CLINICAL AND COMMUNITY STUDIES ETUDES CLINIQUES ET COMMUNAUTAIRES
Chronic status patients in a university hospital: bed-day utilization and length of stay Jacqueline McClaran, MD, FCFPC; Robin Tover-Berglas, BA, MPA; Kathleen Cranley Glass, MA, LLB, BCL Objective: To examine the lengths of stay of chronic status patients in an acute care hospital, to identify discharge stages that contribute to excessive stays, to estimate the length of stay at each discharge stage and to link hospital bed-day utilization by the discharge stage to the experience of the patient. Design: Two-year prospective cohort study. The number of hospital days retrospective to the date of the current admission were included in the analysis. Setting: University hospital. Patients: All 115 inpatients formally declared as achieving chronic status by July 31, 1987. Outcome measures: Lengths of stay (total days and days at acute and chronic status) for chronic status patients, including those still in hospital at the end of the study period. Each bed-day was assigned to a discharge stage that corresponded to the patient's status. The disposition of each patient by the end of the study period was reviewed. Results: The study population spent a total of 101 585 days in hospital. The total length of stay per patient was nearly four times that stated in the hospital's annual report, in which the figure was calculated only on the basis of discharge data. On average only 77.2 (8.7%) of the days were spent in acute care. The remaining days were at the chronic level: 24.1% were spent waiting for completion of an application to a long-term care facility, 25.3% for application approval and 41.9% for an available bed in the assigned long-term care institution. For 30 patients no initiation of the discharge process was ever undertaken. As the number of patients in each progressive discharge stage decreased, the wait per patient increased. By the end of the study period only 32 patients had been transferred to a public long-term care facility; 22 were still in hospital, and 35 had died waiting for placement. Conclusions: Although considered to be a useful measure of hospital efficiency, length of stay determined from discharge data creates an iceberg effect when applied to chronic status patients in acute care hospitals. Lack of access to the assigned resource is the most important reason for a delay in discharge. Interventions, whether undertaken at the patient, hospital or provincial level, must to some degree address this issue. Further study is required to determine which risk factors will predict lags at each discharge stage. Since our discharge staging reflects not only the experience of the patient but also the utilization of hospital bed-days and access to provincial resources, it provides a common language for clinicians, hospital administrators and systems planners. Dr. McClaran is director ofgeriatric medicine, Montreal General Hospital, and associate professor offamily medicine and medicine, McGill University and McGill Centre for Studies in Ageing, Montreal, Que. Mrs. Tover-Berglas is a health care analyst at the Montreal General Hospital, Montreal, Que. Mrs. Glass is an associate member, McGill centres for Medicine, Ethics and Law andfor Studies in Ageing, Montreal, Que.
Reprint requests to: Dr. Jacqueline McClaran, Rm. 1754 W, Division of Geriatric Medicine, Montreal General Hospital, 1650 Cedar Ave.,
Montreal, PQ H3G IA4 -
For prescribing information see page 1392
CAN MED ASSOC J 1991; 145 (10)
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Objectif: Examiner la duree de sejour des malades chroniques dans un h6pital de soins aigus (actifs), identifier les etapes de la sortie qui contribuent a des sejours excessifs, estimer la duree du sejour a chaque etape de sortie et etablir le lien entre l'utilisation des jours-lits d'h6pital et le vecu du malade. Conception: Etude prospective de cohortes de 2 ans. Le nombre de jours d'hospitalisation, remontant a la date d'admission du sejour en cours, a ete inclus dans l'analyse. Contexte: H6pital universitaire. Patients: La totalite des 115 malades hospitalises que l'on a officiellement declares malades chroniques, le 31 juillet 1987. Mesures des resultats: Duree des sejours (jours totaux et jours au niveaux aigu et chronique) chez tous les malades chroniques, y compris ceux qui etaient encore a l'h6pital a la fin de la periode d'etude. Chaque jour-lit etait attribue a une etape de sortie qui correspondait a l'etat du malade. L'orientation de chaque malade a fait l'objet d'un examen a la fin de la periode d'etude. Resultats: Le groupe sous etude a passe en tout 101 585 jours a l'h6pital. La dur6e totale du sejour pour chaque patient constituait pres de quatre fois le sejour mentionne dans le rapport annuel de l'h6pital, ou ce nombre n'etait calcule qu'a partir des donnees sur les sorties. En moyenne, seulement 77,2 jours (8,7 %) etaient passes aux soins aigus. Les autres jours se deroulaient au niveau chronique: 24,1 % consistaient a attendre qu'on remplisse une demande d'admission a un etablissement de soins a long terme, 25,3 % s'ecoulaient pendant l'approbation de la demande et 41,9 % consistaient a attendre qu'un lit soit disponible dans 1'etablissement de soins a long terme designe. Chez 30 malades, on n'a jamais amorce le processus de sortie. A mesure que le nombre de malades diminuait a chaque etape progressive de sortie, l'attente augmentait par malade. A la fin de la periode d'etude, seulement 32 malades avaient ete diriges vers un etablissement public de soins a long terme; 22 etaient toujours a l'h6pital et 35 etaient decedes en attendant d'etre places. Conclusions: Meme si on le considere comme une mesure utile de l'efficacite des h6pitaux, le sejour determine a partir des donnees de sortie cree un effet d'iceberg lorsqu'on le transpose chez les malades chroniques dans les h6pitaux de soins aigus. L'inaccessibilite de la ressource attribuee est le plus important motif d'un delai de sortie. Qu'elles soient amorcees au palier du malade, de l'h6pital ou de la province, les interventions doivent dans une certaine mesure repondre a cette question. L'etude doit se poursuivre pour determiner quels facteurs de risque vont annoncer les ecarts A toutes les etapes de sortie. Puisque l'echelonnement des etapes de la sortie reflete non seulement le vecu du malade, mais aussi l'utilisation des jours-lits d'h6pital et l'acces aux ressources provinciales, elle constitue un langage commun aux cliniciens, aux administrateurs d'h6pitaux et aux planificateurs de systdmes.
N ursing shortages and budget cuts resulting in bed closures in Canada and the United States have made the acute care hospital bed a scarce resource.'-3 Compounding this problem is the inappropriate housing of chronic status patients in acute care beds.4-6 This continues to be the experience at the Montreal General Hospital, even after a universal provincial placement system was established in 1984. Some investigators have described patients at risk of becoming "bedblockers," so that early identification might lead to prompt discharge.6-9 Others have explored means of managing these patients in hospital.'0-'4 Still others have studied the effects of housing these patients in the acute care institution."'5 Evidently the phenomenon is not new.16 Studies undertaken to explain long hospital stays for patients who no longer require acute care cite lack of access to long-term care institutions and third-party payer status as important bar1260
CAN MED ASSOC J 1991; 145 (10)
riers.9'l0'l5-2' In addition, factors inherent to the discharge process have been found to contribute significantly to excessive stays.5,6,9 '0'7-27 Methods tend to rely only on discharge data.'9'2425 Reports that did include patients who were still in hospital at the end of study period did not attempt to show the influence of this hidden burden on the total length of stay.6-23 The result has been a systematic undersampling of patients who are still in hospital, who cannot purchase private care, who require too much or too specialized care or who are otherwise unattractive to alternative institutions and to community support services. Hence, underestimation of the length of stay and of the burden of chronic care on the acute care hospital is likely. Although some studies have attempted to separate hospital stay into stages, none has done this with the discharge process of patients who no longer require acute care, and none has looked at various phases of chronic care in acute care hospitals.4,2'-23 In addition, few studies have focused on ways in which LE 15 NOVEMBRE 1991
the actual discharge process may have impeded timely and appropriate placement, and no study with a bed-day analysis has linked data to specific stages of discharge so that potential interventions could be proposed. Hence, information on length of stay by discharge stage is unknown, and the responsibility for delay at each discharge stage has not been assigned. The following is a report of a 2-year prospective study carried out to examine the lengths of stay of chronic status patients in an acute care hospital, to identify discharge stages that contribute to excessive stays, to estimate the length of stay at each discharge stage and to link hospital bed-day utilization by the discharge stage to the experience of the patient.
Methods Study site The Montreal General Hospital serves a community health district of about 220 000 people and acts as a tertiary care referral centre for patients from outlying regions. This 686-bed facility has an occupancy rate of 83%.28 The Quebec Ministry of Social Affairs requires that all acute care hospitals reserve 10% of their beds for patients formally declared by the hospital as achieving chronic status. However, because of shortages of long-term care hospitals and of community support, the interim licensed complement was I 19 chronic status patients (17%) during the study period.
Study population Quebec's requirement to declare patients as achieving chronic status allows for identification of the study population. The patient's physician determines when acute care is complete and files the declaration. We included all patients with a formal chronic status who were in hospital as of midnight July 31, 1987. These patients were followed up prospectively until discharge or July 31, 1989, whichever came first. The number of hospital bed-days for each patient was identified both prospectively and retrospectively to the date of admission.
Data collection In the first phase of study the computerized hospital information system provided a printout identifying each patient at chronic status as well as the patient's medical record number, age, sex, admission date and ward of admission. The date that the chronic status was declared was supplied by NOVEMBER 15,1991
the hospital business office. Social service files were reviewed to determine whether the hospital had applied for public placement and whether the application had been processed and accepted by the designated provincial placement agency, and if so when. These data were cross-checked with files from the provincial social service centre responsible to the regional council for allocating patients to a level of care. In the second phase the collected data were updated for each study subject to July 31, 1989. The reason for admission and the date of death or discharge were taken from the hospital computer system and checked against the social service records and the hospital charts. The discharge destination was obtained from the social service records and the hospital charts.
Discharge process and hospital bed-day analysis There is a usual sequence of events for public placement from an acute care hospital: clinical recognition that the patient no longer requires acute care; formal declaration of the patient's chronic status by the attending physician to the hospital and, if approved, by the hospital to the Quebec Ministry of Social Affairs; submission of a standard provincial placement application by the hospital to the social service centre designated by the regional council according to district; approval of the application, first through allocation to a level of care by a multidisciplinary team representing the hospital's community health district and second through selection of the institution to receive the patient by another multidisciplinary team representing the community health district of the patient's original address (for the purposes of our study the application approval date was defined as the allocation date); and finally discharge and transfer to the selected facility. Although most hospital patients follow this sequence there may be exceptions. For example, a patient may have already applied for placement before he or she was declared as achieving chronic status; this may have happened while the patient was in the community or during a previous hospital stay. All exceptions were taken into account in the analysis of hospital bed-days. Each day accounted for by these patients was assigned to an exclusive bed-day category that reflected the discharge stage and described the experience of the patient in that stage. Stage I: The time spent in acute care. This includes the days spent by patients who eventually achieved chronic status but who were not yet formally declared by the admitting physician as having that status. CAN MED ASSOC J 1991; 145 (10)
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Stage II: The time spent waiting at the chronic level for the hospital to complete and submit the placement application. Stage III: The time spent waiting for the application to be processed and accepted. Stage IV: The time spent waiting for actual transfer to the designated long-term care facility.
Statistical analysis All data were entered into a computer with the use of dBase III Plus (Ashton-Tate, Torance, Calif.). Descriptive analysis was carried out for the length of stay at each discharge stage and for the utilization of
hospital bed-days.
Results Patient characteristics
chronic level, the average length of stay being 811.2 days; in the fiscal year that elapsed during the study period these patients alone accounted for 29 723 chronic status days.
Discharge stages Table 1 describes the average length of stay at each discharge stage and tracks the patient through the system. When the 1 1 5 acute care patients at stage I were declared as achieving chronic status 17 went directly to stage III (having already applied for placement) and 6 to stage IV (having already been accepted for placement). For the remaining 92 patients who progressed to stage II, 265.8 days on average elapsed before the hospital submitted a placement application. For 30 of these patients no application was ever submitted, and thus they did not progress to stage III during the study period; this failure was not simply a matter of limited study time, since the patients had already waited longer for application than the 62 who eventually progressed to stage III (353.6 v. 224.2 days re-
As of midnight July 31, 1987, 115 (19%) of the 594 beds were occupied by patients officially declared as achieving chronic status. These patients were located on all hospital wards and had a variety spectively). of diagnoses and functional characteristics. Most The 62 patients who progressed from stage II to (70) were women. The patient's age varied from 23 stage III were joined by the 17 from stage I; these 79 to 93 (mean 73.2 [standard deviation 17.4]) years. patients waited 324.9 days on average for the application to be processed and accepted. For 19 of them the application was never processed, so they reBed-day utilization and length of stay mained at stage III for the duration of the study. During their current hospital stays the patients Again, the failure to progress to stage IV was not accounted for 101 585 (mean 888.4) bed-days (Table simply a matter of the limited study period, since 1). Of those only 8880 days (8.7%) were for acute they waited longer for approval than the remaining care; the average length of stay for acute care was 60 patients (379.6 v. 307.7 days respectively). 77.2 days. The remaining 92 705 days were at the The 60 patients who progressed from stage III to Table 1: Hospital bed-day utilization and length of stay by discharge stage for chronic status patients in an acute care hospital Discharge stage
11
Ill lv
Patient status
Waiting for hospital to complete formal chronic status declaration Waiting for hospital to submit application for placement in public long-term care facility Waiting for processing and acceptance of application Waiting for actual transfer to long-term care facility
.All
No. (and O/%) of days in stage
No. of patients with any days at each stage
Mean no. of days per patient (and standard deviation)
(8.7)
115
77.2 (105.3)
Range of days. 1-625
24 453 (24.1)
92
265.8 (457.7)
0-1 843
25 671 (25.3)
79
324.9 (329.3)
0-2 254
42 581 (41.9)
66
645.2 (448.1)
32-1 907
101 585 (100.0)
115
.....
8 880
888^
*Since the number of patients reaching successive stages varied, the total number of days per patient
1262
CAN MED ASSOCJ 1991; 145 (10)
. 9)..*.. 4 (921
888.4 (921.9)* is
not the
sum
40-4 499
of the days at each stage.
LE 15 NOVEMBRE 1991
stage IV were joined by the 6 from stage
I.
These 66 having
had nearly completed the discharge been promised a bed in a long-term care facility. However, they had to wait an additional 645.2 days on average for the actual transfer. Thirty-four were never transferred. The number of patients expecting discharge diminished significantly at each stage. As patients progressed to subsequent stages the average wait lengthened, the number of days per patient nearly doubling in stage IV. Since the number of patients decreased as the stages increased, hospital resources allotted to successive stages would be expected to diminish. However, the increasing wait per patient at each progressive stage more than overcame the effect of the shrinking cohort (Fig. 1). Therefore, stage IV was the most important one for the hospital and the patient, accounting for 41.2% of all hospital days and 45.9% of chronic status days. Only 32 (28%) of the 115 patients completed stage IV and were transferred to the selected long-term care facility. Table 2 shows the outcome of the remaining 83 patients (30 at stage II, 19 at stage III and 34 at stage IV) at the end of the study period. process,
Discussion Length of stay
though considered to be a useful measure of hospital efficiency for diagnosis-related groups (DRGs) of acute care patients the length of stay determined from discharge data creates an iceberg effect when applied to chronic status patients, because most are never discharged within the fiscal year and are never counted. Thus, the hidden burden of chronic care on the acute care hospital is better revealed by bed-day utilization than by discharge data. Even this truncated cohort method systematically underestimated both the length of stay and the bed-day utilization, because 22 of the patients remained in hospital after the study was terminated. At the time this paper was written five patients were still in hospital, at least 3725 days escaped analysis, and the actual average total length of stay exceeded our estimate by at least 32.4 days. Perhaps even more startling is the fact that the patients in our study spent most (91.3%) of their hospital days waiting for an alternative resource. Even this proportion was likely an underestimate, since the actual chronic phase may have begun before the formal declaration was made; this is supported by the difference in the number of acute care days per admission in the hospital's annual report and our study (12.7 v. 77.2 days respectively). It would seem that even the most complicated DRGs are unlikely to explain this discrepancy. A further limitation of the study was that we did not include the days accounted for by patients declared as achieving chronic status after the start of the study.
Our findings not only confirm those of previous reports that hospital stays of chronic care patients in acute care hospitals are long, they also show that the stays are significantly longer than previously estimat- Discharge stages ed from discharge data.10,15,17,18 The average length of To our knowledge this is the first study to stay in our study population would have been identify placement delays in terms of both bed-day those on we relied had only calculated as 228.5 days and length of stay at each discharge stage. utilization in the to that hospital's data. This figure is similar Alstudies.10151718 in previous annual report and Table 2: Outcome of the 115 patients at the end of the study period 100 No. (and %) of patients Outcome Transferred to public
long-term care facility*
Died in hospital Stilt in hospital Home with family Transferred to public
4)
II
ll
IV
Discharge stages
Fig. 1: Proportion of patients (black bars) and of total days (white bars) at each discharge stage and proportion of cumulative days (diagonally striped bars) at each stage. NOVEMBER 15, 1991
or private boarding home Transferred to private long-term care facility
Other
32 (28)
35 (30)
22 (19) 11 (10)
9 (8) 5 (4) 1 (1)
Stage IV is a prerequisite for discharge to a public facility; however, patients may achieve other destinations from stages II, IlIl and IV.
CAN MED ASSOC J 1991; 145 (10)
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.l
Our findings agree with those of studies that examined bed-blocking problems,4,2'-23 identified the lack of discharge planning5'6 and suggested that hospitals impede the discharge process.'8 As Quebec begins to reward hospitals for their efficiency the length of stay of acute care patients will diminish. Presumably this trend will affect patients destined to achieve chronic status, in that their stay in stage I will be shorter. If the alternative to long stays is step-down care, rehabilitation or other discharge planning, the patient's quality of life may also improve. The number of days spent in stage II is the responsibility of the hospital, and it could be reduced. On the same day the patient is declared as achieving chronic status the hospital could submit a placement application. Even if a generous 30-day period were allowed so that all members of the health care team could meet, assess the patient's status, talk with the patient and his or her family and complete the application form 88.7% of the days currently spent at this stage would be eliminated. In addition, the 30 patients who were stuck at stage II during the study period would have moved at least to the next stage. For some patients placement in a public facility may not be appropriate. These patients could be identified and other discharge planning undertaken. For all stage II patients the uncertainty of having progressed from acute care without a discharge plan should be addressed. The days spent in stage III are the shared responsibility of the hospital and the province. Of the 325 days per patient the two-tiered provincial review process accounts for 2 weeks to 3 months. At the time this paper was written the regional council was streamlining and revising its allocation and preadmission procedures.29 Hospital delays at stage III are most often related to poor quality of the data provided in the medical portion of the application. Discrepancies in functional level as reported by the hospital nurse, social worker and physician also contribute to a high rate of return of applications to the hospital (Mr. Barry Pratt, chairman, Allocation Committee: personal communication, 1990). A few applications are refused because the number of nursing hours required is too low to warrant placement. Such patients are expected to receive home care or to be placed in a contracted boarding home by the hospital. If 200 days per patient could be redressed through modifications in hospital procedure and improvements in the quality of applications the number of bed-days would decrease by 61.5%, from 25 671 to 9871 days. However, hospital personnel believe that the provincial placement form is unnecessarily long and complicated. In addition, there is little understanding of the contribution of health care professionals, particularly physicians, in 1264
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determining functional level and hence allocation to level of care. Finally, the priority in which patients have final access to the selected long-term care facility is directly related to the number of applications on file from each acute care hospital. The hospital clinician requesting service for one patient at a time is usually unaware of these factors. An important educational effort would likely be required to affect these attitudes and behaviours. It can only be beneficial for the patient and his or her family to know in anything less than 10 months whether the patient has been accepted for placement and, if so, where. This is so for ethical and practical reasons, since stage III likely spans the closure of the patient's home and the distribution of his or her possessions. The days spent in stage IV are the responsibility of the province. This, the largest bed-day category, reflects an access problem: fewer than half of the patients who reached this stage were transferred to their final destination. Many have explored the notion that the lack of availability of beds in nursing homes impedes timely discharges and contributes to excessive stays.17-21,27 Financial barriers have also been found to delay placement.9"19'26 Others have suggested that the selection from waiting lists of patients for nursing home care has made access difficult for the least desirable patients.'8-20'26'27 Nevertheless, the magnitude of the access problem, as revealed by staging of the discharge process, is shocking. Our findings would correspond reasonably well to those of the regional council except that the council includes the chronic bed quota of acute care hospitals in its calculation of long-stay resources.30 Perhaps it is the intent of the regional council to allow bed-blocking to close some acute care resources and to force the remaining acute care beds to operate more efficiently. If so, the patient should not be led to believe that a more appropriate resource will be made available elsewhere, if only he or she lives long enough. The increase in the patient's wait for placement at each discharge stage may indicate that the effects of excessive days at the final stage trickled backward to the preceding stages. It may also reflect a lack of coordination between the hospital and the community resources responsible for patient placement, as these effects would be felt at each stage of discharge.'0 The physician and the hospital would do their best for the patient by shortening stages I through III. However, unless the access issue is addressed bottlenecking at stage IV will occur, and the total number of hospital days may not decrease. Although we would expect that fewer patients per stage would mean fewer bed-days per stage, the reverse is true. Consequently, stage IV is the most important stage in terms of not only the patient's LE 15 NOVEMBRE 1991
experience but also the total bed-day utilization. This is fortunate only to the extent that patients, health care providers and health care planners would have similar priorities. The social and economic implications of a society expecting 14% of its elderly population to be housed by the state are beyond the scope of this paper. Since demands for medical care, hospital beds or admissions to an institution are not necessarily correlated with improved community services, these issues are complicated.31 Further study is required to determine which risk factors will predict lags at each discharge stage. DRG analysis could be useful for chronic status patients if it is applied at each discharge stage rather than at the final discharge. Since our staging reflects the experience of the patient as well as the utilization of hospital bed-days and access to provincial resources, it provides a common language for clinicians, hospital administrators and systems planners. The Helen McCall Hutchison Gerontology Fund provided support for Mrs. Tover-Berglas, and the Department of Medicine, Montreal General Hospital, provided support for Mrs. Glass during the early phases of data collection and methods development.
References 1. Detsky AS, O'Rourke K, Naylor CD et al: Containing Ontario's hospital costs under universal insurance in the 1980s: What was the record? Can Med Assoc J 1990; 142: 565-572 2. Mullner R, Whiteis DG, McNeil D: Record year for closures in 1987. Hospitals 1988; 62 (7): 33, 36 3. Robinson ML: Economists see closures, cost cuts ahead. Hospitals 1988; 62 (1): 23, 26 4. Lewis H, Purdie G: The blocked bed, a prospective study. NZ MedJ 1988; 101: 575-577 5. Murphy FW: Blocked beds. BMJ 1977; 1: 1395-1396 6. Coid J, Crome P: Bed blocking in Bromely. BMJ 1986; 292: 1253-1256 7. Hodkinson I, Hodkinson HM: The long stay patient. Gerontology 1981; 27: 167-172 8. Maguire PA, Taylor IC, Stout RW: Elderly patients in acute medical wards: factors predicting length of stay in hospital. BMJ 1986; 292: 125 1-1253 9. Weissert WG, Cready CM: Determinants of hospital-to-nursing home placement delays: a pilot study. Health Serv Res
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1988; 23: 619-647 10. Barker WH, Williams TF, Zimmer JG et al: Geriatric consultation teams in acute hospitals: impact on back-up of elderly patients. JAm Geriatr Soc 1985; 33: 422-428 11. Campion EW, Bang A, May MI: Why acute care hospitals must undertake long term care. N Engl J Med 1983; 308: 71 75 12. Gayton D, Wood-Dauphinee S, de Lorimer M et al: Trial of a geriatric consultation team in an acute care hospital. J Am Geriatr Soc 1987; 35: 726-736 13. Pawlson LG: Hospital length of stay of frail elderly patients. J Am Geriatr Soc 1988; 36: 202-208 14. Wells DL, Adolphus PD: Evaluating the care provided to long stay patients. Dimens Health Serv 1987; 64 (8): 20-22 15. Hochstein A: Treating long stay patients in acute hospital beds: an economic diagnosis. Gerontologist 1985; 25: 161-165 16. McArdle C, Wylie JC, Alexander WD: Geriatric patients in an acute medical ward. BMJ 1975; 4: 568-569 17. Coburn AF, Fortinsky RH, McGuire CA: The impact of Medicaid reimbursement policy on subacute care in hospitals. Med Care 1989; 27: 25-33 18. Gruenberg LW, Willemain TR: Hospital discharge queues in Massachusetts. Med Care 1982; 20: 188-201 19. Kenney G, Holahan J: The nursing home market and hospital discharge delays. Inquiry 1990; 27: 73-85 20. Rubin SG, Davies GH: Bed blocking by elderly patients in general hospital wards. Age Ageing 1985; 4: 142-147 21. Selker HP, Beshansky JR, Pauker SG et al: The epidemiology of delays in a teaching hospital: the development and use of a tool that detects unnecessary hospital days. Med Care 1989; 27: 112-122 22. Anderson P, Meara J, Brodhurst S et al: Use of hospital beds: a cohort study of admissions to a provincial teaching hospital. BMJ 1988; 297: 910-912 23. Beveridge P: Staging acute medical care for the elderly: an analysis of patient admissions. NZ Med J 1986; 79: 461-464 24. Cable EP, Mayers SP Jr: Discharge planning effect on length of hospital stay. Arch Phys Med Rehabil 1983; 64: 57-60 25. Kane RL, Mathias R, Sampson S: The risk of placement in a nursing home after acute hospitalization. Med Care 1983; 21:
1055-1061 26. Lagoe RJ: A community wide effort to reduce hospital utilization by patients requiring nursing home placement. Gerontologist 1989; 29: 67-73 27. Shapiro E, Roos NP: The geriatric long-stay hospital patient: a Canadian case study. J Health Polit Policy Law 1981; 6: 4961 28. Annual Report, Montreal General Hospital, Montreal, 1988 29. Systeme de CTMSP, Conseil de la sante et des services de la region de Montreal metropolitain, Montreal, 1991: annexe B 30. Rapport du Comitd des soins de longue duree en CHSCD, Conseil de la sante et des services de la region de Montreal metropolitain, Montr6al, 1990 31. Shapiro E, Tate RB: Is health care use changing? A comparison between physician, hospital, nursing-home and home-care use of two elderly cohorts. Med Care 1989; 27: 1002-1014
CAN MED ASSOC J 1991; 145 (10)
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Chronic status patients in a university hospital: bed-day utilization and length of stay Jacqueline McClaran, MD, FCFPC; Robin Tover-Berglas, BA, MPA; Kathleen Cranley Glass, MA, LLB, BCL Objective: To examine the lengths of stay of chronic status patients in an acute care hospital, to identify discharge stages that contribute to excessive stays, to estimate the length of stay at each discharge stage and to link hospital bed-day utilization by the discharge stage to the experience of the patient. Design: Two-year prospective cohort study. The number of hospital days retrospective to the date of the current admission were included in the analysis. Setting: University hospital. Patients: All 115 inpatients formally declared as achieving chronic status by July 31, 1987. Outcome measures: Lengths of stay (total days and days at acute and chronic status) for chronic status patients, including those still in hospital at the end of the study period. Each bed-day was assigned to a discharge stage that corresponded to the patient's status. The disposition of each patient by the end of the study period was reviewed. Results: The study population spent a total of 101 585 days in hospital. The total length of stay per patient was nearly four times that stated in the hospital's annual report, in which the figure was calculated only on the basis of discharge data. On average only 77.2 (8.7%) of the days were spent in acute care. The remaining days were at the chronic level: 24.1% were spent waiting for completion of an application to a long-term care facility, 25.3% for application approval and 41.9% for an available bed in the assigned long-term care institution. For 30 patients no initiation of the discharge process was ever undertaken. As the number of patients in each progressive discharge stage decreased, the wait per patient increased. By the end of the study period only 32 patients had been transferred to a public long-term care facility; 22 were still in hospital, and 35 had died waiting for placement. Conclusions: Although considered to be a useful measure of hospital efficiency, length of stay determined from discharge data creates an iceberg effect when applied to chronic status patients in acute care hospitals. Lack of access to the assigned resource is the most important reason for a delay in discharge. Interventions, whether undertaken at the patient, hospital or provincial level, must to some degree address this issue. Further study is required to determine which risk factors will predict lags at each discharge stage. Since our discharge staging reflects not only the experience of the patient but also the utilization of hospital bed-days and access to provincial resources, it provides a common language for clinicians, hospital administrators and systems planners. Dr. McClaran is director ofgeriatric medicine, Montreal General Hospital, and associate professor offamily medicine and medicine, McGill University and McGill Centre for Studies in Ageing, Montreal, Que. Mrs. Tover-Berglas is a health care analyst at the Montreal General Hospital, Montreal, Que. Mrs. Glass is an associate member, McGill centres for Medicine, Ethics and Law andfor Studies in Ageing, Montreal, Que.
Reprint requests to: Dr. Jacqueline McClaran, Rm. 1754 W, Division of Geriatric Medicine, Montreal General Hospital, 1650 Cedar Ave.,
Montreal, PQ H3G IA4 -
For prescribing information see page 1392
CAN MED ASSOC J 1991; 145 (10)
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Objectif: Examiner la duree de sejour des malades chroniques dans un h6pital de soins aigus (actifs), identifier les etapes de la sortie qui contribuent a des sejours excessifs, estimer la duree du sejour a chaque etape de sortie et etablir le lien entre l'utilisation des jours-lits d'h6pital et le vecu du malade. Conception: Etude prospective de cohortes de 2 ans. Le nombre de jours d'hospitalisation, remontant a la date d'admission du sejour en cours, a ete inclus dans l'analyse. Contexte: H6pital universitaire. Patients: La totalite des 115 malades hospitalises que l'on a officiellement declares malades chroniques, le 31 juillet 1987. Mesures des resultats: Duree des sejours (jours totaux et jours au niveaux aigu et chronique) chez tous les malades chroniques, y compris ceux qui etaient encore a l'h6pital a la fin de la periode d'etude. Chaque jour-lit etait attribue a une etape de sortie qui correspondait a l'etat du malade. L'orientation de chaque malade a fait l'objet d'un examen a la fin de la periode d'etude. Resultats: Le groupe sous etude a passe en tout 101 585 jours a l'h6pital. La dur6e totale du sejour pour chaque patient constituait pres de quatre fois le sejour mentionne dans le rapport annuel de l'h6pital, ou ce nombre n'etait calcule qu'a partir des donnees sur les sorties. En moyenne, seulement 77,2 jours (8,7 %) etaient passes aux soins aigus. Les autres jours se deroulaient au niveau chronique: 24,1 % consistaient a attendre qu'on remplisse une demande d'admission a un etablissement de soins a long terme, 25,3 % s'ecoulaient pendant l'approbation de la demande et 41,9 % consistaient a attendre qu'un lit soit disponible dans 1'etablissement de soins a long terme designe. Chez 30 malades, on n'a jamais amorce le processus de sortie. A mesure que le nombre de malades diminuait a chaque etape progressive de sortie, l'attente augmentait par malade. A la fin de la periode d'etude, seulement 32 malades avaient ete diriges vers un etablissement public de soins a long terme; 22 etaient toujours a l'h6pital et 35 etaient decedes en attendant d'etre places. Conclusions: Meme si on le considere comme une mesure utile de l'efficacite des h6pitaux, le sejour determine a partir des donnees de sortie cree un effet d'iceberg lorsqu'on le transpose chez les malades chroniques dans les h6pitaux de soins aigus. L'inaccessibilite de la ressource attribuee est le plus important motif d'un delai de sortie. Qu'elles soient amorcees au palier du malade, de l'h6pital ou de la province, les interventions doivent dans une certaine mesure repondre a cette question. L'etude doit se poursuivre pour determiner quels facteurs de risque vont annoncer les ecarts A toutes les etapes de sortie. Puisque l'echelonnement des etapes de la sortie reflete non seulement le vecu du malade, mais aussi l'utilisation des jours-lits d'h6pital et l'acces aux ressources provinciales, elle constitue un langage commun aux cliniciens, aux administrateurs d'h6pitaux et aux planificateurs de systdmes.
N ursing shortages and budget cuts resulting in bed closures in Canada and the United States have made the acute care hospital bed a scarce resource.'-3 Compounding this problem is the inappropriate housing of chronic status patients in acute care beds.4-6 This continues to be the experience at the Montreal General Hospital, even after a universal provincial placement system was established in 1984. Some investigators have described patients at risk of becoming "bedblockers," so that early identification might lead to prompt discharge.6-9 Others have explored means of managing these patients in hospital.'0-'4 Still others have studied the effects of housing these patients in the acute care institution."'5 Evidently the phenomenon is not new.16 Studies undertaken to explain long hospital stays for patients who no longer require acute care cite lack of access to long-term care institutions and third-party payer status as important bar1260
CAN MED ASSOC J 1991; 145 (10)
riers.9'l0'l5-2' In addition, factors inherent to the discharge process have been found to contribute significantly to excessive stays.5,6,9 '0'7-27 Methods tend to rely only on discharge data.'9'2425 Reports that did include patients who were still in hospital at the end of study period did not attempt to show the influence of this hidden burden on the total length of stay.6-23 The result has been a systematic undersampling of patients who are still in hospital, who cannot purchase private care, who require too much or too specialized care or who are otherwise unattractive to alternative institutions and to community support services. Hence, underestimation of the length of stay and of the burden of chronic care on the acute care hospital is likely. Although some studies have attempted to separate hospital stay into stages, none has done this with the discharge process of patients who no longer require acute care, and none has looked at various phases of chronic care in acute care hospitals.4,2'-23 In addition, few studies have focused on ways in which LE 15 NOVEMBRE 1991
the actual discharge process may have impeded timely and appropriate placement, and no study with a bed-day analysis has linked data to specific stages of discharge so that potential interventions could be proposed. Hence, information on length of stay by discharge stage is unknown, and the responsibility for delay at each discharge stage has not been assigned. The following is a report of a 2-year prospective study carried out to examine the lengths of stay of chronic status patients in an acute care hospital, to identify discharge stages that contribute to excessive stays, to estimate the length of stay at each discharge stage and to link hospital bed-day utilization by the discharge stage to the experience of the patient.
Methods Study site The Montreal General Hospital serves a community health district of about 220 000 people and acts as a tertiary care referral centre for patients from outlying regions. This 686-bed facility has an occupancy rate of 83%.28 The Quebec Ministry of Social Affairs requires that all acute care hospitals reserve 10% of their beds for patients formally declared by the hospital as achieving chronic status. However, because of shortages of long-term care hospitals and of community support, the interim licensed complement was I 19 chronic status patients (17%) during the study period.
Study population Quebec's requirement to declare patients as achieving chronic status allows for identification of the study population. The patient's physician determines when acute care is complete and files the declaration. We included all patients with a formal chronic status who were in hospital as of midnight July 31, 1987. These patients were followed up prospectively until discharge or July 31, 1989, whichever came first. The number of hospital bed-days for each patient was identified both prospectively and retrospectively to the date of admission.
Data collection In the first phase of study the computerized hospital information system provided a printout identifying each patient at chronic status as well as the patient's medical record number, age, sex, admission date and ward of admission. The date that the chronic status was declared was supplied by NOVEMBER 15,1991
the hospital business office. Social service files were reviewed to determine whether the hospital had applied for public placement and whether the application had been processed and accepted by the designated provincial placement agency, and if so when. These data were cross-checked with files from the provincial social service centre responsible to the regional council for allocating patients to a level of care. In the second phase the collected data were updated for each study subject to July 31, 1989. The reason for admission and the date of death or discharge were taken from the hospital computer system and checked against the social service records and the hospital charts. The discharge destination was obtained from the social service records and the hospital charts.
Discharge process and hospital bed-day analysis There is a usual sequence of events for public placement from an acute care hospital: clinical recognition that the patient no longer requires acute care; formal declaration of the patient's chronic status by the attending physician to the hospital and, if approved, by the hospital to the Quebec Ministry of Social Affairs; submission of a standard provincial placement application by the hospital to the social service centre designated by the regional council according to district; approval of the application, first through allocation to a level of care by a multidisciplinary team representing the hospital's community health district and second through selection of the institution to receive the patient by another multidisciplinary team representing the community health district of the patient's original address (for the purposes of our study the application approval date was defined as the allocation date); and finally discharge and transfer to the selected facility. Although most hospital patients follow this sequence there may be exceptions. For example, a patient may have already applied for placement before he or she was declared as achieving chronic status; this may have happened while the patient was in the community or during a previous hospital stay. All exceptions were taken into account in the analysis of hospital bed-days. Each day accounted for by these patients was assigned to an exclusive bed-day category that reflected the discharge stage and described the experience of the patient in that stage. Stage I: The time spent in acute care. This includes the days spent by patients who eventually achieved chronic status but who were not yet formally declared by the admitting physician as having that status. CAN MED ASSOC J 1991; 145 (10)
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Stage II: The time spent waiting at the chronic level for the hospital to complete and submit the placement application. Stage III: The time spent waiting for the application to be processed and accepted. Stage IV: The time spent waiting for actual transfer to the designated long-term care facility.
Statistical analysis All data were entered into a computer with the use of dBase III Plus (Ashton-Tate, Torance, Calif.). Descriptive analysis was carried out for the length of stay at each discharge stage and for the utilization of
hospital bed-days.
Results Patient characteristics
chronic level, the average length of stay being 811.2 days; in the fiscal year that elapsed during the study period these patients alone accounted for 29 723 chronic status days.
Discharge stages Table 1 describes the average length of stay at each discharge stage and tracks the patient through the system. When the 1 1 5 acute care patients at stage I were declared as achieving chronic status 17 went directly to stage III (having already applied for placement) and 6 to stage IV (having already been accepted for placement). For the remaining 92 patients who progressed to stage II, 265.8 days on average elapsed before the hospital submitted a placement application. For 30 of these patients no application was ever submitted, and thus they did not progress to stage III during the study period; this failure was not simply a matter of limited study time, since the patients had already waited longer for application than the 62 who eventually progressed to stage III (353.6 v. 224.2 days re-
As of midnight July 31, 1987, 115 (19%) of the 594 beds were occupied by patients officially declared as achieving chronic status. These patients were located on all hospital wards and had a variety spectively). of diagnoses and functional characteristics. Most The 62 patients who progressed from stage II to (70) were women. The patient's age varied from 23 stage III were joined by the 17 from stage I; these 79 to 93 (mean 73.2 [standard deviation 17.4]) years. patients waited 324.9 days on average for the application to be processed and accepted. For 19 of them the application was never processed, so they reBed-day utilization and length of stay mained at stage III for the duration of the study. During their current hospital stays the patients Again, the failure to progress to stage IV was not accounted for 101 585 (mean 888.4) bed-days (Table simply a matter of the limited study period, since 1). Of those only 8880 days (8.7%) were for acute they waited longer for approval than the remaining care; the average length of stay for acute care was 60 patients (379.6 v. 307.7 days respectively). 77.2 days. The remaining 92 705 days were at the The 60 patients who progressed from stage III to Table 1: Hospital bed-day utilization and length of stay by discharge stage for chronic status patients in an acute care hospital Discharge stage
11
Ill lv
Patient status
Waiting for hospital to complete formal chronic status declaration Waiting for hospital to submit application for placement in public long-term care facility Waiting for processing and acceptance of application Waiting for actual transfer to long-term care facility
.All
No. (and O/%) of days in stage
No. of patients with any days at each stage
Mean no. of days per patient (and standard deviation)
(8.7)
115
77.2 (105.3)
Range of days. 1-625
24 453 (24.1)
92
265.8 (457.7)
0-1 843
25 671 (25.3)
79
324.9 (329.3)
0-2 254
42 581 (41.9)
66
645.2 (448.1)
32-1 907
101 585 (100.0)
115
.....
8 880
888^
*Since the number of patients reaching successive stages varied, the total number of days per patient
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CAN MED ASSOCJ 1991; 145 (10)
. 9)..*.. 4 (921
888.4 (921.9)* is
not the
sum
40-4 499
of the days at each stage.
LE 15 NOVEMBRE 1991
stage IV were joined by the 6 from stage
I.
These 66 having
had nearly completed the discharge been promised a bed in a long-term care facility. However, they had to wait an additional 645.2 days on average for the actual transfer. Thirty-four were never transferred. The number of patients expecting discharge diminished significantly at each stage. As patients progressed to subsequent stages the average wait lengthened, the number of days per patient nearly doubling in stage IV. Since the number of patients decreased as the stages increased, hospital resources allotted to successive stages would be expected to diminish. However, the increasing wait per patient at each progressive stage more than overcame the effect of the shrinking cohort (Fig. 1). Therefore, stage IV was the most important one for the hospital and the patient, accounting for 41.2% of all hospital days and 45.9% of chronic status days. Only 32 (28%) of the 115 patients completed stage IV and were transferred to the selected long-term care facility. Table 2 shows the outcome of the remaining 83 patients (30 at stage II, 19 at stage III and 34 at stage IV) at the end of the study period. process,
Discussion Length of stay
though considered to be a useful measure of hospital efficiency for diagnosis-related groups (DRGs) of acute care patients the length of stay determined from discharge data creates an iceberg effect when applied to chronic status patients, because most are never discharged within the fiscal year and are never counted. Thus, the hidden burden of chronic care on the acute care hospital is better revealed by bed-day utilization than by discharge data. Even this truncated cohort method systematically underestimated both the length of stay and the bed-day utilization, because 22 of the patients remained in hospital after the study was terminated. At the time this paper was written five patients were still in hospital, at least 3725 days escaped analysis, and the actual average total length of stay exceeded our estimate by at least 32.4 days. Perhaps even more startling is the fact that the patients in our study spent most (91.3%) of their hospital days waiting for an alternative resource. Even this proportion was likely an underestimate, since the actual chronic phase may have begun before the formal declaration was made; this is supported by the difference in the number of acute care days per admission in the hospital's annual report and our study (12.7 v. 77.2 days respectively). It would seem that even the most complicated DRGs are unlikely to explain this discrepancy. A further limitation of the study was that we did not include the days accounted for by patients declared as achieving chronic status after the start of the study.
Our findings not only confirm those of previous reports that hospital stays of chronic care patients in acute care hospitals are long, they also show that the stays are significantly longer than previously estimat- Discharge stages ed from discharge data.10,15,17,18 The average length of To our knowledge this is the first study to stay in our study population would have been identify placement delays in terms of both bed-day those on we relied had only calculated as 228.5 days and length of stay at each discharge stage. utilization in the to that hospital's data. This figure is similar Alstudies.10151718 in previous annual report and Table 2: Outcome of the 115 patients at the end of the study period 100 No. (and %) of patients Outcome Transferred to public
long-term care facility*
Died in hospital Stilt in hospital Home with family Transferred to public
4)
II
ll
IV
Discharge stages
Fig. 1: Proportion of patients (black bars) and of total days (white bars) at each discharge stage and proportion of cumulative days (diagonally striped bars) at each stage. NOVEMBER 15, 1991
or private boarding home Transferred to private long-term care facility
Other
32 (28)
35 (30)
22 (19) 11 (10)
9 (8) 5 (4) 1 (1)
Stage IV is a prerequisite for discharge to a public facility; however, patients may achieve other destinations from stages II, IlIl and IV.
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.l
Our findings agree with those of studies that examined bed-blocking problems,4,2'-23 identified the lack of discharge planning5'6 and suggested that hospitals impede the discharge process.'8 As Quebec begins to reward hospitals for their efficiency the length of stay of acute care patients will diminish. Presumably this trend will affect patients destined to achieve chronic status, in that their stay in stage I will be shorter. If the alternative to long stays is step-down care, rehabilitation or other discharge planning, the patient's quality of life may also improve. The number of days spent in stage II is the responsibility of the hospital, and it could be reduced. On the same day the patient is declared as achieving chronic status the hospital could submit a placement application. Even if a generous 30-day period were allowed so that all members of the health care team could meet, assess the patient's status, talk with the patient and his or her family and complete the application form 88.7% of the days currently spent at this stage would be eliminated. In addition, the 30 patients who were stuck at stage II during the study period would have moved at least to the next stage. For some patients placement in a public facility may not be appropriate. These patients could be identified and other discharge planning undertaken. For all stage II patients the uncertainty of having progressed from acute care without a discharge plan should be addressed. The days spent in stage III are the shared responsibility of the hospital and the province. Of the 325 days per patient the two-tiered provincial review process accounts for 2 weeks to 3 months. At the time this paper was written the regional council was streamlining and revising its allocation and preadmission procedures.29 Hospital delays at stage III are most often related to poor quality of the data provided in the medical portion of the application. Discrepancies in functional level as reported by the hospital nurse, social worker and physician also contribute to a high rate of return of applications to the hospital (Mr. Barry Pratt, chairman, Allocation Committee: personal communication, 1990). A few applications are refused because the number of nursing hours required is too low to warrant placement. Such patients are expected to receive home care or to be placed in a contracted boarding home by the hospital. If 200 days per patient could be redressed through modifications in hospital procedure and improvements in the quality of applications the number of bed-days would decrease by 61.5%, from 25 671 to 9871 days. However, hospital personnel believe that the provincial placement form is unnecessarily long and complicated. In addition, there is little understanding of the contribution of health care professionals, particularly physicians, in 1264
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determining functional level and hence allocation to level of care. Finally, the priority in which patients have final access to the selected long-term care facility is directly related to the number of applications on file from each acute care hospital. The hospital clinician requesting service for one patient at a time is usually unaware of these factors. An important educational effort would likely be required to affect these attitudes and behaviours. It can only be beneficial for the patient and his or her family to know in anything less than 10 months whether the patient has been accepted for placement and, if so, where. This is so for ethical and practical reasons, since stage III likely spans the closure of the patient's home and the distribution of his or her possessions. The days spent in stage IV are the responsibility of the province. This, the largest bed-day category, reflects an access problem: fewer than half of the patients who reached this stage were transferred to their final destination. Many have explored the notion that the lack of availability of beds in nursing homes impedes timely discharges and contributes to excessive stays.17-21,27 Financial barriers have also been found to delay placement.9"19'26 Others have suggested that the selection from waiting lists of patients for nursing home care has made access difficult for the least desirable patients.'8-20'26'27 Nevertheless, the magnitude of the access problem, as revealed by staging of the discharge process, is shocking. Our findings would correspond reasonably well to those of the regional council except that the council includes the chronic bed quota of acute care hospitals in its calculation of long-stay resources.30 Perhaps it is the intent of the regional council to allow bed-blocking to close some acute care resources and to force the remaining acute care beds to operate more efficiently. If so, the patient should not be led to believe that a more appropriate resource will be made available elsewhere, if only he or she lives long enough. The increase in the patient's wait for placement at each discharge stage may indicate that the effects of excessive days at the final stage trickled backward to the preceding stages. It may also reflect a lack of coordination between the hospital and the community resources responsible for patient placement, as these effects would be felt at each stage of discharge.'0 The physician and the hospital would do their best for the patient by shortening stages I through III. However, unless the access issue is addressed bottlenecking at stage IV will occur, and the total number of hospital days may not decrease. Although we would expect that fewer patients per stage would mean fewer bed-days per stage, the reverse is true. Consequently, stage IV is the most important stage in terms of not only the patient's LE 15 NOVEMBRE 1991
experience but also the total bed-day utilization. This is fortunate only to the extent that patients, health care providers and health care planners would have similar priorities. The social and economic implications of a society expecting 14% of its elderly population to be housed by the state are beyond the scope of this paper. Since demands for medical care, hospital beds or admissions to an institution are not necessarily correlated with improved community services, these issues are complicated.31 Further study is required to determine which risk factors will predict lags at each discharge stage. DRG analysis could be useful for chronic status patients if it is applied at each discharge stage rather than at the final discharge. Since our staging reflects the experience of the patient as well as the utilization of hospital bed-days and access to provincial resources, it provides a common language for clinicians, hospital administrators and systems planners. The Helen McCall Hutchison Gerontology Fund provided support for Mrs. Tover-Berglas, and the Department of Medicine, Montreal General Hospital, provided support for Mrs. Glass during the early phases of data collection and methods development.
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1988; 23: 619-647 10. Barker WH, Williams TF, Zimmer JG et al: Geriatric consultation teams in acute hospitals: impact on back-up of elderly patients. JAm Geriatr Soc 1985; 33: 422-428 11. Campion EW, Bang A, May MI: Why acute care hospitals must undertake long term care. N Engl J Med 1983; 308: 71 75 12. Gayton D, Wood-Dauphinee S, de Lorimer M et al: Trial of a geriatric consultation team in an acute care hospital. J Am Geriatr Soc 1987; 35: 726-736 13. Pawlson LG: Hospital length of stay of frail elderly patients. J Am Geriatr Soc 1988; 36: 202-208 14. Wells DL, Adolphus PD: Evaluating the care provided to long stay patients. Dimens Health Serv 1987; 64 (8): 20-22 15. Hochstein A: Treating long stay patients in acute hospital beds: an economic diagnosis. Gerontologist 1985; 25: 161-165 16. McArdle C, Wylie JC, Alexander WD: Geriatric patients in an acute medical ward. BMJ 1975; 4: 568-569 17. Coburn AF, Fortinsky RH, McGuire CA: The impact of Medicaid reimbursement policy on subacute care in hospitals. Med Care 1989; 27: 25-33 18. Gruenberg LW, Willemain TR: Hospital discharge queues in Massachusetts. Med Care 1982; 20: 188-201 19. Kenney G, Holahan J: The nursing home market and hospital discharge delays. Inquiry 1990; 27: 73-85 20. Rubin SG, Davies GH: Bed blocking by elderly patients in general hospital wards. Age Ageing 1985; 4: 142-147 21. Selker HP, Beshansky JR, Pauker SG et al: The epidemiology of delays in a teaching hospital: the development and use of a tool that detects unnecessary hospital days. Med Care 1989; 27: 112-122 22. Anderson P, Meara J, Brodhurst S et al: Use of hospital beds: a cohort study of admissions to a provincial teaching hospital. BMJ 1988; 297: 910-912 23. Beveridge P: Staging acute medical care for the elderly: an analysis of patient admissions. NZ Med J 1986; 79: 461-464 24. Cable EP, Mayers SP Jr: Discharge planning effect on length of hospital stay. Arch Phys Med Rehabil 1983; 64: 57-60 25. Kane RL, Mathias R, Sampson S: The risk of placement in a nursing home after acute hospitalization. Med Care 1983; 21:
1055-1061 26. Lagoe RJ: A community wide effort to reduce hospital utilization by patients requiring nursing home placement. Gerontologist 1989; 29: 67-73 27. Shapiro E, Roos NP: The geriatric long-stay hospital patient: a Canadian case study. J Health Polit Policy Law 1981; 6: 4961 28. Annual Report, Montreal General Hospital, Montreal, 1988 29. Systeme de CTMSP, Conseil de la sante et des services de la region de Montreal metropolitain, Montreal, 1991: annexe B 30. Rapport du Comitd des soins de longue duree en CHSCD, Conseil de la sante et des services de la region de Montreal metropolitain, Montr6al, 1990 31. Shapiro E, Tate RB: Is health care use changing? A comparison between physician, hospital, nursing-home and home-care use of two elderly cohorts. Med Care 1989; 27: 1002-1014
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