Output force and ratio of laparoscopic graspers: an evaluation of operating room ergonomics.

BACKGROUND: "Laparoscopist's thumb," or thenar paresthesia, can result from prolonged or excessive grip force during laparoscopy, as can more general syndromes, such as carpal tunnel syndrome. This is particularly relevant in gynecology, where laparoscopic procedures are standard. Although this method of injury is well known, there is a paucity of data to guide surgeons in selecting more efficient, ergonomic instruments. OBJECTIVE: This study compared the ratio of applied tissue force and required surgeon input in a sample of common ratcheting laparoscopic graspers in a small-handed surgeon, to provide potential metrics applicable to surgical ergonomics and surgeon instrument choice. STUDY DESIGN: Laparoscopic graspers with varied ratcheting mechanisms and tip shapes were evaluated. Brands included Snowden-Pencer, Covidien, Aesculap, and Ethicon. A Kocher was used as an open instrument comparison. Flexiforce A401 thin-film force sensors were used to measure applied forces. Data were collected and calibrated using an Arduino Uno microcontroller board with Arduino and MATLAB software. Single-handed, complete closure of each device's ratcheting mechanism was performed 3 times. The maximum required input force in Newtons was recorded and averaged. The average output force was measured with a bare sensor and the same sensor between 2 different thicknesses of LifeLike BioTissue. RESULTS: The most ergonomic ratcheting grasper for a small-handed surgeon was identified by the output ratio: the highest output force relative to the required surgeon input (the most force for the least amount of effort). The Kocher required an average input force of 33.66 N, with its highest output ratio of 3.46 (112 N output). The Covidien Endo Grasp was the most ergonomic, with an output ratio of 0.96 on the bare force sensor (31.4 N output). The Snowden-Pencer Wavy grasper was the least ergonomic, with an output ratio of 0.06 when applied to the bare force sensor (5.9 N output). All graspers except for the Endo Grasp had improving output ratios as tissue thickness and subsequent grasper contact area increased. Input force above that provided by the ratcheting mechanisms did not increase output force in a clinically relevant amount for any of the instruments evaluated. CONCLUSION: Laparoscopic graspers vary widely in their ability to provide reliable tissue force without requiring excessive input by the surgeon, and a point of diminishing returns often exists with increased surgeon input over designed ratcheting mechanisms. Output force and output ratio are potential quantitative measures of the efficiency of laparoscopic instruments. Providing users with this type of data could assist in optimizing instrument ergonomics.

Frequency of 6-week follow-up appointment scheduling after intrauterine device insertion.

INTRODUCTION: Long-acting reversible contraception (LARC) is widely recommended to reduce unintended pregnancy in the USA. As intrauterine device (IUD) use increases, evaluating the role of post-insertion follow-up is important. METHODS: A retrospective patient record review was conducted to assess the follow-up experience of women who had an IUD placed at the University of Kansas Medical Center from 1 January to 30 June 2015. Data were collected on patient demographics, IUD placement, follow-up visit attendance, and outcomes in the 12 months following placement. The primary outcome of interest was the proportion of patients who attended a 6-week follow-up visit. Secondary outcomes included adverse events detected at the 6-week visit and IUD removal within a year of placement. RESULTS: Among 380 women who had an IUD inserted, physician documentation of a recommended 6-week follow-up visit was present in 91.3% of patient medical records. Two-thirds (66.6%) of patients receiving a recommendation returned for a follow-up visit. Of the 380 women who had an IUD placed, 66 (17.4%) had their IUD removed within 1 year of placement. Of those, 50 women attended the 6-week follow-up visit and 16 did not (19.8% vs 12.6%, p=0.08). Of the IUD removals, 14 occurred at the 6-week visit. After excluding IUD removals which occurred at the 6-week visit, attending a 6-week follow-up visit was not associated with IUD removal or retention (p=0.52). CONCLUSION: Despite recommendations to forgo the 6-week follow-up visit, visits were still common, with no demonstrated value added.

Pressure ulcers: treatment.

INTRODUCTION: Unrelieved pressure or friction of the skin, particularly over bony prominences, can lead to pressure ulcers in up to one third of people in hospitals or community care, and one fifth of nursing home residents. Pressure ulcers are more likely in people with reduced mobility and poor skin condition, such as older people or those with vascular disease. METHODS AND OUTCOMES: We conducted a systematic overview, aiming to answer the following clinical question: What are the effects of treatments in people with pressure ulcers? We searched: Medline, Embase, The Cochrane Library, and other important databases up to January 2014 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS: At this update, searching of electronic databases retrieved 307 studies. After deduplication and removal of conference abstracts, 203 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 163 studies and the further review of 40 full publications. Of the 40 full articles evaluated, seven systematic reviews and two RCTs were added at this update. We performed a GRADE evaluation for 15 PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for 15 interventions based on information about the effectiveness and safety of air-fluidised supports, alternating-pressure surfaces (including mattresses), debridement, dressings, electrotherapy, hyperbaric oxygen, low-air-loss beds, low-level laser therapy, low-tech constant-low-pressure supports, nutritional supplements, seat cushions, surgery, therapeutic ultrasound, topical negative pressure, and topical phenytoin.

Reduced fitness and abnormal cardiopulmonary responses to maximal exercise testing in children and young adults with sickle cell anemia.

Physiologic contributors to reduced exercise capacity in individuals with sickle cell anemia (SCA) are not well understood. The objective of this study was to characterize the cardiopulmonary response to maximal cardiopulmonary exercise testing (CPET) and determine factors associated with reduced exercise capacity among children and young adults with SCA. A cross-sectional cohort of 60 children and young adults (mean 15.1 ± 3.4 years) with hemoglobin SS or S/ß(0) thalassemia and 30 matched controls (mean 14.6 ± 3.5 years) without SCA or sickle cell trait underwent maximal CPET by a graded, symptom-limited cycle ergometry protocol with breath-by-breath, gas exchange analysis. Compared to controls without SCA, subjects with SCA demonstrated significantly lower peak VO2 (26.9 ± 6.9 vs. 37.0 ± 9.2 mL/kg/min, P < 0.001). Subjects demonstrated slower oxygen uptake (ΔVO2/ΔWR, 9 ± 2 vs. 12 ± 2 mL/min/watt, P < 0.001) and lower oxygen pulse (ΔVO2/ΔHR, 12 ± 4 vs. 20 ± 7 mL/beat, P < 0.001) as well as reduced oxygen uptake efficiency (ΔVE/ΔVO2, 42 ± 8 vs. 32 ± 5, P < 0.001) and ventilation efficiency (ΔVE/ΔVCO2, 30.3 ± 3.7 vs. 27.3 ± 2.5, P < 0.001) during CPET. Peak VO2 remained significantly lower in subjects with SCA after adjusting for age, sex, body mass index (BMI), and hemoglobin, which were independent predictors of peak VO2 for subjects with SCA. In the largest study to date using maximal CPET in SCA, we demonstrate that children and young adults with SCA have reduced exercise capacity attributable to factors independent of anemia. Complex derangements in gas exchange and oxygen uptake during maximal exercise are common in this population.

Peripartum cardiomyopathy: predictors of recovery and current state of implantable cardioverter-defibrillator use.

OBJECTIVES: The purpose of this study was to identify the predictors of left ventricular (LV) recovery in patients with peripartum cardiomyopathy (PPCM) and to record rates of implantable cardioverter-defibrillator (ICD) use. BACKGROUND: PPCM is a rare, life-threatening disease. The use of ICDs has not been clearly understood in this patient group. Identification of the predictors of persistent LV dysfunction can help select patients at risk for sudden cardiac death. METHODS: A retrospective study was conducted at 2 academic centers between January 1, 1999, and December 31, 2012. Clinical and demographic variables and delivery records of patients with a diagnosis of PPCM (International Classification of Diseases, 9th Revision code 674.5) were reviewed. Improvement in LV function was noted from echocardiography reports. RESULTS: The total sample comprised 100 patients, of whom 55% were African Americans, 39% were Caucasians, and 6% were Hispanic, with a mean age of 30 ± 6 years. Mean left ventricular ejection fraction (LVEF) at diagnosis was 28 ± 9%. Forty-two percent of patients showed improvement in LVEF over a mean duration of 33 ± 21 months. Postpartum diagnosis (hazard ratio: 3.0; p = 0.01) and Caucasian/Hispanic race (hazard ratio: 2.2; p = 0.01) were predictors of improvement in LVEF. Only 7 of the 58 patients (12%) who did not have improvement in their LVEF had an ICD implanted. There were 11 deaths, with a trend toward higher mortality in those who did not display improved LV function (15% vs. 5%; p = 0.1). CONCLUSIONS: More than one-third of women with PPCM improve LV function with delayed recovery noted in the majority of these patients. Caucasians and those diagnosed in the postpartum period appear to be the most likely to recover. The rate of ICD implantation for primary prevention of sudden cardiac death in this patient group is low.

Pressure ulcer prevention in patients with advanced illness.

PURPOSE OF REVIEW: Pressure ulcers can be challenging to prevent, particularly in patients with advanced illnesses. This review summarizes the relevant literature since 2011. RECENT FINDINGS: Through a MEDLINE and CINAHL database search from January 1, 2011 to June 1, 2012, a total of 14 abstracts were found addressing the prevention of pressure ulcers in persons with advanced illness. Search terms included pressure ulcer, prevention, and control. Advanced illness was defined as patients transitioning from curative to supportive and palliative care. Ten original studies and four review articles specifically addressed pressure ulcer prevention. There were four articles that specifically addressed patients with advanced illness. The studies varied in quality. One systematic review, one randomized controlled trial, three prospective trials, two retrospective trials, one cost-effectiveness analysis, one quality improvement project, one comparative descriptive design, and four review articles were found. The interventions for pressure ulcer prevention were risk assessment, repositioning, surface selection, nutritional support and maintenance of skin integrity with or without incontinence. SUMMARY: The quality of pressure ulcer prevention studies in persons with advanced illness is poor. Increased number and higher quality studies are needed to further investigate this important topic for these fragile patients.

Age-Dependent Impact of Fluoroscopic Radiation on the Gender of Off-Spring: An International Survey of Cardiologists.

Background: Fluoroscopic radiation has been implicated in reducing the sex ratio (M:F) by potentially damaging the Y chromosome. We examined the effects of exposure to fluoroscopic radiation on gender of offspring of cardiologists across the world. Methods: An internet based survey was e-mailed worldwide to 8000 physicians who practice invasive electrophysiology and/or interventional cardiology. Survey questions included age, race, sub-specialty, hours of exposure to radiation, number of children, gender of off-spring, miscarriages and mutations and exposure to radiation prior to conception of each child. Logistic regression analyses were performed on years of exposure and gender of offspring born post radiation exposure. Results: Responses of 377 cardiologists (84% male and 16% female) were reviewed. With a total of 398 males and 402 females born to 377 cardiologists, although reduced, the overall sex ratio (0.99) was not significantly different from that observed in the general population (1.05). Univariate logistic regression analysis identified higher male births with increasing hours of radiation exposure (OR 1.034, CI 1.003-1.067 p=0.03) and increasing paternal age (OR 1.05, CI 1.01-1.08, p=0.002). Subgroup analysis of children of male cardiologists revealed higher incidence of male births with increasing age and radiation exposure and multivariate analysis only identified paternal age as predictor of higher incidence of male births (OR 1.05, CI 1.01-1.089, p=0.0027). Conclusion: Exposure to ionizing radiation leads to a decrease in the sex ratio (M/F) in younger male cardiologists, while this effect is reversed with greater number of male births in older male cardiologists.

Wound care in short-term rehabilitation facilities and long-term care: special needs for a special population.

Chronic wounds can pose a challenging diagnostic and treatment dilemma in the older frail adult population. The benefits of short-term rehabilitation and long-term care settings are the access to interdisciplinary resources. Rehabilitative specialists, dieticians, and skilled nurses are readily available to meet the patients' needs as they transition to home or remain in a long-term care setting for their higher level of care needs. This article follows 3 cases: a skin tear complicated by venous ulceration, a pressure ulcer with fever, and arterial ulcers in a patient who opts for comfort care. The cases illustrate the higher needs of this population and emphasize the attention that must be paid to respect nursing-time intensiveness, incorporate realistic goals of care for wound healing, and ensure excellent communication with the team members, patients, and family.

Does this patient have an infection of a chronic wound?

CONTEXT: Chronic wounds (those that have not undergone orderly healing) are commonly encountered, but determining whether wounds are infected is often difficult. The current reference standard for the diagnosis of infection of a chronic wound is a deep tissue biopsy culture, which is an invasive procedure. OBJECTIVES: To determine the accuracy of clinical symptoms and signs to diagnose infection in chronic wounds and to determine whether there is a preferred noninvasive method for culturing chronic wounds. DATA SOURCES: We searched multiple databases from inception through November 18, 2011, to identify studies focusing on diagnosis of infection in a chronic wound. STUDY SELECTION: Original studies were selected if they had extractable data describing historical features, symptoms, signs, or laboratory markers or were radiologic studies compared with a reference standard for diagnosing infection in patients with chronic wounds. Of 341 studies initially retrieved, 15 form the basis of this review. These studies include 985 participants with a total of 1056 chronic wounds. The summary prevalence of wound infection was 53%. DATA EXTRACTION: Three authors independently assigned each study a quality grade, using previously published criteria. One author abstracted operating characteristic data. DATA SYNTHESIS: An increase in the level of pain (likelihood ratio range, 11-20) made infection more likely, but its absence (negative likelihood ratio range, 0.64-0.88) did not rule out infection. Other items in the history and physical examination, in isolation or in combination, appeared to have limited utility when infection was diagnosed in chronic wounds. Routine laboratory studies had uncertain value in predicting infection of a chronic wound. CONCLUSIONS: The presence of increasing pain may make infection of a chronic wound more likely. Further evidence is required to determine which, if any, type of quantitative swab culture is most diagnostic.

Pressure ulcers.

INTRODUCTION: Unrelieved pressure or friction of the skin, particularly over bony prominences, can lead to pressure ulcers in up to one third of people in hospitals or community care, and one fifth of nursing home residents. Pressure ulcers are more likely in people with reduced mobility and poor skin condition, such as older people or those with vascular disease. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of preventive interventions in people at risk of developing pressure ulcers? What are the effects of treatments in people with pressure ulcers? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 64 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: air-filled vinyl boots, air-fluidised supports, alternating-pressure surfaces (including mattresses), alternative foam mattresses, constant low-pressure supports, debridement, electric profiling beds, electrotherapy, hydrocellular heel supports, low-air-loss beds (including hydrotherapy beds), low-level laser therapy, low-tech constant-low-pressure supports, medical sheepskin overlays, nutritional supplements, orthopaedic wool padding, pressure-relieving overlays on operating tables, pressure-relieving surfaces, repositioning (regular "turning"), seat cushions, standard beds, standard care, standard foam mattresses, standard tables, surgery, therapeutic ultrasound, topical lotions and dressings, topical negative pressure, and topical phenytoin.

Dry skin in the elderly: complexities of a common problem.

Dry skin, or xerosis, is a common skin condition in older adults, but it is not a normal part of aging. The geriatric patient may have several incurable, but treatable, chronic diseases that affect their skin. Xerosis in older adults is multifactorial: intrinsic changes in keratinization and lipid content, use of diuretics and similar medications, and overuse of heaters or air conditioners all contribute. Xerosis causes pruritus, which then leads to excoriations and risk of skin infections. Patients can minimize the effect of xerosis by increasing the ambient humidity, modifying their bathing technique and products, and using emollients to replace the lipid components of the skin. Care should be made to avoid skin sensitizers, such as lanolin, aloe vera, and parabens, that are commonly found in emollients. These may lead to a delayed hypersensitivity reaction. This contribution reviews the intrinsic and extrinsic aging processes of skin aging and advises practical changes in environment and emollient application that can be distributed to patients.

Treatment of pressure ulcers: a systematic review.

CONTEXT: Many treatments for pressure ulcers are promoted, but their relative efficacy is unclear. OBJECTIVE: To systematically review published randomized controlled trials (RCTs) evaluating therapies for pressure ulcers. DATA SOURCES AND STUDY SELECTION: The databases of MEDLINE, EMBASE, and CINAHL were searched (from inception through August 23, 2008) to identify relevant RCTs published in the English language. DATA EXTRACTION: Methodological characteristics and outcomes were extracted by 3 investigators. DATA SYNTHESIS: A total of 103 RCTs met inclusion criteria. Of these, 83 did not provide sufficient information about authors' potential financial conflicts of interest. Methodological quality was variable. Most trials were conducted in acute care (38 [37%]), mixed care (25 [24%]), or long-term care (22 [21%]) settings. Among 12 RCTs evaluating support surfaces, no clear evidence favored one support surface over another. No trials compared a specialized support surface with a standard mattress and repositioning. Among 7 RCTs evaluating nutritional supplements, 1 higher-quality trial found that protein supplementation of long-term care residents improved wound healing compared with placebo (improvement in Pressure Ulcer Scale for Healing mean [SD] score of 3.55 [4.66] vs 3.22 [4.11], respectively; P < .05). Other nutritional supplement RCTs showed mixed results. Among 54 RCTs evaluating absorbent wound dressings, 1 found calcium alginate dressings improved healing compared with dextranomer paste (mean wound surface area reduction per week, 2.39 cm(2) vs 0.27 cm(2), respectively; P<.001). No other dressing was superior to alternatives. Among 9 RCTs evaluating biological agents, several trials reported benefits with different topical growth factors. However, the incremental benefit of these biological agents over less expensive standard wound care remains uncertain. No clear benefit was identified in 21 RCTs evaluating adjunctive therapies including electric current, ultrasound, light therapy, and vacuum therapy. CONCLUSIONS: Little evidence supports the use of a specific support surface or dressing over other alternatives. Similarly, there is little evidence to support routine nutritional supplementation or adjunctive therapies compared with standard care.

Skin and wound care: important considerations in the older adult.

PURPOSE: To provide the wound care practitioner with a review of important considerations for skin and wound care in the older adult. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After reading this article and taking this test, the reader should be able to:

Oral drug therapy for multiple neglected tropical diseases: a systematic review.

CONTEXT: The neglected tropical diseases include 13 conditions that occur in areas of extreme poverty and are poverty promoting. The neglected tropical diseases produce a disease burden almost as great as that associated with human immunodeficiency virus/AIDS, tuberculosis, or malaria, yet are virtually unknown by health care workers in North America, because they occur almost exclusively in the poorest regions of the world. Seven of the most prevalent diseases have existing oral drug treatments. Identifying treatments that are effective against more than 1 disease could facilitate efficient and inexpensive treatment. OBJECTIVES: To systematically review the evidence for drug treatments and to increase awareness that neglected tropical diseases exist and that treatments are available. DATA SOURCES AND STUDY SELECTION: Using a MEDLINE search (1966 through June 2007), randomized controlled trials (RCTs) were reviewed that examined simultaneous treatment of 2 or more of the 7 most prevalent neglected tropical diseases using oral drug therapy. DATA SYNTHESIS: Twenty-nine RCTs were identified, of which 3 targeted 4 diseases simultaneously, 20 targeted 3 diseases, and 6 targeted 2 diseases. Trials were published between 1972 and 2005 and baseline prevalence of individual diseases varied among RCTs. Albendazole plus diethylcarbamazine significantly reduced prevalence of elephantiasis (16.7% to 5.3%), hookworm (10.3% to 1.9%), roundworm (34.5% to 2.3%), and whipworm (55.5% to 40.3%). Albendazole plus ivermectin significantly reduced prevalence of elephantiasis (12.6% to 4.6%), hookworm (7.8% to 0%), roundworm (33.5% to 6.1%), and whipworm (42.7% to 8.9%). Levamisole plus mebendazole significantly reduced prevalence of hookworm (94.0% to 71.8%), roundworm (62.0% to 1.4%), and whipworm (93.1% to 74.5%). Pyrantel-oxantel significantly reduced hookworm (93.4% to 85.2%), roundworm (22.8% to 1.4%), and whipworm (86.8% to 59.5%), while albendazole alone significantly reduced prevalence of hookworm (8.1% to 1.3%), roundworm (28.4% to 0.9%), and whipworm (51.9% to 31.9%). No RCT examined treatment of river blindness or trachoma as part of an intervention to target 2 or more neglected tropical diseases. Adverse events were generally inadequately reported. CONCLUSIONS: At least 2 of the most prevalent neglected tropical diseases can be treated simultaneously with existing oral drug treatments, facilitating effective and efficient treatment. Increasing awareness about neglected tropical diseases, their global impact, and the availability of oral drug treatments is an essential step in controlling these diseases.

Residues of the human nuclear vitamin D receptor that form hydrogen bonding interactions with the three hydroxyl groups of 1alpha,25-dihydroxyvitamin D3.

Most of the biological effects of 1,25-dihydroxyvitamin D(3) (hormone D) are mediated through the nuclear vitamin D receptor (VDR). Hormone binding induces conformational changes in VDR that enable the receptor to activate gene transcription. It is known that residues S237 and R274 form hydrogen bonds with the 1-hydroxyl group of hormone D, while residues Y143 and S278, and residues H305 and H397 form hydrogen bonds with the 3-hydroxyl and the 25-hydroxyl groups of the hormone. A series of VDR mutations were constructed (S237A, R274A, R274Q, Y143F, Y143A, S278A, H305A, and H397F; double mutants: S237A/R274A, Y143F/S278A, Y143A/S278A, and H305A/H397F). The relative binding affinities of the wild-type and variant VDRs were assessed. All of the mutants except H397F resulted in lower binding affinity compared to wild-type VDR. Binding to hormone was barely detectable in Y143F, H305A, and H305A/H397F mutants, and undetectable in mutants R274A, R274Q, Y143A, S237A/R274A, and Y143A/S278A, indicating the importance of these residues. Ability to activate gene transcription was also assessed. All of the VDR mutants, except the single mutant S278A, required higher doses of hormone D for half-maximal response. Defining the role of hormone D-VDR binding will lead to a better understanding of the vitamin D signal transduction pathway.

Preventing pressure ulcers: a systematic review.

CONTEXT: Pressure ulcers are common in a variety of patient settings and are associated with adverse health outcomes and high treatment costs. OBJECTIVE: To systematically review the evidence examining interventions to prevent pressure ulcers. DATA SOURCES AND STUDY SELECTION: MEDLINE, EMBASE, and CINAHL (from inception through June 2006) and Cochrane databases (through issue 1, 2006) were searched to identify relevant randomized controlled trials (RCTs). UMI Proquest Digital Dissertations, ISI Web of Science, and Cambridge Scientific Abstracts were also searched. All searches used the terms pressure ulcer, pressure sore, decubitus, bedsore, prevention, prophylactic, reduction, randomized, and clinical trials. Bibliographies of identified articles were further reviewed. DATA SYNTHESIS: Fifty-nine RCTs were selected. Interventions assessed in these studies were grouped into 3 categories, ie, those addressing impairments in mobility, nutrition, or skin health. Methodological quality for the RCTs was variable and generally suboptimal. Effective strategies that addressed impaired mobility included the use of support surfaces, mattress overlays on operating tables, and specialized foam and specialized sheepskin overlays. While repositioning is a mainstay in most pressure ulcer prevention protocols, there is insufficient evidence to recommend specific turning regimens for patients with impaired mobility. In patients with nutritional impairments, dietary supplements may be beneficial. The incremental benefit of specific topical agents over simple moisturizers for patients with impaired skin health is unclear. CONCLUSIONS: Given current evidence, using support surfaces, repositioning the patient, optimizing nutritional status, and moisturizing sacral skin are appropriate strategies to prevent pressure ulcers. Although a number of RCTs have evaluated preventive strategies for pressure ulcers, many of them had important methodological limitations. There is a need for well-designed RCTs that follow standard criteria for reporting nonpharmacological interventions and that provide data on cost-effectiveness for these interventions.

Long-term care in the St. John's region: impact of single entry and prediction of bed need.

In 1996, the St. John's region had a population of 8,435 > or = 75 years, with 996 nursing home (NH) beds and 550 supervised care (SC) beds. A single entry system to these institutions was implemented in 1995. To determine the impact of the single entry system, the demographic and clinical characteristics of NH residents were assessed in 1997 (N = 1,044) and in 2003 (N = 963). To determine the efficiency of placement and the need for long-term care beds, two incident cohorts requesting placement were studied in 1995/96 (N = 467) and in 1999/2000 (N = 464). Degree of disability was determined using the Residents Utilization Groups III classification (RUG-III) and the Alberta Resident Classification Score (ARCS), and time to placement and to death was measured. In prevalent NH residents, the percentage without RUGS-III disability decreased from 18.5% in 1997 and to 9.9% in 2003. The proportion recommended for NH was 75% in 1995/96 and 72% in 1999/2000, despite the fact that the proportion with RUGS-III disability was 64% in both periods. Using a decision tree, optimal placement for the 1999/2000 cohort was 36% to SC, 20% to SC for the cognitively impaired, and 44% to NH. Predicted need for long-term care beds in 2004 matched poorly with current provision of NH and SC beds, and the mismatch will be worse in 2014. It was concluded that the single entry system was associated with improved appropriateness of NH bed utilization. However, there was a mismatch in need for and provision of institutional long-term care. Investment in the reconfiguration of long-term care beds by case mix and by geography is necessary.