Greenberg Sharon A, Halpern Pinchas, Ziv-Baran Tomer, Gamzu Ronni
Emergency medicine department, Tel-Aviv Sourasky Medical Center, 6 Weizmann st, 6423906, Tel-Aviv, Israel.
Department of Epidemiology and preventive Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel.
Isr J Health Policy Res. 2018 Nov 20;7(1):69. doi: 10.1186/s13584-018-0265-5.
In 2011 the Israeli Ministry of Health (MOH) instructed hospitals to limit occupancy in the internal medicine wards to 120%, which was followed by a nationwide reduction in hospitalization rates. We examined how readmission and mortality rates changed in the five years following the changes in occupancy rates and hospitalization rates.
All visits to the Tel Aviv Medical Center internal Emergency Medicine Department (ED) in 2010, 2014 and 2016 were captured, with exclusion of visits by patients below 16 of age and patients with incomplete or faulty data. The main outcomes were one-week readmission rates and one-month death rates. The secondary outcomes were admission rate, ED visit length & admission-delay time (minutes), and rates of admission-delayed patients.
After exclusion, a total of 168,891 internal medicine ED patients were included in the analysis. Mean age was 58.0 and 49% were males. During the relevant period (2010-2016), total medical ED visits increased by 11% - 53,327, 56,588 and 59,066 in 2010, 2014 and 2016 respectively. Hospitalization rates decreased from 46% in 2010 to 35% in 2015 (p < 0.001), with the most prominent reduction in the elderly population. One-week readmission rates were 6.5, 6.4 and 6.7% in 2010, 2014 and 2016 respectively (p = 0.347 and p = 0.21). One-month mortality was similar in 2010 and 2014 (4.4 and 4.5%, p = 0.388) and lower in 2016 (4.1%, p = 0.048 compared with 2010). Average ED visit length increased from 184 min in 2010 to 238 and 262 min in 2014 & 2016 (p < 0.001 for both) and average delay time to ward admission increased from 97 min in 2010 to 179 and 240 in 2014 & 2016 (p < 0.001 for both). In 2010 24% of the admitted patients were delayed in the ED more than 2 h, numbers that increased to 53% in 2014 and 66% in 2016 (p < 0.001 for both).
Following the 2011 MOH's decision to establish a 120% occupancy limit for internal medicine wards along with natural growth in population volume, significant changes were noted in the work of a large, presumably representative emergency department in Israel. Although a steady increase in total ED visits along with a steady reduction in hospitalization rates were observed, the readmission and mortality rates remained low. The increase in the average length of ED visits and in the delay from ED admission to a ward reflects higher burden on the ED. The study was not able to establish a causal connection between the MOH directive and the subsequent changes in ED activity. Nonetheless, the study has significant potential implications for policy makers, including the presence of senior ED physicians during afterhours, creation of short-stay diagnostic units and proper adjustments in ED size and personnel.
2011年，以色列卫生部指示医院将内科病房占用率限制在120%，随后全国住院率下降。我们研究了占用率和住院率变化后的五年里再入院率和死亡率是如何变化的。
收集了2010年、2014年和2016年所有前往特拉维夫医疗中心内科急诊科就诊的病例，但排除了16岁以下患者以及数据不完整或有错误的患者。主要结局指标为一周再入院率和一个月死亡率。次要结局指标为入院率、急诊科就诊时长及入院延迟时间（分钟），以及入院延迟患者的比例。
排除后，共有168,891名内科急诊科患者纳入分析。平均年龄为58.0岁，男性占49%。在相关时期（2010 - 2016年），内科急诊科就诊总人次增加了11%，2010年、2014年和2016年分别为53,327人次、56,588人次和59,066人次。住院率从2010年的46%降至2015年的35%（p < 0.001），老年人群的下降最为显著。2010年、2014年和2016年的一周再入院率分别为6.5%、6.4%和6.7%（p = 0.347和p = 0.21）。2010年和2014年的一个月死亡率相似（4.4%和4.5%，p = 0.388），2016年较低（4.1%，与2010年相比p = 0.048）。急诊科平均就诊时长从2010年的184分钟增加到2014年和2016年的238分钟和262分钟（两者p均 < 0.001），平均入院延迟时间从2010年的97分钟增加到2014年和2016年的179分钟和240分钟（两者p均 < 0.001）。2010年24%的入院患者在急诊科延迟超过2小时，这一数字在2014年增至53%，2016年增至66%（两者p均 < 0.001）。
2011年以色列卫生部决定将内科病房占用率限制在120%，加之人口自然增长，以色列一家大型、可能具有代表性的急诊科的工作出现了显著变化。尽管观察到急诊科就诊总人次稳步增加，住院率稳步下降，但再入院率和死亡率仍然较低。急诊科平均就诊时长和从急诊科入院到病房的延迟时间增加，反映出急诊科负担加重。该研究未能确定卫生部指令与急诊科活动随后变化之间的因果关系。尽管如此，该研究对政策制定者具有重要的潜在意义，包括下班后安排资深急诊科医生值班、设立短期诊断单元以及对急诊科规模和人员进行适当调整。
