Underutilization of acute care settings in a tertiary care hospital.

OBJECTIVE: To estimate underutilization of acute care settings in a tertiary care hospital. DESIGN: A retrospective and concurrent cohort study using chart reviews and the Intensity of service, Severity of illness, Discharge screen for Acute Care (ISD-AC(R)) tool to measure appropriateness of acute care for patients who were receiving care in a less acute setting, as an indicator of underutilization. SETTING: A 450-bed tertiary care teaching hospital. STUDY PARTICIPANTS: Patients discharged from the emergency department, patients discharged from acute care inpatient units and patients in acute, non-critical care settings. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The percentage of patients discharged from the emergency department who did not meet the criteria for acute care discharge screens; the percentage of patients discharged from an acute care inpatient unit who did not meet the criteria for discharge screens; and the percentage of patients who were in acute, non-critical care beds and who met the criteria for critical care. RESULTS: It was found that six out of 168 patients [3.57%; 95% confidence interval (CI), 1.32-7.61%] did not meet the discharge screens at the time of discharge from the emergency department. Four out of 156 patients (2.56%; 95% CI, 0.70-6.43%) did not meet the discharge screens at the time of discharge from an acute care inpatient service and two out of 156 acute care patients (1.33%; 95% CI, 0.02-4.73%) who were in non-critical care beds met the criteria for critical care. CONCLUSION: These findings of underutilization may help to quantitate an unmet need in health care.

Economic evaluation of 2 treatments for pediatric femoral shaft fractures.

The purpose of this study was to assess the relative health system costs of early hip spica cast immobilization and external fixation for pediatric femoral shaft fractures. A cost analysis was performed from the viewpoint of the study hospital and physicians using protocols based on current practice. Cost estimates were based on patient and financial information from April 1, 1993, to January 31, 1994, including the fully allocated inpatient and outpatient costs. A sensitivity analysis was conducted to analyze the effect of complications on costs. Total estimated costs (in 1994 Canadian dollars, $1.00 = $0.75 US) of uncomplicated external fixation and hip spica treatments were $7626.30 and $5970.11, respectively. Fifty percent of this difference was attributable to longer inpatient stays for the external fixation treatment. The remaining difference was because of the cost of the fixator, additional operating room staff time costs, and additional professional and technical fees. Total expected costs of treatment complicated by loss of reduction, pin tract infection, and return to the operating room were $7716.01 and $6128.44 for the external fixation and hip spica treatment options, respectively. For the range of complication probabilities considered, expected total costs were always greater with the external fixation option than with the hip spica treatment.

An assessment of the introduction of a multi-skilled worker into an acute care setting.

The first reengineering project undertaken by the Sunnybrook Health Science Centre after adopting a philosophy of patient-focused care was the introduction of a new category of worker: the multi-skilled service assistant. This article describes the experiences of the first two cohorts of service assistants and assesses the changes made to the work itself and the integration of the new workers into the work environment. It concludes by sharing recommendations for introducing a new work role.