Portal de Periódicos da CAPES

An Acute Care Unit in a Multilevel Geriatric Facility: The First Two Years of the New Baycrest Hospital

1990; Wiley; Volume: 38; Issue: 6 Linguagem: Inglês

10.1111/j.1532-5415.1990.tb01452.x

1532-5415

Michael Gordon, Mark C. M. Cheung, Sandy Wiesenthal,

Frailty in Older Adults

To the Editor:—Most North American long-term care facilities do not have the ability to look after their patients during acute intercurrent illnesses.1 Transfer to a general hospital is often necessitated by the inability to evaluate, treat, and monitor such patients. The transfer of elderly, frail, and cognitively impaired individuals to acute care hospitals from long-term care facilities can be devastating.2 Unfamiliar surroundings, staff with whom they have had no previous contact, and excessive and often inappropriate use of technology and drugs frequently lead patients to unnecessary confusion, agitation, and poor medical outcomes.3 Such trauma can be minimized by treating patients within the long-term care facility when they develop acute intercurrent illnesses. The Baycrest Centre for Geriatric Care is a multilevel facility, one component of which is the Baycrest Hospital. Unlike other “chronic care” hospitals in Toronto, it already had acute care ability on a limited scale until April 1986.4 With the opening of the new Baycrest Hospital in 1986, its acute care potential expanded from 4 beds to 10 acute (concentrated care unit or CCU) and 17 subacute (step-down unit or SDU) beds, which are housed on one subdivided nursing unit. The new 300-bed hospital replaced the previous 150-bed facility and is central to Baycrest's multilevel campus. Two residential facilities—one for well elderly persons (Baycrest Terrace or BT) and one for frail elderly persons (Jewish Home for the Aged or JHA)—together with the hospital comprise the 870 inpatient Baycrest population. The mandate of the CCU/SDU is to treat acute medical crises that arise in Baycrest's population. Community patients cannot be admitted to the CCU/SDU. Other than acute surgical problems and massive hemorrhage, all acute medical problems can be dealt with, including acute myocardial ischemia/infarction, cardiac and respiratory failure, cerebrovascular events, sepsis, metabolic disorders, and adverse drug reactions. During the first two years of CCU/SDU operation the majority of Centre patients with acute illnesses have been treated on-site. All ten beds in the CCU and the four in the SDU are monitored. There are also two telemetry channels for ambulatory rhythm monitoring. An external pacemaker and a full CPR crash cart is situated on the unit. The Baycrest Centre “arrest team” is composed of CCU/SDU staff and has center-wide resuscitative responsibilities. The first two years of CCU/SDU operation have witnessed a growth of use, an expansion of services, and progress in staff education. The focus of geriatric medical educational programs for house-staff rotating through the Centre from Toronto's Mount Sinai Hospital and the University of Toronto has been incorporated into the unit. During the first year (1986/1987) there were 324 admissions to the CCU/SDU, which increased to 381 (18%) during the second year (1987/1988). The majority of transfers to the CCU come from the JHA and BT. There are many internal transfers between the CCU (heavily monitored, intensive nursing) and the SDU (less heavily monitored, less intensive nursing), which result in changes in nursing staff but not medical staff, as the latter look after the whole unit. The average length of stay for 1986/1987 was 4.98 days for the CCU and 10.7 days for the SDU and 6.03 and 14.6, respectively, in 1987/1988. Patients admitted to the CCU are transferred to the SDU as their conditions stabilize and nursing needs diminish. Some patients are admitted directly to the SDU when they require more intensive care than can be given elsewhere in the Centre but do not require full monitoring or high-ratio nursing. Patients may also be transferred from general hospitals directly to the SDU following surgery or medical procedures. A survey of three comparable long-term care facilities in Toronto reveals that one 601-bed facility transferred 190 patients to general hospitals during 1988/1989, a second 780-bed facility transferred 220 patients, and a third 636-bed facility transferred 202 patients during the same period. In the year prior to the opening of the new hospital, Baycrest Centre transferred 162 patients to general hospitals, despite its four-bed acute care unit. During the first two years of operation of the new hospital, there have been 64 and 94 patients transferred, respectively. The average length of stay in the combined CCU/SDU is 15.75 days for 1986/1987 and 20.19 days for 1987/1988 (18.17 days for 1988/1989). These figures are not that different from those of some general hospitals of between 200 to 399 beds, as reported in the Hospital Council of Metropolitan Toronto monthly report for February 1989, and only somewhat longer than the 17 days noted in the previous study that examined BT transfers to the old four-bed hospital unit.4 It is difficult to estimate potential cost savings to the Ontario Health Insurance Plan by having patients admitted to a CCU/SDU bed rather than having them transferred to a general hospital. With global funding, Ontario's public hospitals do not necessarily “gain” or “lose” money by having one type of medical patient admitted rather than another, other than the costs of high technology, expensive drugs, and so on. In 1988/1989 the per diem cost of Baycrest Hospital was $343.89, which compares favorably with the per diem cost of $585 for Mount Sinai, our closely affiliated general hospital. As important as theoretical cost savings (approximately $1.5 million) is the fact that displacement, lack of familiarity, and loss of continuity of care, as well as loss of identity, alienation, and emotional isolation, combined with negative attitudes and resentment by receiving staff in emergency rooms result in less than optimal care for such elderly patients.2,3,5 Even under the best of circumstances, the older long-term patient is at a disadvantage when transferred from the institution that has become home to the alien environment of a general hospital. The Baycrest experience demonstrates an alternative to transfer. The model may not be suitable for all long-term care facilities, but appropriate modifications can be made depending on the size, resources, and funding structure of the institution.6,7 The ability of geriatric longterm care facilities to look after frail, older patients with acute medical problems should ideally fall within the mandate of some large long-term care facilities. Smaller institutions with more limited resources and staff may have to develop models that will allow some, if not all, medical/nursing problems (e.g., dehydration, infection) to be treated on-site.6,7 This model can assure caring, consideration, and sensitivity to the special needs of our institutionalized elderly patients, as well as appropriate use of technology and medication that is and must continue to be the focus of excellent geriatric care. Organization and funding for this alternative method of care should be sought so as to assure high-quality acute medical service for elderly patients requiring such care.