated patients in medical departments, which may reach up to 15% or more of medical beds, especially during winter months, posing serious challenges such as: delivery of adequate treatment, guaranteeing patient safety, nosocomial infections, emergence and spread of resistant organisms, dissatisfaction among family members and medical and nursing staff, as well as enormous direct and indirect expenses.

This paper assumes that no change in ICU reimbursement will occur in the near future. We, therefore, describe a number of policy issues that should ideally be addressed together in order to cope realistically with the increase in mechanically ventilated patients in medical departments. First, all medical departments should operate a 5-bed augmented care room with one dedicated nurse per shift. Medical residents should receive a mandatory 3-month ICU rotation in their first year of residency, and attending physicians should receive adequate training in mechanical ventilation and vasopressor support, point-of-care ultrasound and central venous catheterization. Second, family physicians should be required to discuss and fill relevant forms with advance directives for elderly and/or chronically ill patients. Third, rules for terminal extubation should be established, even if only applied infrequently. Finally, co-payment should be considered for families of patients demanding all possible medical treatment in spite of contrary medical advice, considering these patients’ terminal status.

Implementation of these recommendations will require policy decision making in the Ministry of Health, Scientific Council of the Israeli Medical Association, the professional societies (for internal medicine and family practice) and finally by the leadership of individual hospitals.

Mechanical ventilation patterns and trends over 20 years in an Israeli hospital system: policy ramifications

Background

Mechanical ventilation is a life supporting modality increasingly utilized when caring for severely ill patients. Its increasing use has extended the survival of the critically ill leading to increasing healthcare expenditures. We examined changes in the hospital-wide use of mechanical ventilation over 20 years (1997–2016) in two Israeli hospitals to determine whether there were specific patterns (e.g. seasonality, weekday vs. weekend) and trends (e.g. increases or decreases) among various hospital departments and units.

Methods

Retrospective analysis of prospectively collected data on all mechanically ventilated patients over 20-years in a two-hospital Israeli medical system was performed. Data were collected for each hospital unit caring for ventilated patients. Time-series analysis examined short and long-term trends, seasonality and intra-week variation.

Results

Over two decades overall ventilator-days increased from 11,164 (31 patients/day) in 1997 to 24,317 (67 patients/day) in 2016 mainly due to more patients ventilated on internal medicine wards (1997: 4 patients/day; 2016: 24 patients/day). The increases in other hospital areas did not approach the magnitude of the internal medicine wards increases. Ventilation on wards reflected the insufficient number of ICU beds in Israel. A detailed snapshot over 4 months of patients ventilated on internal medicine wards (n = 745) showed that they tended to be elderly (median age 75 years) and that 24% were ventilated for more than a week. Hospital-wide ventilation patterns were the weighted sum of the various individual patient units with the most noticeable pattern being peak winter prevalence on the internal medical wards and in the emergency department. This seasonality is not surprising, given the greater incidence of respiratory ailments in winter.

Conclusions

Increased mechanical ventilation plus seasonality have budgetary, operational and staffing consequences for individual hospitals and the entire healthcare system. The Israeli healthcare leadership needs to plan and support expanding, equipping and staffing acute and chronic care units that are staffed by providers trained to care for such complex patients.

Electronic supplementary material

The online version of this article (10.1186/s13584-019-0291-y) contains supplementary material, which is available to authorized users.