The impact of health care restructuring: RESULTS

19 Jan
2012

Hospital patient volume and acuity: Although between 1993/94, and 1996/97, there was a 10% decline in patient beds (645 to 586), the number of ICU beds was unchanged and slightly increased as a proportion all beds, from 13.2% to 14.7%. Annual hospital admissions fell from 29,085 to 23,597 (19%). Overall, there was a 17% decline in annual hospital patient days (29,085/year to 23,597/year). The distribution of hospital days by medical service radically changed. Some services markedly increased their patient days (neurosurgery 49%, nephrology 30%, orthopedic surgery 24% and general surgery 16%), others markedly reduced patient days (obstetrics and gynecology 99%, ophthalmology 100%, general pediatrics 38%, adult medicine 41%, neonatology 25% and psychiatry 16%) and a few re­mained relatively unchanged (cardiology 4% increase, hema- tology 4% decrease). Within the hospital’s seven ICUs, the use of CVCs increased from 9852 days/year before restructuring to 13,876/year after restructuring (41%). The hospital’s he­modialysis unit increased the number of dialysis runs given by 9%, from 19,294/yearto 20,963/year and inpatient use of TPN increased from 6632 days/year to 8322/year (25%).

TABLE 1 Nosocomial blood stream infection rates for selected medical services at the University of Alberta Hospital

Rate/10,000
patient days

Service

1993/1994

1996/1997

P

General surgery

23.4

18.6

>0.05

Neurosurgery

9.8

15.8

>0.05

Orthopedic surgery

5.8

2.6

>0.05

Cardiac surgery

40.7

46.8

>0.05

Cardiology*

12.7

20.6

>0.05

Nephrology

70.8

124.8

<0.001

Hematology*

54.4

86.2

0.04

General paediatrics

4.6

24.6

0.009

Adult medicine

5.6

12.0

0.002

All services

8.2

13.3

<0.001

Nosocomial blood stream infections: In the two years before restructuring, 481 nosocomial blood stream infections occurred, and 630 occurred in the two years following restruc­turing, an increase of 31%. Increases occurred in both ICU (242 to 276 infections, 14.0%) and non-ICU units (240 to 354 infections, 47.5%). Infections increased in the dialysis unit from 13 in 1993/94 to 57 in 1996/97, a 338% increase. The hos­pital wide annual infection rate increased from 8.3/1000 ad­missions to 13.3/1000 admissions (rate ratio 1.6,95% CI 1.4 to 1.8), an increase of 60%. The rate significantly increased for primary infections (largely attributable to various forms of in­travascular devices), from 4.9/1000 admissions to 8.2/1000 admissions (rate ratio 1.6,95% CI 1.4 to 1.9), and secondary in­fections, from 3.3/1000 admissions to 5.1/1000 admissions (rate ratio 1.6, 95% CI 1.3 to 1.9). Within the group of secon­dary infections, blood stream infection from a lower respira­tory source increased by the largest amount from 7.0/1000 admissions to 15.0/1000 admissions (P>0.05). Infection rates were also calculated using hospital patient days as a denomi­nator for medical services and each of the ICUs (Tables 1,2). Within ICUs, the authors were able to calculate CVC-associated blood stream infection rates using central line days as the de­nominators. While the total number of ICU CVC-associated in­fections increased from 130 before restructuring to 195 after restructuring, none of the ICUs increased their CVC infection rates using CVC days as the denominator (data not shown). For the ICUs as a group, the pooled CVC infection rate was 7.3/10,000 CVC days before and 7.1/10,000 after restructuring (P>0.05). TPN-related infections did not change in number (121 in 1993/94 and 122 in 1996/97) and decreased in rate from 88.7/1000 TPN days to 73.3/1000 TPN days (P=0.08).

TABLE 2 Intensive care unit nosocomial blood stream infections at the University of Alberta Hospital

Unit

Rate/10,000
patient days
1993/1994
1996/1997

P

General adult

43.3

63.1

<0.001

Cardiac surgery

53.1

50.2

>0.05

Neonatal

54.4

47.3

>0.05

Neurosurgery

15.4

47.3

>0.05

Burn

19.2

76.6

<0.001

Paediatric

92.1

69.7

>0.05

Coronary care

16.4

25.3

>0.05

Table 3 shows organism-specific changes for seven differ­ent microorganisms that increased in number or rate. For four different organism groups (Staphyloccus aureus, Enterococ- cus species, Candida species and Pseudomonas species), the rate increase was statistically significant. The greatest increase occurred for infection due to Enterococcus species, from 30 in­fections or 0.5/1000 admissions before to 82 infections or 7.8/1000 after restructuring (rate ratio 3.6, 95% CI 1.3 to 5.5).
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TABLE 3 Organism-specific nosocomial blood stream infections at the University of Alberta Hospital

1993/1994

1996/1997

Number of

Rate/10,000

Number of

Rate/10,000

Organism

episodes

admissions

episodes

admissions

Coagulase-

187

3.1

180

3.8

negative

staphylococci

Staphylococcus

82

1.4

124

2.6*

aureus

Enterococcus

30

0.5

87

1.8+

species

Candida

29

0.5

40

0.8*

species

Escherichia coli

40

0.7

46

1.0

Klebsiella

29

0.5

36

0.8

species

Pseudomonas

17

0.3

28

0.6§

species

Enterobacter

16

0.3

17

0.4

species

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