Adecuación de la hospitalización en una unidad de estancia corta de un hospital universitario. Un estudio controladoAppropriateness of hospitalization in a short stay unit of a teaching hospital. A controlled study
Fundamento y Objetivo
Conocer el grado y las causas de inadecuación hospitalaria de una unidad de estancia corta (UEC), en relación con otras áreas de hospitalización que atienden a pacientes con los mismos diagnósticos
Pacientes y Método
Se ha aplicado el Appropriateness Evaluation Protocol a 352 pacientes ingresados en la UEC y a 203 ingresados en un área de medicina (grupo control)
Resultados
Los ingresos (un 0,6 frente al 3%; p = 0,023) y las estancias inadecuados (el 6,9 frente al 18,7%; p <0,001) fueron menores en la UEC que en el grupo control. Las principales causas de inadecuación fueron también significativamente menos frecuentes: atención médica conservadora (el 9,4 frente al 41,4%; p = 0,001), retraso en las exploraciones complementarias (el 3,4 frente al 11,3%; p <0,001) y problemas sociofamiliares (el 2,8 frente al 9,4%; p = 0,001)
Conclusiones
La UEC es un buen instrumento para la adecuación hospitalaria, ya que permite minimizar las causas de estancias inadecuadas
Background and Objective
Our aim was to evaluate the rate and the reasons for inappropriate hospital use in a medical Short Stay Unit (SSU) in comparison with conventional hospitalization
Patients and Method
The Appropriateness Evaluation Protocol was applied to 352 patients admitted in the SSU and to 203 patients admitted in a department of internal medicine (control group)
Results
The rates of inappropriate hospital admissions (0.6% vs 3%; p = 0.023) and stays (6.9% vs 18.7%; p <0.001) were signi-ficantly lower in the SSU with respect to the control group. Main causes of inappropria-teness were also lower: conservative physi-cian's attitude (9.4% vs 41.4%; p = 0.001), delay in diagnostic procedures (3.4% vs 11.3%; p <0.001), and social and familiar factors (2.8% vs 9.4%; p = 0.001)
Conclusions
A SSU is useful for the appropriateness of hospital use, due to its capacity to minimize the number and causes of inappropriate stays
Referencias bibliográficas (10)
- S. Peiró et al.
Identificación del uso inapropiado de la hospitalización: la búsqueda de la eficiencia
Med Clin (Barc)
(1994) - M.L. Baré et al.
Appropriateness of admissions and hospitalization days in an acute-care teaching hospital
Rev Epidém Santé Publ
(1995) - G. Navarro et al.
Review of the utilisation of a university hospital in Barcelona (Spain): evolution 1992–1996
Eur J Epidemiol
(2001) - S. Peiró et al.
Validez del protocolo de evaluación del uso inapropiado de la hospitalización
Med Clin (Barc)
(1996) - J.E. Gloor et al.
Appropriateness of hospitalization in a canadian pediatric hospital
Pediatrics
(1993)
Cited by (39)
Prolonged hospitalization in patients admitted for acute heart failure in the short stay unit (EPICA-UCE study): Study of associated factors
2014, Medicina ClinicaEstudiar los factores asociados con una estancia prolongada de los pacientes ingresados por insuficiencia cardiaca aguda (ICA) en las unidades de corta estancia (UCE) españolas.
Estudio de cohorte multipropósito y multicéntrico, con seguimiento prospectivo, que incluyó a todos los pacientes ingresados por ICA en las 11 UCE del registro EAHFE. Se recogieron variables demográficas, antecedentes personales, situación basal cardiorrespiratoria y funcional, datos del episodio de urgencias, del ingreso y del seguimiento a 60 días. La variable resultado fue la estancia prolongada en la UCE (mayor de 72 h). Se utilizó un modelo de regresión logística para controlar los efectos de los factores de confusión.
Se incluyeron 819 pacientes, con una edad media (DE) de 80,9 (8,4) años; 483 (59,0%) eran mujeres. La mediana de estancia fue de 3 días (intervalo intercuartílico 2,0-5,0), y la mortalidad intrahospitalaria del 2,7%. Fueron factores independientes asociados a una estancia prolongada, la coexistencia de enfermedad pulmonar obstructiva crónica (odds ratio [OR] 1,56, intervalo de confianza del 95% [IC 95%] 1,02-2,38; p = 0,040) y anemia (OR 1,72, IC 95% 1,21-2,44; p = 0,002), una saturación de oxígeno basal a la llegada a urgencias < 90% (OR 2,21, IC 95% 1,51-3,23; p < 0,001), una crisis hipertensiva como factor precipitante de la ICA (factor protector, OR 0,49, IC 95% 0,26-0,93; p = 0,028) e ingresar en jueves (OR 1,90, IC 95% 1,19-3,05; p = 0,008). No hubo diferencias significativas entre ambos grupos respecto a la mortalidad intrahospitalaria (2,4 frente a 3,0%), mortalidad (4,1 frente a 4,2%) ni revisita a 60 días (18,4 frente a 21,6%).
En los pacientes con ICA que ingresan en la UCE, se tienen que considerar factores como la presencia de crisis hipertensiva, insuficiencia respiratoria, anemia, antecedente de enfermedad pulmonar obstructiva crónica, e ingresar un jueves para evitar hospitalizaciones prolongadas.
To study the factors associated with prolonged hospitalization in patients admitted for acute heart failure (AHF) in Spanish short-stay units (SSUs).
This was a multicentre, multipurpose cohort study with prospective follow-up including all patients admitted for AHF in the 11 SSUs of the EAHFE registry. Demographic data, previous illness, baseline cardiorespiratory and functional status, acute episode and admission and follow up variables at 60 days were recorded. The primary outcome was prolonged hospitalization in the SSU (> 72 h). A logistic regression model was used to control the effects of confounding factors.
Eight-hundred and nineteen patients were included with a mean age of 80.9 (SD 8.4) years, 483 (59.0%) being women. The median length stay was 3.0 (IQR 2.0-5.0) days with an in-hospital mortality of 2.7%. The independent factors associated with prolonged hospitalization were the coexistence of chronic obstructive pulmonary disease (odds ratio [OR] 1.56; 95% IC 1.02-2.38; P = .040) and anaemia (OR 1.72; 95% CI 1.21-2.44; P = .002), basal oxygen saturation < 90% on arrival to the Emergency Department (OR 2.21, 95% CI 1.51-3.23; P < .001), hypertensive episode as the precipitating factor of the AHF (protective factor OR 0.49; 95% CI 0.26-0.93; P = .028) and admission on Thursday (OR 1.90; 95% CI 1.19-3.05; P = .008). There were no significant differences between both groups regarding to in-hospital mortality (2.4 vs. 3.0%), mortality (4.1 vs. 4.2%) or revisit at 60 days (18.4 vs. 21.6%).
Several factors including hypertensive episode, insufficiency respiratory, anaemia, chronic obstructive pulmonary disease, and admission on Thursday should be taken into account in patients with AHF admitted in SSU stay to avoid prolonged hospitalization.
Impact of short-stay units on the quality of medical care in Spain
2013, Revista de Calidad AsistencialLas unidades de corta estancia (UCE) se han desarrollado como alternativa a la hospitalización convencional. El objetivo de este estudio es analizar la influencia de las UCE creadas en España sobre la calidad asistencial.
Se realizó una revisión sistemática de la literatura en Medline e Índice Médico Español para identificar estudios que evaluaran los resultados de la implantación de las UCE de nuestro país, en términos de efectividad clínica, eficiencia y satisfacción de pacientes y se revisaron las referencias de los artículos hallados. Se extrajeron datos relativos a estancia media y tasas de mortalidad y de reingreso, entre otros.
Se encontraron 27 artículos con una importante heterogeneidad tanto en el tipo de UCE evaluada como en el propio diseño de los estudios. Tras comparar los resultados se observó que las UCE proporcionan cuidados asistenciales con efectividad. Además, se encontró evidencia de calidad baja que apoya que las UCE reducen la estancia media en el conjunto del hospital o del servicio considerado, sin encontrar evidencias que supongan otros beneficios al compararlas con otro tipo de unidades de hospitalización.
Las UCE pueden ayudar a mejorar la efectividad de la asistencia sanitaria en pacientes seleccionados, así como a reducir la estancia media hospitalaria, aunque es preciso realizar nuevas investigaciones para definir su papel y su modelo óptimo de funcionamiento.
Short-stay units (SSUs) have been developed as an alternative to conventional hospitalisation. The aim of this study is to analyse the impact of short-stay units on the quality of medical care in Spain.
A systematic review was performed by retrieving studies that analysed the results of SSUs in Spain, in terms of clinical effectiveness, efficiency and satisfaction among patients, using an electronic database search (Pubmed/Medline and Spanish Medical Index) and a review of selected references. The data collected included, mortality, length of stay and re-admission rates, as well as other variables.
Twenty-seven articles were found, with a great heterogeneity in both study design and type of SSU analysed. After analysing results, it was observed that SSUs in Spain provided effective clinical care. Low-quality evidence was also found supporting the hypothesis that SSUs are able to reduce overall length of stay in the whole hospital or department where they were created. There are not enough data to support any other advantages or benefits of SSUs, when compared with other hospitalisation units.
SSUs may be able to effectively improve clinical care in selected patients, and may help to shorten overall length of stay. Further research is needed in order to define their exact role and to establish their optimal model.
The Day Hospital: Analysis of Results, Costs and Management of Pneumology Resources
2013, Archivos de BronconeumologiaLos hospitales de día de neumología constituyen un instrumento relativamente nuevo de atención al paciente respiratorio complejo. Faltan estudios sobre su eficacia y eficiencia.
Estudiar el impacto de la instauración de un hospital de día neumológico en una institución terciaria de 500 camas.
Análisis de eficacia, eficiencia y calidad.
En el período analizado (2 años) el hospital de día incrementó progresivamente su actividad. Esto se acompañó de mayor actividad clínica global en neumología, pero también de una reducción en el número de altas hospitalarias, aunque en el período estudiado no varió la presión de pacientes sobre urgencias. Como consecuencia, también se redujo la necesidad de camas en la sala de hospitalización convencional. Por otra parte, aumentó la complejidad de los pacientes ingresados, aunque la eficiencia (razón de funcionamiento estándar) y calidad (reingresos y mortalidad) de la atención en ese dispositivo se mantuvieron estables.
Los hospitales de día neumológicos constituyen un instrumento útil en la gestión de la atención a pacientes respiratorios, ya que reducen las necesidades de hospitalización, manteniendo la calidad asistencial y complementando otros dispositivos.
Day hospital units specialized in pulmonology are a relatively new instrument for providing care to complex respiratory patients. However, the number of studies focused on the efficacy and efficiency of day hospitals is scarce.
Therefore, the aim of the present study was to analyze the effects of implementing a specialized respiratory day hospital in a standard teaching hospital with 500 beds.
An analysis of efficacy, efficiency and quality care.
Throughout the study period (2 years) the day hospital progressively increased its activity. Although patient pressure on the emergency department remained constant, this was associated with a parallel increase in the overall medical activity of the Pulmonology Department and a reduction in the number of discharges from the hospital. There was a reduction in the number of admissions, and consequently in the need for beds in the Pulmonology Department. The complexity of the hospitalized patients increased, although the efficiency (standard functioning ratio) and quality (readmissions and mortality) of patient care remained stable.
Day hospital pulmonology units are a useful tool in the management of respiratory patient care. They reduce the need for hospitalizations, while maintaining healthcare quality and complementing other care management instruments.
Quick diagnosis units or conventional hospitalisation for the diagnostic evaluation of severe anaemia: A paradigm shift in public health systems?
2012, European Journal of Internal MedicineCitation Excerpt :In Spain and other countries, due to deficiencies in outpatient services, acute beds are increasingly occupied by patients requiring diagnostic tests for non-acute but potentially severe diseases that often need no immediate treatment, thereby lessening the number of beds available for acute patients [2,3]. Reports suggest 9%–17% of patients admitted to Spanish internal medicine units could be studied on an outpatient basis [4–7]. However, the long delays in outpatient diagnostic tests in the Spanish public health system make a diagnosis outside conventional hospitalisation unviable, especially for patients requiring rapid access to tests due to suspected malignancy.
Acute hospital bed utilisation is a growing concern for health care systems in most countries with public health models, as it represents a significant share of health costs. Anaemia with haemoglobin levels below 8 g/l has traditionally been a criterion used to hospitalise patients in our centre for diagnosis.
We conducted a longitudinal study with a prospective and retrospective cohort to investigate the usefulness of a Quick Diagnosis Unit (QDU) for the evaluation of patients with severe anaemia as compared with hospitalisation in a tertiary public hospital. We recorded pretransfusion haemoglobin and haematocrit values, Charlson comorbidity index, waiting time for the first visit, time to diagnosis (length-of-stay in hospitalised patients), final diagnosis, costs, and responses to an opinion survey.
QDU patients were significantly younger [65.63 years (17.44)] than hospitalised patients [76.11 years (12.68)] (P < .0001). No significant differences were observed regarding time to diagnosis/length-of-stay, haemoglobin concentrations and Charlson index. Iron-deficiency anaemia was the commonest type of anaemia in both cohorts and benign digestive lesions accounted for most cases. The mean cost per process (admission-discharge episode) was 2920.62 Euros in the QDU and 18,278.01 Euros in hospitalised patients. If further diagnostic tests were required, 85% of patients would prefer the QDU care model to conventional hospital admission.
For diagnostic purposes, patients with severe anaemia can be managed similarly in a QDU or in-hospital setting, but the QDU model is more cost-saving than traditional hospitalisation. Most QDU patients preferred the QDU model to hospital admission.
Survey of Spanish Society of internal medicine on health care provision by internists in the public health system
2011, Revista Clinica EspanolaConocer la organización de los servicios de medicina interna (SMI) y la opinión de sus jefes.
En 2008 se envió una encuesta a 410 jefes de SMI de 313 hospitales públicos de España. Incluía un formulario de preguntas estructuradas sobre plantilla, actividad de hospitalización, consulta, interconsultas, investigación y docencia. Además se pedía opinión y sugerencias sobre gestión, proyectos y futuro.
Se cumplimentaron 68 encuestas (22%). De media un internista hace 3 guardias mensuales y anualmente 200 altas, 500 consultas y 40 interconsultas. El SMI está constituido por 10 internistas y tiene asignadas 1/5 de las camas del hospital. Un tercio de los hospitales tiene alternativas de hospitalización; la más frecuente, cuidados paliativos. La consulta monográfica más habitual es enfermedades infecciosas, 1/3 no tiene estructurada su relación con Atención Primaria y urgencias no depende del SMI. La mitad tiene al menos un residente de MI, 6 de otras especialidades, realiza al menos dos ensayos clínicos y 1/3 participa en formación médica pregraduada. Se detectan problemas de relación con directivos, otras especialidades y población. La excesiva presión asistencial, el envejecimiento y la desmotivación de la plantilla y los problemas sociales tienen efectos negativos. Aún así se desea poner en marcha algún proyecto, existe optimismo respecto al futuro e interés por investigar en epidemiología clínica.
Aunque la muestra es pequeña y heterogénea, el estudio permite conocer la estructura y funcionamiento estándar de un SMI en España, así como sus expectativas de futuro y principales áreas de mejora.
To know the organization of internal medicine departments (IMD) and the opinion of their heads of department.
In 2008, a survey was mailed to 410 heads of department of the IMD of 313 Spanish public hospitals. It included a standardized structured questionnaire on staff, hospitalization, outpatients, consultation, research and teaching. The heads of departments were also asked for their opinion and suggestions on management, projects and future. Results: Sixty-eight surveys (22%) were filled out. Internists are on call an average of 3 times a month and perform 200 discharges, 500 outpatient visits and 40 consultations in a year. The average IMD consists of 10 internists with one-fifth of the hospital beds. One third of hospitals have alternatives to inpatient care, the most frequent being palliative care. Infectious diseases accounts for the most common monographic outpatient visit, one-third of IMD lack a structured relationship with primary care and the emergency department is independent of IMD. Half of the IMD have at least one IM resident and 6 residents in other specialties; half are involved in at least two clinical trials and one-third train medical students. The heads of the IMD identify problems in their relationship with hospital managers, other specialties and local population. Excessive workload, aging and discouragement of staff and patients’ social problems have negative effects. Even so, they want to initiate projects, are optimistic about the future and take an interest in clinical epidemiology research.
Although the sample is small and heterogeneous, it permits a valuable panoramic view of the structure and standard operation of a Spanish IMD as well as their expectations and areas of improvement.
Outpatient quick diagnosis units for the evaluation of suspected severe diseases: An observational, descriptive study
2011, ClinicsHospitals in countries with public health systems have recently adopted organizational changes to improve efficiency and resource allocation, and reducing inappropriate hospitalizations has been established as an important goal.
Our goal was to describe the functioning of a Quick Diagnosis Unit in a Spanish public university hospital after evaluating 1,000 consecutive patients. We also aimed to ascertain the degree of satisfaction among Quick Diagnosis Unit patients and the costs of the model compared to conventional hospitalization practices.
Observational, descriptive study.
Our sample comprised 1,000 patients evaluated between November 2008 and January 2010 in the Quick Diagnosis Unit of a tertiary university public hospital in Barcelona. Included patients were those who had potentially severe diseases and would normally require hospital admission for diagnosis but whose general condition allowed outpatient treatment. We analyzed several variables, including time to diagnosis, final diagnoses and hospitalizations avoided, and we also investigated the mean cost (as compared to conventional hospitalization) and the patients' satisfaction.
In 88% of cases, the reasons for consultation were anemia, anorexia-cachexia syndrome, febrile syndrome, adenopathies, abdominal pain, chronic diarrhea and lung abnormalities. The most frequent diagnoses were cancer (18.8%; mainly colon cancer and lymphoma) and Iron-deficiency anemia (18%). The mean time to diagnosis was 9.2 days (range 1 to 19 days). An estimated 12.5 admissions/day in a one-year period (in the internal medicine department) were avoided. In a subgroup analysis, the mean cost per process (admission-discharge) for a conventional hospitalization was 3,416.13 Euros, while it was 735.65 Euros in the Quick Diagnosis Unit. Patients expressed a high degree of satisfaction with Quick Diagnosis Unit care.
Quick Diagnosis Units represent a useful and cost-saving model for the diagnostic study of patients with potentially severe diseases. Future randomized study designs involving comparisons between controls and intervention groups would help elucidate the usefulness of Quick Diagnosis Units as an alternative to conventional hospitalization.