Adult cardiac surgery during COVID-19 lockdown: Impact on activity and outcomes in a high-volume centre.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak had a direct impact on adult cardiac surgery activity, which systematically necessitates a postoperative stay in intensive care. AIM: To study the effect of the COVID-19 lockdown on cardiac surgery activity and outcomes, by making a comparison with the corresponding period in 2019. METHODS: This prospective observational cohort study compared adult cardiac surgery activity in our high-volume referral university hospital from 9 March to 10 May 2020 versus 9 March to 10 May 2019. Data were collected in our local certified database and a national database sponsored by the French society of thoracic and cardiovascular surgery. The primary study endpoints were operative mortality and postoperative complications. RESULTS: With 105 interventions in 2020, our activity dropped by 57% compared with the same period in 2019. Patients were at higher risk, with a significantly higher EuroSCORE II score (3.8±4.5% vs. 2.0±1.8%; P<0.001) and higher rates of active endocarditis (7.6% vs. 2.9%; P=0.047) and recent myocardial infarction (9.5% vs. 0%; P<0.001). The weight and priority of the interventions were significantly different in 2020 (P=0.019 and P<0.001, respectively). The rate of acute aortic syndromes was also significantly higher in 2020 (P<0.001). Operative mortality was higher during the lockdown period (5.7% vs. 1.7%; P=0.038). The postoperative course was more complicated in 2020, with more postoperative bleeding (P=0.003), mechanical circulatory support (P=0.032) and prolonged mechanical ventilation (P=0.005). Only two patients (1.8%) developed a positive status for severe acute respiratory syndrome coronavirus 2 after discharge. CONCLUSIONS: Adult cardiac surgery was heavily affected by the COVID-19 lockdown. A further modulation plan is necessary to improve outcomes and reduce postponed operations to decrease operative mortality and morbidity.

A national healthcare response to intensive care bed requirements during the COVID-19 outbreak in France.

BACKGROUND: Whereas 5415 Intensive Care Unit (ICU) beds were initially available, 7148 COVID-19 patients were hospitalised in the ICU at the peak of the outbreak. The present study reports how the French Health Care system created temporary ICU beds to avoid being overwhelmed. METHODS: All French ICUs were contacted for answering a questionnaire focusing on the available beds and health care providers before and during the outbreak. RESULTS: Among 336 institutions with ICUs before the outbreak, 315 (94%) participated, covering 5054/5531 (91%) ICU beds. During the outbreak, 4806 new ICU beds (+95% increase) were created from Acute Care Unit (ACU, 2283), Post Anaesthetic Care Unit and Operating Theatre (PACU & OT, 1522), other units (374) or real build-up of new ICU beds (627), respectively. At the peak of the outbreak, 9860, 1982 and 3089 ICU, ACU and PACU beds were made available. Before the outbreak, 3548 physicians (2224 critical care anaesthesiologists, 898 intensivists and 275 from other specialties, 151 paediatrics), 1785 residents, 11,023 nurses and 6763 nursing auxiliaries worked in established ICUs. During the outbreak, 2524 physicians, 715 residents, 7722 nurses and 3043 nursing auxiliaries supplemented the usual staff in all ICUs. A total number of 3212 new ventilators were added to the 5997 initially available in ICU. CONCLUSION: During the COVID-19 outbreak, the French Health Care system created 4806 ICU beds (+95% increase from baseline), essentially by transforming beds from ACUs and PACUs. Collaboration between intensivists, critical care anaesthesiologists, emergency physicians as well as the mobilisation of nursing staff were primordial in this context.

[COVID-19 Pandemic: Impact and rapid reaction of Urology]. / Pandemia COVID-19: impacto y reacción rápida de la Urología.

The COVID-19 pandemic caused by the SARS-CoV-2 virus has caused tens of thousands of deaths in Spain and has managed to breakdown the healthcare system hospitals in the Community of Madrid, largely due to its tendency to cause severe pneumonia, requiring ventilatory support. This fact has caused our center to collapse, with 130% of its beds occupied by COVID-19 patients, thus causing the absolute cessation of activity of the urology service, the practical disappearance of resident training programs, and the incorporation of a good part of the urology staff into the group of medical personnel attending these patients. In order to recover from this extraordinary level of suspended activity, we will be obliged to prioritize pathologies based on purely clinical criteria, for which tables including the relevance of each pathology within each area of urology are being proposed. Technology tools such as online training courses or surgical simulators may be convenient for the necessary reestablishment of resident education.

Principled decisions and virtuous care: an ethical assessment of the SIAARTI Guidelines for allocating intensive care resources.

This article sets forth ethical principles for responding to extraordinary circumstances in which the demand for medical care threatens to overwhelm available resources, as in the COVID-19 pandemic. In light of these principles, the author then assesses the ethics of the SIAARTI guidelines for rationing ICU beds and ventilators under such circumstances.

Medicare, swing beds, and critical access hospitals.

Critical Access Hospitals (CAHs) receive cost-based reimbursement from Medicare for inpatient care, including post-acute skilled care provided in swing beds (skilled swing days). Because the reimbursement formula treats swing bed and acute days equally, there is concern that CAH skilled swing days are "overreimbursed" as compared with skilled days provided in other settings. The reimbursement formula is complex; thus, empirical estimates are needed to identify the marginal cost per day to the hospital and the implied Medicare expenditure per day, accounting for fixed cost transfers between services. Using Medicare cost report data, we find that Medicare paid, on average, $581 for the routine portion of a CAH skilled swing day in 2009--more than the estimated marginal cost of $262, but less than the 2009 average per diem of $1,302. Estimates varied widely across the 1,300 CAHs; therefore, payment policy changes would likely have a broad range of effects.

Workload of postanaesthesia care unit nurses and intensive care overflow.

The admission of intensive care unit (ICU) overflow patients in the post anaesthesia care unit (PACU) has come about as a result of an increasing demand for ICU services, which is not followed by a respective increase in the number of available beds. This has raised many concerns from nurses, with extensive workload and lack of personnel being the most important. This study was conducted in the General University Hospital of Patras, Greece, from 1 January 2003 to 30 June 2004. Admissions of ICU patients in the PACU were recorded and Project Research in Nursing (PRN), a Canadian workload measurement system, was used to estimate nursing workload. One hundred and three ICU patients were admitted and they stayed for a total time of 2812 hours. PRN scores of these ICU patients were much higher than for post anaesthesia patients. Clinically important increases of total PRN score, total care time and nursing personnel needs were evident in the presence of an ICU overflow patient during all shifts. Unless there is the appropriate number of personnel, increases in total care time are likely to lead to the neglect of post anaesthesia patients' needs.

Strategies for cutting hospital beds: the impact on patient service.

OBJECTIVE: To develop insights on the impact of size, average length of stay, variability, and organization of clinical services on the relationship between occupancy rates and delays for beds. DATA SOURCES: The primary data source was Beth Israel Deaconess Medical Center in Boston. Secondary data were obtained from the United Hospital Fund of New York reflecting data from about 150 hospitals. STUDY DESIGN: Data from Beth Israel Deaconess on discharges and length of stay were analyzed and fit into appropriate queueing models to generate tables and graphs illustrating the relationship between the variables mentioned above and the relationship between occupancy levels and delays. In addition, specific issues of current concern to hospital administrators were analyzed, including the impact of consolidation of clinical services and utilizing hospital beds uniformly across seven days a week rather than five. PRINCIPAL FINDINGS: Using target occupancy levels as the primary determinant of bed capacity is inadequate and may lead to excessive delays for beds. Also, attempts to reduce hospital beds by consolidation of different clinical services into single nursing units may be counterproductive. CONCLUSIONS: More sophisticated methodologies are needed to support decisions that involve bed capacity and organization in order to understand the impact on patient service.

Use of general practitioner beds in Leicestershire community hospitals.

BACKGROUND: The shift in care from secondary to primary services is likely to place greater demands on community hospitals. Before changes in the provision of community hospitals can occur, baseline data are needed, outlining their current use. AIM: A study was undertaken to obtain baseline data describing the use of general practitioner beds in Leicestershire community hospitals. METHOD: A three-month prospective, observational study was carried out between February and May 1992 using data from a questionnaire completed by nurses and general practitioners and from patient hospital records. Study patients comprised all patients admitted to general practitioner beds in all eight Leicestershire community hospitals. RESULTS: A 100% questionnaire response rate was obtained giving data on 685 hospital admissions. Around 70% of admissions were of patients aged 75 years and over. Of admissions, 35% were for acute care, 31% for respite care, 22% for rehabilitation, 7% for terminal/palliative care and 5% for other reasons. Fifteen per cent of patients had been transferred from a consultant bed. Of those not transferred, 91% were admitted by their usual general practitioner or practice partner and for 96% of these patients this was the general practitioner's first choice for care. There was significant variation in both the age mix and care category mix of patients between individual hospitals. Medical deterioration in an underlying condition and family pressure on the general practitioner or carers' inability to cope each contributed to around half of all admissions. Of all admissions, 38% lived alone, and 18% of carers were disabled. Incontinence was reported for 35% of patients, and 26% of all patients were of a high nursing dependency. There was low utilization of community services before admission and 33% received none. There was variation between individual hospitals in use of local and district general hospital investigations, specialist referral and types of therapy. Of 685 admissions 11% died during their stay. Of those discharged, 76% went to their own or a relative's home, 10% to a residential or nursing home and 9% were transferred to an acute bed. Nine percent of discharges were postponed and 10% were brought forward. On discharge to non-residential care, 26% of patients received no community services. CONCLUSION: Shifting resources from secondary to primary care is a priority for purchasers. Both the introduction of the National Health Service and community care act 1990, and acute units having increasing incentives for earlier discharge, are likely to place greater demands on community hospital beds. Not all general practitioners have the option of community hospital beds. Before access to general practitioner beds can be broadened, existing beds should be used appropriately and shown to be cost-effective. Purchasers therefore require criteria for the appropriateness of admissions to general practitioner beds, and the results of a general practitioner bed cost-benefit analysis.

Comparison of rural and urban skilled nursing facility benefit use.

In this article, differences in use of Medicare's skilled nursing facility (SNF) benefit in urban and rural areas are examined. Using SNF benefit bills from 1987, the study finds that there appear to be systematic differences by residential location both in the level of use of the benefit and in whether enrollees are admitted to nursing homes and hospital swing beds. Rural Medicare enrollees use the SNF benefit at a rate that is 15 percent higher than the rate for urban enrollees. Furthermore, the swing-bed program appears to play a critical role in providing access to post-acute care for the rural elderly. In rural areas, almost 29 percent of all SNF benefit admissions are to swing beds.

Swing bed program in a small rural hospital: discharge outcome.

Swing beds contribute significantly to inpatient rehabilitation and skilled nursing care of the rural elderly, but little information is available in the general clinical literature regarding the types and outcomes of patients admitted to these programs. All swing bed admissions to a small rural hospital for the 1989 fiscal year were identified and the records were reviewed. The mean age of the patients was 81 years, and the average length of stay was 13 days. Most patients were admitted because of acute problems necessitating short-term rehabilitation or because no bed was available in an appropriate skilled-care nursing home. At discharge, 40% of patients were able to return home. Information regarding the availability and appropriate use of swing beds needs to be disseminated to physicians who care for the elderly. More study is needed to determine optimal use of and requirements for swing beds on a national level.

Small rural hospitals with long-term care: 1983 to 1987.

Rural hospitals were under tremendous stress in the 1980s, as evidenced by decreasing use and closures. Rural populations increased in the two proportions of people older than 65 years relative to urban areas. Rural communities had more chronically ill residents than urban areas. Population aging and hospital stress have opened an option for small rural hospitals to develop long-term care units. Analysis of a national cohort of 750 small rural hospitals was undertaken in 1983, 1985, and 1987 to identify the characteristics of these hospitals, their communities, and the relative contribution of the small rural hospital to long-term care bed supply. Hospitals more likely to have long-term care during this period of time had lower occupancy rates and higher expenses per admission both prior to and after developing long-term care. While only 14 percent of the 750 hospitals studied had long-term care, they contributed nearly 30 percent of the total long-term care bed supply in their counties. Population-based need and bed supply measures were not significantly different in counties having a small rural hospital with long-term care. Areas of further analysis of the small rural hospital as a resource for long-term care are suggested. The implications for the health care system of small rural hospitals with long-term care are discussed.

Long-term care patients in acute care beds: a community-based analysis.

This paper describes an analysis of hospital utilization by alternate care patients, those who receive long-term care in hospital beds because postdischarge services are not available. During a 3-year period, the number of hospital beds occupied by these patients in Syracuse, New York reached 184, or 14% of the area's medical-surgical capacity. These patients were heterogeneous with respect to disposition, age, functional ability, and payor status. For this reason, the control of hospital alternate care should involve the management of admissions to nursing homes, home care, and elderly housing in a focused manner.

Swing-bed services under the Medicare program, 1984-87.

Under Medicare, swing beds are beds that can be used by small rural hospitals to furnish both acute and post-acute care. The swing-bed program was instituted under the provisions of the Omnibus Reconciliation Act of 1980 (Public Law 96-499). Under Medicare, post-acute care in the hospital would be covered as services equivalent to skilled nursing facility level of care. Data show that the program has had a rapid rate of growth. By 1987, swing beds accounted for 9.7 percent of the admissions to skilled nursing facility services, 6.0 percent of the covered days of care, and 6.2 percent of the reimbursements. Over one-half of the swing-bed services are furnished in the North Central States.

The long good-bye: the great transformation of the British Columbia hospital system.

Much is made of the "threat" an aging population poses to North American health care systems. In this article, we present hospital utilization data from British Columbia over the period 1969-1985, which reinforce our earlier (Barer, Evans, Hertzman, et al. 1987) conclusion: it is not aging per se that poses the threat; rather, it is what we are choosing (through our health care system) to do to and with our elderly. In 1969, British Columbia hospital patients over 65 years of age and staying longer than 60 days accounted for 12.5 percent of all days; by 1985/86, they were accounting for 39 percent. Furthermore, in 1985/86, 1 patient in 200 was using one-quarter of all patient days and dying at the end of the process, and 2 patients in 100 (who stayed over 60 days whether discharged alive or dead) were accounting for almost one-half of all days.