Original ArticleThe effects of hospitalization on multiple units
Introduction
During the course of a hospitalization, a patient may reside on multiple care units within the hospital. Although transfers are usually done to provide the patient with the appropriate type and level of care, it is possible that residing on multiple units during a hospitalization may affect the quality of health care. Within the health care industry, there is a growing acknowledgement that quality is a function of coordinated care during the episode of hospitalization. This is made apparent by the recent development and use of the Tracer Methodology by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to evaluate the safety and quality of patient care provided in acute care hospitals (JCAHO, 2004). With this method of evaluation, the JCAHO surveyor retraces the path that a particular patient has taken through the health care organization during an inpatient episode. The surveyor evaluates patient safety and the health care organization's compliance with JCAHO standards at multiple points along the path the patient has traveled.
Additionally, the Institute of Medicine (IOM) has been critical of the quality of care provided by the U.S. health care system and attributes this in part to its complexity and resultant inefficiencies (IOM, Committee on the Quality of Health Care in America, 2001). The IOM has acknowledged that health care often involves multiple patient “handoffs” or the transfer of patients and the responsibility for their care between health care providers, shifts, units, and health care organizations. Patient handoffs, particularly when unanticipated or not well done, can interrupt the continuity of care through slowdowns in care processes, loss of information, and redundancy of care and ultimately decrease efficiency and quality (Cook et al., 2000, Institute of Medicine. Committee on the Quality of Health Care in America, 2001, Institute of Medicine (IOM). Committee on the Work Environment for Nurses and Patient Safety. Board on Health Care Services, 2004). However, the effects of moving a patient across multiple units during a hospitalization with regard to efficiency and quality of health care have not been well studied (Krogstad, Hofoss, & Hjortdahl, 2002).
The purpose of this study was to describe the impact of multiunit hospitalizations on selected nursing treatments, resource use, and clinical outcomes. After controlling for the primary medical diagnosis, severity of illness, and comorbid medical conditions, three research questions were addressed:
- 1.
What is the effect of a patient residing on multiple inpatient units during a hospitalization on the average daily use of the nursing treatments of patient teaching and discharge planning?
- 2.
What is the effect of a patient residing on multiple inpatient units during a hospitalization on resource use (length of stay, total hospital cost)?
- 3.
What is the effect of a patient residing on multiple inpatient units during a hospitalization on the clinical outcomes of nosocomial infection, adverse occurrence, patient fall, medication error, discharge disposition, and mortality?
Section snippets
Background
The health care literature contains little published research that examines the impact of residing on multiple units on nursing treatments, resource use, or clinical outcomes. No studies that examined the relationship of the number of units per hospitalization to the average daily use of nursing treatments were found in the literature. With the recent application of the Nursing Interventions Classification (NIC) in health care information systems, it is now possible to generate this type of
Research design
The data and sample for this study were extracted from a large data repository of a primary study on nursing outcomes effectiveness research (Titler, 2000). The data repository was constructed with clinical and administrative record data from a large Midwestern academic medical center that was among the first to incorporate the NIC (Dochterman & Bulechek, 2004) into the information system for use in planning and documenting nursing care. The integrity and reliability of the data were validated
Results
The sample of 7,851 patients was primarily older (M = 75 years, SD = ±9), female (52%), Caucasian (93%), married (54%), Protestant (63%), retired (74%), admitted from home (63%), and discharged back to home (64%). The most frequent primary medical diagnoses were those circulatory in nature (29%), neoplasms (15%), and injury/poisoning (11%). Common comorbid medical conditions included hypertension (50%), chronic pulmonary disease (18%), and uncomplicated diabetes (18%). The severity of illness
Discussion and practice implications
This study, while controlling for the primary medical diagnosis, severity of illness, and comorbid medical conditions, demonstrated a statistically significant association between the number of units resided on during hospitalization and the use rate of selected nursing treatments, resource use, and clinical outcomes. The patients who resided on a greater number of units during their hospitalization received, on average, less patient teaching and discharge planning from the nurses. They
Limitations
First, although the sample size was large, the generalization of the findings may be limited by the fact that the sample was obtained from a single health care organization. Second, the use of secondary data limited the analyses to variables that were present in the preexisting primary data set. Third, only the first clinical outcome (e.g., fall, medication error) was studied for each patient. A future study might examine the effect of residing on multiple units upon the number of nosocomial
Conclusion
The study's focus on the number of units per hospitalization is a topic that has not been well studied. It is hoped that the numerous statistically significant findings generated by this study will stimulate further research into the relationships between residency on multiple units and the delivery of nursing treatments, resource use, and clinical outcomes.
Acknowledgment
This research was supported by a grant from NIH/AHRQ (PI: Titler. NINR R01 NR05331).
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