eMJA: Hillman, The changing role of acute-care hospitals

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The changing role of acute-care hospitals

Acute-care hospitals are moving away from their central role in the healthcare system and becoming specialised institutions for the care of a particular kind of patient.

Ken Hillman

MJA 1999; 170: 325-328
For editorial comment, see Braithwaite & Hindle

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Introduction - The technological boom - System failure - Community care alternatives - A narrower role for the hospital? - Enter: a new specialty - Clinical experience and education - General practice and innovation - References - Authors' details
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Introduction

The publicly funded acute-care hospital had its origins as a charitable institution.¹ Until the middle part of this century, the working life of medical practitioners was predominantly based on private practice. Private patients were attended in doctors' rooms and, when necessary, usually cared for in small private hospitals.² Large public hospitals were for the poor. The clinician would visit the public hospital for several hours each week to attend the poor and teaching and research were centred on these patients. Everyone seemingly gained. The sick received free care and the clinician's conscience and sense of righteousness were satisfied.

Because private medical practitioners were accommodating the poor on a charitable basis, the hospital system was established around practitioners' needs. For example, surgeons had their own operating theatre, theatre nurse, ward, ward nursing staff and a cluster of junior doctors, usually organised in a hierarchical way, with house staff at the bottom and senior registrars-in-training at the top. Similar systems existed for other specialties, such as internal medicine and obstetrics.

The legacy of these arrangements is that the acute-care hospital has grown in a haphazard way, resulting in inefficiencies, duplication and the development of a system that is often designed around medical practitioners rather than patients. This system is now clashing with increasing demands by consumers to be involved in their own care, pressures from funders for more financial accountability and changing technology in medical care. As a result, the nature and role of acute-care hospitals are undergoing upheaval.

The technological boom

Until as recently as 40 years ago, hospitals were mainly places for bedrest and convalescence. The range of surgical operations was limited, high-powered investigations and monitoring were almost non-existent and medical treatments were largely restricted to a small number of procedures and relatively simple drugs. Nature, more than medical interventions, determined whether patients recovered or not.

An explosion of medical knowledge occurred in the 1950s. Complex surgery such as cardiac valve replacement, transplant surgery, microsurgery and complex cancer surgery became commonplace. Great advances occurred in anaesthesia, making the performance of these procedures possible. Intensive care units (ICUs) kept many patients alive who previously would not have survived. Physicians developed interventions such as endoscopy and chemotherapy. Investigations such as computed tomography expanded our knowledge of diseases and treatment options.

Whereas previously all hospitals provided a similar range of options for patients, there now emerged a complex institution serviced by an expanding range of medical specialties, complemented by expensive technology. A two-tiered system of hospitals developed. One was limited in its range of expertise and technology, while the other was keeping abreast of all the rapidly emerging developments. The winners were the hospitals in the heart of capital cities. Outer metropolitan and rural hospitals increasingly had to refer patients to these centres of excellence.

The reasons why some hospitals developed as centres of excellence and others did not are complex; it was largely related to the clustering of medical expertise in large, centrally located, university-affiliated hospitals. The developing expertise in one specialty was often dependent on similar rates of development in others, in order to perform increasingly sophisticated interventions.

System failure

Despite increasing specialisation and remarkable advances in technology, the fundamental organisation in hospitals has changed little. Concepts such as clinical directorates, clinical pathways, evidence-based medicine, benchmarking and quality improvement are to a greater or lesser extent affecting the way we manage patients in acute-care hospitals. However, patients are still admitted under an individual clinician who "owns" them; the patient is discharged at the admitting clinician's convenience; and, in the larger institutions, nursing staff, together with a hierarchy of junior medical staff, still manage the day-to-day care of the patient. Basic issues such as standardised indications and protocols for the admission and discharge process are usually not addressed and patient management is usually not well coordinated. The flow of patients through a hospital is often inefficient, dislocated and disorganised.

While individual specialists and departments may deliver excellent individual standards of care, the system often falls apart at the interfaces of that care. For example, a patient may be operated on by the world's best plastic surgeon and be treated in a ward renowned for plastic surgical care, but, if the patient bleeds excessively, the system may soon be sorely tried. Let us imagine that the patient becomes tachycardic and hypotensive. Hypovolaemic shock is not a common occurrence in a plastic surgery ward. Vital signs are only recorded four-hourly. Nursing staff inform junior medical staff, who in turn inform up the hierarchy. The plastic surgery registrar may be a great technician, but often does not have formal training in management of the seriously ill and recent advances in resuscitation. Let us imagine further that the patient, as is increasingly common, has comorbidities such as underlying ischaemic heart disease, hypertension and chronic lung disease related to smoking. The patient has a myocardial infarction and things go from bad to worse. The system fails, because it is a system designed for performing procedures, somewhat at the convenience of doctors, and not a system for the coordinated care of patients.

A sobering example of system failure has recently been widely reported.³ Between 10 000 and 14 000 preventable deaths may occur in Australian hospitals each year.⁴ Similar problems exist in other countries.⁵ Of course, this is the tip of the iceberg: for every preventable death, there are many potentially preventable serious complications. The incidence is the same whether the hospital is a small rural one, a large metropolitan hospital or a teaching and referral centre.⁴

This incidence of adverse events may worsen as hospital bed numbers are "downsized" and the remaining patients become more seriously ill and at risk of preventable death and complications. There is now enormous pressure to reduce hospital bed numbers, to cut hospital admissions and to reduce the length of stay in hospitals. Hospitals will have to respond by lifting the effectiveness of their system of care.

Community care alternatives

These pressures are largely due to financial constraints, yet it may not be such a bad thing for most patients to spend less time in hospital. Institutional care in hospitals is not necessarily the most sensitive and caring environment for many patients, including those who are dying, those requiring rehabilitation and those with mental illness. In other words, it may not only be cheaper but better for ambulant patients to be treated in more appropriate environments.⁶ As alternatives are developed, hospitals are restricting their function to managing patients who have serious, complex and potentially recoverable illnesses. Specialties such as psychiatry, geriatrics, rehabilitation and palliative care are increasingly becoming community based. Many investigations, even the more complex ones, are now being performed in the community. Up to 60% of patients are now having day-only surgery.⁷ Imaginative alternatives to hospital-based care are being developed. This is leading to a radical change, both for the broader healthcare picture and for the future of acute-care hospitals.

A narrower role for the hospital?

The acute-care hospital will, in the near future, care mainly for the sick who have a chance of recovering.^8,9 Increasingly, in-hospital patients will have more complex problems and a greater number of comorbidities. Specialised units caring for the seriously ill are increasing. Emergency departments are increasingly managing the seriously ill rather than offering primary healthcare; operating suites are performing more complex procedures for in-hospital patients. As a result, far more intensive-care and high-dependency beds are required, while the total number of acute-care hospital beds is decreasing as the more ambulant and less sick are managed elsewhere.¹⁰

Ironically, the increasing specialisation that has occurred over the last 40 years may not provide support for the changing population of hospital patients. Specialists will, of course, continue to provide specific expertise. Opinions will be sought on a particular problem or a specialised procedure will be performed, but modern specialists may not always be appropriate for providing overall care for a complex in-hospital patient.^10-12 Increasingly, specialists who were once based almost entirely in a hospital setting are providing care for patients in ambulant and out-of-hospital settings.

Enter: a new specialty

These developments have led in some countries to the emergence of a "hospitalist"¹³ who has a wide range of expertise, but concentrating more on acute hospital medicine -- more like a general physician, but specialising in acute and serious illness rather than chronic and mainly ambulant medicine. The hospitalist also has advanced resuscitation and procedural skills. They are familiar with the medical comorbidities increasingly associated with surgical patients and understand how different organs fail and interact in acute illness. They are a move back to the generalist physician. The equivalent in Australia is probably the intensive care or emergency physician. The hospitalist also understands about continuity and coordination of patient care, managing the patient's in-patient course and arranging a seamless transition to a community setting.¹³

The proponents of the hospitalists argue that, as hospital stay becomes shorter and more intense, it is unlikely that high value care can continue to be delivered by traditional specialists who spend only some of their day in an acute hospital setting and do not have the time to keep abreast of all the developments in acute-care and emergency medicine, or to maintain competence in acute-care resuscitation.

It has always been the case that most acute hospital care is performed by the permanent hospital junior medical and nursing staff.¹¹ The role of the specialist has changed little in that way over the last hundred years. Specialists manage their in-hospital patients at a distance, using rotating junior medical staff and nursing staff for most of the day-to-day care. A hospitalist could enable community-based specialists to devote more time to what they do best, rather than being continuously confronted by the dilemma of maintaining a busy professional practice with tight appointment schedules and having seriously ill in-hospital patients who might require their attention day or night in an unpredictable way. Having skilled clinical cover 24 hours a day would also help guarantee patient safety. However, there are many ways of achieving this goal, and, while the concept of a "hospitalist" may be working in the United States, Australia could explore other ways of achieving the same standards.

Clinical experience and education

The changing nature of acute-care hospitals will also have wide-ranging effects on undergraduate and postgraduate medical training in Australia.^14,15 While many welcome changes have occurred in undergraduate training in Australia, the bulk of it remains based on hospital patients, who are in turn not only decreasing in number but (even more importantly) represent an increasingly limited part of the healthcare spectrum. Patients with the common problems on which undergraduate education was based are now managed in other environments, such as the specialist's rooms or in the community.

Moreover, the skills necessary to manage an increasingly ill population of in-hospital patients have either never been taught, or are taught suboptimally.^16,17 Similarly with postgraduate education. While physicians and surgeons may have had some exposure to emergency and intensive care medicine, there is currently no formal or obligatory requirement for training in advanced resuscitation. With increasing specialisation, this might become even more of a problem for physicians as their skills become more orientated to the less seriously ill and more ambulant patients. Moreover, hospital systems are poorly designed to deal 24 hours a day with the seriously ill. Up to 80% of in-hospital cardiac arrests are preceded, often for many hours, by slow and documented deterioration in vital signs.¹⁸ Among critically ill patients who do not have an arrest, there is a high incidence of serious complications that are not adequately managed in a timely fashion.¹⁹

Systems dealing with the seriously ill, such as those for trauma²⁰ and acute in-hospital medical problems,^21,22 are being developed in some centres but they are not, as yet, seen as fundamental to the care of the critically ill. In-hospital patients with cross-specialty problems are usually subject to a complex system of referral. This works well for non-life-threatening problems, but for the increasing population of at-risk patients in acute-care hospitals the lack of systems which work at the interfaces between specialists, professions and departments may be contributing to excessive mortality and morbidity.^19,23

General practice and innovation

The role of the general practitioner (GP) in the larger health picture is also being re-evaluated. While GPs have probably always seen acute-care hospitals as expensive and relatively insignificant players in the big healthcare picture, acute-care hospitals have, until recently, seen themselves as the self-appointed flagships of healthcare. Now GPs and community-based healthcare delivery are becoming more dominant in healthcare. Healthcare is being devolved back to them at a rapid rate, as acute-care hospitals attempt to decrease admission rates, reduce length of stay and facilitate early discharge.

The way community health and hospital care interact is also being reinvented. Most Western countries are struggling with the issue of how to deliver better healthcare at the same or reduced cost. Australia has a unique opportunity to develop its own way of achieving this without necessarily slavishly adopting overseas systems such as managed care or seeing privatisation as a panacea for healthcare delivery problems. Already we are seeing many exciting Australian examples of innovation in this area. The New South Wales system of discrete Health Areas, with one authority being responsible for all acute-care hospital and community-based services, is proving an exciting platform for re-engineering health in innovative ways. The Commonwealth Government has funded innovative models developed by actively practising clinicians working together from community and acute-care hospitals (National Demonstration Hospital Programs).

Hospitals will increasingly develop systems based on patient needs as well as the needs of the admitting clinicians. Community-based healthcare, including GPs, will provide most healthcare. Hospitals will treat fewer patients who are increasingly ill. Acute-care hospitals will become more specialised in their function and, as such, will probably be inappropriate platforms for comprehensive undergraduate and postgraduate medical training. Whether adequate funding to the community will follow this change in healthcare is debatable. As a result of these changes, it is crucial that we carefully and methodically devote more health research funding to evaluate the effects of these changes on patients.

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Authors' details

The Simpson Centre for Health Service Innovation, The University of New South Wales, Sydney, NSW.
Ken Hillman, FRCA, FFICANZCA, Director, and Professor of Intensive Care.

Reprints will not be available from the author.
Correspondence: Professor K M Hillman, Co-Director, Division of Critical Care, The Liverpool Health Service, PO Box 103, Liverpool, NSW 2170.
Email: k.hillmanATunsw.edu.au

		The hospitalist Cares for patients with complex acute illness Specialises in acute-care hospital medicine Makes a career wholly within the hospital system Has advanced resuscitation and procedural skills Knows the medical morbidities of surgical patients the interactive effects of organ systems in stress and failure Coordinates care for patients across departments, from doctor to doctor Ensures continuity of care for patients and through these skills and action Prevents hospital systems failure
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