Impact of Telemedicine on Mortality, Length of Stay, and Cost Among Patients in Progressive Care Units: Experience From a Large Healthcare System.

OBJECTIVES: To determine whether Telemedicine intervention can affect hospital mortality, length of stay, and direct costs for progressive care unit patients. DESIGN: Retrospective observational. SETTING: Large healthcare system in Florida. PATIENTS: Adult patients admitted to progressive care unit (PCU) as their primary admission between December 2011 and August 2016 (n = 16,091). INTERVENTIONS: Progressive care unit patients with telemedicine intervention (telemedicine PCU [TPCU]; n = 8091) and without telemedicine control (nontelemedicine PCU [NTPCU]; n = 8000) were compared concurrently during study period. MEASUREMENTS AND MAIN RESULTS: Primary outcome was progressive care unit and hospital mortality. Secondary outcomes were hospital length of stay, progressive care unit length of stay, and mean direct costs. The mean age NTPCU and TPCU patients were 63.4 years (95% CI, 62.9-63.8 yr) and 71.1 years (95% CI, 70.7-71.4 yr), respectively. All Patient Refined-Diagnosis Related Group Disease Severity (p < 0.0001) and All Patient Refined-Diagnosis Related Group patient Risk of Mortality (p < 0.0001) scores were significantly higher among TPCU versus NTPCU. After adjusting for age, sex, race, disease severity, risk of mortality, hospital entity, and organ systems, TPCU survival benefit was 20%. Mean progressive care unit length of stay was lower among TPCU compared with NTPCU (2.6 vs 3.2 d; p < 0.0001). Postprogressive care unit hospital length of stay was longer for TPCU patients, compared with NTPCU (7.3 vs 6.8 d; p < 0.0001). The overall mean direct cost was higher for TPCU ($13,180), compared with NTPCU ($12,301; p < 0.0001). CONCLUSIONS: Although there are many studies about the effects of telemedicine in ICU, currently there are no studies on the effects of telemedicine in progressive care unit settings. Our study showed that TPCU intervention significantly decreased mortality in progressive care unit and hospital and progressive care unit length of stay despite the fact patients in TPCU were older and had higher disease severity, and risk of mortality. Increased postprogressive care unit hospital length of stay and total mean direct costs inclusive of telemedicine costs coincided with improved survival rates. Telemedicine intervention decreased overall mortality and length of stay within progressive care units without substantial cost incurrences.

Ideal timing to transfer from an acute care hospital to an interdisciplinary inpatient rehabilitation program following a stroke: an exploratory study.

BACKGROUND: Timely accessibility to organized inpatient stroke rehabilitation services may become compromised since the demand for rehabilitation services following stroke is rapidly growing with no promise of additional resources. This often leads to prolonged lengths of stays in acute care facilities for individuals surviving a stroke. It is believed that this delay spent in acute care facilities may inhibit the crucial motor recovery process taking place shortly after a stroke. It is important to document the ideal timing to initiate intensive inpatient stroke rehabilitation after the neurological event. Therefore, the objective of this study was to examine the specific influence of short, moderate and long onset-admission intervals (OAI) on rehabilitation outcomes across homogeneous subgroups of patients who were admitted to a standardized interdisciplinary inpatient stroke rehabilitation program. METHODS: A total of 418 patients discharged from the inpatient neurological rehabilitation program at the Montreal Rehabilitation Hospital Network after a first stroke (79% of all cases reviewed) were included in this retrospective study. After conducting a matching procedure across these patients based on the degree of disability, gender, and age, a total of 40 homogeneous triads (n = 120) were formed according to the three OAI subgroups: short (less than 20 days), moderate (between 20 and 40 days) or long (over 40 days; maximum of 70 days) OAI subgroups. The rehabilitation outcomes (admission and discharge Functional Independence Measure scores (FIM), absolute and relative FIM gain scores, rehabilitation length of stay, efficiency scores) were evaluated to test for differences between the three OAI subgroups. RESULTS: Analysis revealed that the three OAI subgroups were comparable for all rehabilitation outcomes studied. No statistical difference was found for admission (P = 0.305-0.972) and discharge (P = 0.083-0.367) FIM scores, absolute (P = 0.533-0.647) and relative (P = 0.496-0.812) FIM gain scores, rehabilitation length of stay (P = 0.096), and efficiency scores (P = 0.103-0.674). CONCLUSION: OAI does not seem to affect significantly inpatient stroke rehabilitation outcomes of patients referred from acute care facilities where rehabilitation services are rapidly initiated after the onset of the stroke and offered throughout their stay. However, other studies considering factors such as the type and intensity of the rehabilitation are required to support those results.

The use of risk predictions to identify candidates for intermediate care units. Implications for intensive care utilization and cost.

OBJECTIVE: To develop a predictive equation that estimates the probability of life-supporting therapy among ICU monitor admissions and to explore its potential for reducing cost and improving ICU utilization. DESIGN: Prospective inception cohort analysis. PARTICIPANTS: Forty-two ICUs in 40 US hospitals with more than 200 beds and a consecutive sample of 17,440 ICU admissions. INTERVENTIONS: A multivariate equation was developed to estimate the probability of life support for ICU monitoring admissions during an entire ICU stay. MEASUREMENTS: Demographic, physiologic, and treatment information obtained during the first 24 h in the ICU and over the first 7 ICU days. RESULTS: The most important determinants of subsequent risk for life-supporting (active) treatment were diagnosis, the acute physiology score of APACHE III, age, operative status, and the patient's location and hospital length of stay before ICU admission. Among 8,040 ICU monitoring admissions, 6,180 (76.8%) had a low (< 10%) risk for receiving active treatment during the ICU stay; 95.6% received no subsequent active treatment. Review of outcomes and the type and amount of therapy received suggest that most low-risk ICU monitor admissions could be safely cared for in an intermediate care setting. CONCLUSION: Objective predictions can accurately identify groups of ICU admissions who are at a low risk for receiving life support. This capability can be used to assess ICU resource use and develop strategies for providing graded critical care services at a reduced cost.

Waiting for the break of dawn? The effects of discharge time, discharge TISS scores and discharge facility on hospital mortality after intensive care.

OBJECTIVE: To assess the effects of discharge Therapeutic Intervention Scoring System (TISS) scores, discharge time and type of discharge facility on ultimate hospital mortality after intensive care. DESIGN: Retrospective cohort study. SETTING: General intensive care unit (ICU) in a district general hospital. PATIENTS AND PARTICIPANTS: One thousand six hundred fifty-four ICU patients discharged to hospital wards or high dependency units (HDUs). MAIN MEASUREMENTS AND RESULTS: Vital status at ultimate hospital discharge was the main outcome measurement. The crude hospital mortality after ICU discharge (12.6%) was significantly associated with increasing discharge TISS scores (chi(2) for trend =9.0, p=0.028). This trend was similarly observed after adjusting for severity of disease. Patients with high TISS scores (>30) who were discharged to hospital wards had a higher risk (1.31; CI: 1.02-1.83) of in-hospital death compared with patients discharged to HDUs. Crude mortality was significantly higher for late 20.00 h to 7.59 h) than for early (8.00 h to 19.59 h) discharges (18.8% versus 11.2%, chi(2) =12.1, p=0.0004). Adjusted for disease severity, the mortality risk was 1.70-fold (CI: 1.28-2.25) increased for late ICU discharges. Patients discharged late to hospital wards had significantly higher severity-adjusted risks (1.87; CI:1.36-2.56) than had patients discharged to HDUs (1.35; CI: 0.77-2.36). CONCLUSIONS: Both late discharge and high discharge TISS scores are indicators of "premature" ICU discharge and were associated with increased mortality. Intermediate care reduced the mortality of patients discharged "prematurely" from ICU. This adds to the growing evidence of the benefits of intermediate care after ICU discharge.

Subacute care, Medicare benefits, and nursing home behavior.

Two policy changes in 1988, one administrative and one legislative, allowed greater Medicare coverage of subacute care in skilled nursing facilities (SNFs). The Medicare Catastrophic Coverage Act (MCCA) of 1988, in conjunction with an administrative directive, or transmittal, from the Health Care Financing Administration (HCFA), changed the Medicare SNF benefit structure substantially. In this study, we specified a simultaneous equation system to explain the effects of the benefit changes on Medicare use. The results suggest that the two policy changes increased Medicare use in Pennsylvania SNFs substantially; however, the increase was associated with facility and case mix characteristics, which suggest that the increase was largely attributable to reclassification of current patients from other payer categories, Medicaid and self-pay, rather than new admissions. The effects of the MCCA and the HCFA transmittal on increased Medicare use were unanticipated and have important implications for the way in which subacute care is defined and financed in future benefit discussions.

Balancing acute and long-term care: the mathematics of throughput in departments of geriatric medicine.

The empirical distribution of length of stay of patients in departments of geriatric medicine is fit extremely well by a sum of two exponentials. Most of the patients in a geriatric department are rehabilitated and discharged or they die within a few weeks of admission, but the few who become long-stay patients remain for months or even years. A model is presented for the flow of patients through a geriatric department, which has analogies to models of drug flow in pharmacokinetics. The theoretical model explains why the empirical pattern of length of stay in the occupied beds fits a sum of two exponentials; conversely, the empirical distribution, obtained from the midnight bed state report, can be used to study the effect of various policy decisions on both immediate and future admission rates for the department, and shows the benefits of policies which reduce long-stay patient numbers by improving long-stay rehabilitation.

Requirement for nursing care services and associated costs in acute spinal cord injury.

The purpose of this study was to analyze the requirement for professional nursing care and the nursing care costs for patients with acute spinal cord injury. This descriptive study used a convenience sample of 50 consecutively admitted spinal cord-injured (SCI) patients who agreed to participate. Trained data collectors interviewed patients daily, reviewed the chart and spoke with the patient's nurses, after which nursing diagnoses were determined and acuity calculated. The sample consisted of 26 quadriplegic (Q), 5 ventilator-dependent quadriplegic (V) and 19 paraplegic (P) SCI subjects. The median length of stay (LOS) was 16 days with an intensive care unit (ICU) LOS of 4 days. LOS in the intermediate unit was 11 days. Median hours of nursing care was 143 (translating to $2458) for the entire acute care hospitalization. Specific hours of care and consequent costs were determined for all three groups through both phases of care. Significant differences were found in the hours of nursing care required among the three groups (X2 7.18, df = 2, p < .03), even though no difference was found in the LOS. A nursing consumption ratio (hours of nursing care/hours of LOS) demonstrated that ventilator-dependent SCI patients required the greatest number of nursing care hours.

Step-down units and telemetry monitoring: optimizing utilization.

In this article, we address the issue of patient-flow problems in the hospital, which often occur because of improper utilization of step-down (intermediate care) unit resources. Utilization is often adversely affected by the inappropriate use of telemetry monitoring (traditionally offered in step-down units) as a rationale for placing patients in step-down areas, even when they would benefit from other types of monitoring or just the proper level of nursing care. We also discuss the other types of patient monitoring available, as well as other monitoring issues (see "Communicating Alarm Event").

Integrated subacute care: 20% of your patient days.

New strategies are changing the profile of subacute care, and patients are beginning to move out of the hospital into subacute or home care services. It's a money-losing proposition for hospitals, writes Donald E.L. Johnson.

What's new in subacute care?

What's new in subacute care? Despite growth, the industry has yet to prove it can deliver the cost savings it has promised, according to a recently released study. Moreover, after all these years much disagreement remains over just what is meant by the term ¿subacute care.¿

Riding the express. Is your subacute strategy on track?

For many health care providers, it's time to catch the bullet train called subacute care, an area of health care that's booming and offers new opportunity. But riding the rails of this new mode of transport isn't as easy as it seems. In fact, it can be downright tricky. That's why experts are warning hospital executives, in particular, to know beforehand exactly what they're getting into.

Home hospitalization unit: an alternative to standard inpatient hospitalization from the emergency department.

OBJECTIVE: To assess the characteristics of the patients admitted to a home hospitalization unit (HHU) after a first emergency department (ED) visit. METHODS: This was a descriptive, retrospective study. The setting of the study was the ED of a 500-bed teaching hospital, which treats 125 000 emergency visits per year. HHU admits patients from the ED when hospitalization is imminent. Participants were all patients attending our ED from 1 January 2005 to 31 December 2005 and finally admitted to HHU. Variables were age, sex, diagnostic, mean length of stay, and readmission rate. RESULTS: A cohort composed of 250 patients admitted to HHU directly from the ED was identified. Mean age was 75 years. One hundred and fifty-eight were males (63%). The most common diagnoses were acute exacerbation of chronic obstructive pulmonary disease (127 of 250 patients, 50.8%), acute exacerbation of chronic heart failure (32 of 250 patients, 12.8%), pneumonia (24 of 250 patients, 9.6%), urinary tract infection (20 of 250 patients, 8%), and leg deep venous thrombosis (14 of 250 patients, 5.6%). Mean length of stay was 8 days. Readmission rate was 9%. CONCLUSION: A HHU proved to be effective and safe for acutely ill individuals who required hospitalization.

The impact of the observation ward on acute admissions at Guy's Hospital.

This paper describes an evaluation of the short-stay ward at Guy's Hospital Accident and Emergency Department. It includes an audit of the operational policy, the care provided to patients, and the impact of the short-stay ward on hospital admissions. The results indicate that by concentrating patients in a short-stay ward, the quality of care is improved, delays are reduced, and the pressure on inpatient beds is relieved.

Beyond patient dependency: family characteristics and access of elderly patients to home care services following hospital discharge.

Access to Skilled Nursing and Home Health Aid services among elderly patients (N = 580) and their family caregivers post hospital discharge was examined using logistic regression. A majority of the sample (65%) were referred for Skilled Nursing services while only 28% were referred for Home Health Aid services. Caregiving situations in which the spouse was the primary caregiver were less than half as likely to be referred for either service when compared to non-spouses. As expected, ADL limitations were a significant predictor of referral for both services. Women patients with the same ADL limitation as men were only about a fourth as likely to be referred for Home Health Aid services as men. Findings are discussed in terms of access to care and the need for policy to consider more than patient limitations in the referral criteria.

Association between nurse-physician collaboration and patient outcomes in three intensive care units.

OBJECTIVE: To investigate the association of collaboration between intensive care unit (ICU) physicians and nurses and patient outcome. DESIGN: Prospective, descriptive, correlational study using self-report instruments. SETTINGS: A community teaching hospital medical ICU, a university teaching hospital surgical ICU, and a community non-teaching hospital mixed ICU, all in upstate New York. SUBJECTS: Ninety-seven attending physicians, 63 resident physicians, and 162 staff nurses. PROCEDURE: When patients were ready for transfer from the ICU to an area of less intensive care, questionnaires were used to assess care providers' reports of collaboration in making the transfer decision. After controlling for severity of illness, the association between interprofessional collaboration and patient outcome was assessed. Unit-level organizational collaboration and patient outcomes were ranked. MEASURES: Healthcare providers' reported levels of collaboration, patient severity of illness and individual risk, patient outcomes of death or readmission to the ICU, unit-level collaboration, and unit patient risk of negative outcome. MAIN RESULTS: Medical ICU nurses' reports of collaboration were associated positively with patient outcomes. No other associations between individual reports of collaboration and patient outcome were found. There was a perfect rank order correlation between unit-level organizational collaboration and patient outcomes across the three units. CONCLUSIONS: The study offered some support for the importance of physician-nurse collaboration in ICU care delivery, a variable susceptible to intervention and further study.