1 4 SA MEDICAL JOURNAL October 99 A Critical Look at Geriatrics in a Teaching Hospital Part I. The Situation L. R. TIBBIT SUMMARY A survey of the admission and discharge patterns of geriatric patients admitted to Groote Schuur Hospital, Cape Town, during July and August 98 was conducted. The findings highlight a lack of methodology in the economic use of beds, a lack of rehabilitation services and of follow-up services on discharge, and poor liaison regarding facilities outside the hospital setting. S. A/r. med. J.,, 4 (99). The Minister of Health in his opening address delivered at the Biennial Meeting of the South African National Council for the Aged in Cape Town in November 9 stated: 'Unfortunately many urgently needed hospital beds are blocked by elderly long-stay patients who cannot be discharged because they are not able to look after themselves or have no family'.' The Director of the South African National Council for the Aged wrote in 9: 'Effective planning requires effective participation by all concerned. Doctors and others associated with medical care will have to contribute towards any plans for solving the problems of the frail and infirm ag.e~'! It was therefore decided to survey the overall position of the admission and discharge patterns of patients aged years and over at Groote Schuur Hospita~, Cape Town, to ascertain whether optimal use of hospital beds and services to the maximum benefit of this geriatric group was being achieved. Sir W. Ferguson Anderson of Glasgow states: 'It is worth recording that the methodology of geriatrics prevents the long term use of acute beds ~y patients who no longer need them, and allows a rapid flow of patients by placing the right patient in the ~pp.ro priate accommodation. This is of great economic Importance.' It was thought that a comparative study of this methodology as propounded by overseas authors and that practised at Groote Schuur Hospital would be of practical value in the light of the abovementioned statements. Furthermore, demographic studies have shown that t~e dramatic rise in the number of people over years m developed countries (Fig. ) is not only here to stay but will also escalate: It has been said that a 40% increase in people over years will tak~ place in the pr:ofessio?al lifetime of most current readers m the UK. An mterestmg demographic study pertaining to Cape Town is shown in Department of Comprehensive and Co!"~unity Medi.cine, University of Cape Town, and Cape DIVISional Councd L. R. TIBBIT, M.B. CH.B., Registrar Date received: January 99. Fig.." The striking difference between the White and Coloured population is very apparent, the Coloured aged spread of population being more in keeping with that of a developing country. It is also interesting to note that the percentage of Whites over years in the Atlantic (Sea Point) area (%) is identical with that of the number of under 4-year-olds of the whole Coloured population of Cape Town (Fig. ). These demographic factors were further considered to be cogent reasons for undertaking this survey, particularly in view of the fact that Groote Schuur Hospital was originally completed in 98. OBJECTIVES The objectives of the survey were to determine whether geriatric patients ( years of age and older) occupy acute beds for periods longer than warranted by their clinical disability in terms of other possible facilities, and at the other end of the scale to determine whether they are being discharged before optimal health can be achieved by hospitalization. The third objective was to determine the necessity for bridging accommodation and services. Bridging accommodation, for these purposes, is defined as those types of accommodation and services necessary for geriatric patients, who after recovery from an illness are still in a state of disability that would render them unfit for discharge from hospital to an independent existence. Disability states for the purposes of this study are defined simply as follows: disability status includes those individuals who are able to attend to their basic needs independently; disability status includes individuals who require help with their basic needs; and disability status inoludes individuals totally dependent on others for their basic needs. SELECTION OF SAMPLE GROUPS A random study sample of geriatric patients, 0 each from the Coloured and White groups, who normally reside in the Cape Town area and who were actually in multiple wards of Groote Sehuur Hospital during July and August 98 was selected. Psychogeriatric patients were excluded from the study on the grounds that the results of a similar survey for that group have very recently been published.' Also, the percentage of patients of years of age and over in multiple wards was to be calculated during this period. METHOD OF DATA COLLECTION Case folders of the randomly selected patients in multiple wards were perused to ascertain personal details and
2 48 SA MEDICAL JOURNAL October o In G-4 H':':':';':':';';';,;,;.r'" ''''9 H"""""...'T tg-u.. 9 G- ot>- WHOLE WHITE POPULATION CAPE TOWN WHOLE COLOURED POPULATION CAPE TOWN vascular accidents. Four in each group suffered from arthritis of varying severity. One White female was blind, and 4 White females had been admitted for hip fractures. Eight of the Whites had one medical condition apart from the main diagnosis on admission, had two, had four concomitant diagnoses, and I had six other conditions. In the Coloured group, 0 had one additional diagnosis, had two, had three and had four other conditions apart from the diagnosis that precipitateo admission. Previous Recent (within Years) Admissions In the White group, patients had been admitted once previously, 4 twice previously, and three times previously. In the Coloured group, 8 patients had been admitted once previously, twice and three times....9 CENTRAL ~. COLOUREDS J&-J9 ~' R~~~ '''9 b;;;;;;;;;;;;;""'""""... ~~~~~~,.., 9 ~+.f.;;;;~~iw ~~~WR 'G-4... :;:;:;:;:;:;=;:;:;:;:;=::;:;=;:;:;=;=;:; ATLANTIC WHITES Fig.. Population distribution by S-year intervals in selected health districts in Cape Town, with an estimate for the City (9 Census data). females, were married, were single, and were widowed. In the Coloured sample, 8 patients were male and were female. The mean ages were, and years respectively, the oldest male being 8 years and the oldest female 80 years. Fourteen patients were between and years, 9 between and years, between and 80 years, and between 8 and 8 years. Of the males, were married and were widowers, and females were married and were widowed. Income Eight of the White group were recorded as having small private incomes and were pensioners. All of the Coloured group were recorded as pensioners. Diagnosis The commonest cause of disability in both groups was cardiac disease ( Coloureds and 8 Whites). There were 0 diabetics in the Coloured group and only in the White. Eight Coloureds and Whites had chronic obstructive airways disease. There were cases of malignant disease in the Coloured group and 4 in the White group. Peripheral vascular disease was present in of the Coloureds but only in Whites. There were lower limb amputees, of which were bilateral in the Coloured group, and in the White sample there were unilateral amputees. Four Coloureds and Whites had had cerebro- Utilization of Preventive Services No White patients and Coloured patients had been visited by local authority community health nurses before admission. 0 Whites and 4 Coloured patients had attended local authority geriatric clinics. Three Whites and Coloured patient had attended voluntary organization service centres. No patients in either group were visited by these agencies in hospital and there was no evidence of referral to them on discharge. Pre-admission Referral and Treatment In the White group 4, and in the Coloured group were referred by private practitioners. It is significant that many of these Coloured patients were attended by general practitioners only in the crisis that led to admission, and many of them regularly attended the Outpatient Department of Groote Schuur Hospital () and day hospitals (). Some attended both. Four White and Coloured patients were referred for admission from the Outpatient Department of Groote Schuur Hospital. Two White patients and Coloured patients were referred by day hospitals. Two Whites and 4 Coloured patients presented themselves for admission through the Outpatient Department without any reference. One patient was actually visiting a friend in hospital when she became ill enough to warrant admission for a haematemesis. Five Coloured patients had been visited at home by district nurses from the day hospitals, and by local authority health visitors. Twenty-two of the White sample regularly attended the Outpatient Department of Groote Schuur Hospital and were attended with varying degrees of regularity by general practitioners. Only of the White group attended day hospitals, and had been visited at home by a district nurse. It is significant to record here, in the light of subsequent discussion, that no patient was visited at home by medical or nursing staff or social workers from Groote Schuur Hospital. Local Authority Preventive Clinics and Health Visit.ors It is interesting to note that 4 of the Coloured patients
3 Oktober 99 SA MEDIESE TYDSKRIF 49 had attended these clinics during the past years, while no Whites had attended. It was on these occasions that home visits from the local authority health visitors occurred as previously mentioned. No health visitors (community nurses) visited any patient in either of the samples during their stay in hospital. Voluntary Organizations Three White patients and Coloured patient in the sample had previously attended a seniors club. None was receiving Meals on Wheels, home help, laundry service, or guidance from a social worker employed by a voluntary organization. Social Reasons for Admission All Coloured patients were admitted for medical reasons, and only Whites for various medical and social reasons, e.g. female who was blind and who was suffering from a mild exacerbation of obstructive airways disease was admitted to the casualty ward in transit to a convalescent home to give her niece, who cared for her, a well-earned rest. DISCHARGE AND REFERRALS The admission and discharge disability status relating to length of stay and discharge referrals in White patients is shown in Table I. Six patients who were admitted in "a.totally dependent condition died, having been in hospital for periods varying from to 9 days. One other patient admitted to the casualty ward in disability status was discharged after days in the same status (having had a severe cerebrovascular accident) with referral to the Outpatient Department of Groote Schuur Hospital, with no arranged interim medical or nursing attention. The family undertook to provide care. Six patients admitted in status were discharged in status after lengths of hospital stay varying from to 98 days, with a mean of days. Two of these patients were discharged to convalescent homes, and 4 were to attend the Outpatient Department of Groote Schuur Hospital during the next weeks with no arrangement for interim medical or nursing care. Nine patients were admitted in status and discharged in the same condition after hospital stays varying from to 49 days (mean days). Three of this group were referred to convalescent or old-age homes, of whom waited for days in an 'acute' bed for a holiday placement. Six patients were referred back to the Outpatient Department with no interim care arranged. Two patients were admitted in status and discharged in status, and a further were admitted and discharged in status with no referral problems. It was judged that patients occupied 'acute' beds for unduly long periods in terms of other possible facilities to be discussed later - ranging from 9 to 98 days with a mean of days. Of this group, died, 9 were discharged in disability status, and patients in status. It was also judged that patients were discharged before optimal health could be achieved. One patient with a cerebrovascular accident (previously mentioned) was discharged in status and the remainder of this group in status. Their mean length of hospital stay was,8 days. Discharge referrals were all to the Outpatient Department, again with no interim care arranged. The overall mean length of hospital stay in the White group was, days. Only of the White group of 0 geriatric patients were not in need of bridging accommodation or services as provided by overseas geriatric units. However, it must be mentioned that 4 of these patients were referred by letter by private practitioners outside the hospital, and it is assumed that they would be notified of the discharges or deaths in due course. Nineteen were discharged to their own homes, but in of these cases, facilities or personnel were lacking for their home care. Furthermore, since these people are of a low income group, it is unlikely that funds would be available for very expensive private medical, nursing and ancillary care. Eight patients in the White group had contact with hospital social workers who dealt with their accommodation problems on discharge. There was evidence of.contact with relatives by the attending doctor in cases and by nursing staff in cases. As previously mentioned, social workers investigated the home conditions and made contact with families in 8 cases. Sixteen patients in the White group received physiotherapy, but no patients received occupational therapy in the department or the wards. There was no evidence of any patients having speech therapy or clinical psychological services. Admission and discharge disability status relating to length of stay and discharge referrals in Coloured patients is shown in Table II. Three patients in this group died after,, and days of hospitalization respectively. Two patients admitted in disability status were discharged in the same status after and days respectively. The former had had a cerebrovascular acc.dent and was referred to a day hospital, and the latter had a gangrenous leg but refused amputation. He was asked to return to the Outpatient Department during the next few days but was subsequently lost to this survey. Fourl-=cn patients were admitted in status and discharged in status, after hospital stays varying from I to 0 days with a mean of, days. Two of these patients were discharged to convalescent homes, were referred to the day hospitals with requests for district nursing attention, and 9 were referred to the Outpatient Department of Groote Schuur Hospital with no arrangement for interim medical or nursing attention. One patient in this group had suffered a sudden cerebrovascular accident, had remained in the casualty ward for days and was referred for day hospital and district nurse care. Seven patients were admitted in disability status and discharged in the same status after stays from to 4 days with a mean..of days. They were all referred to the Outpatient Department of Groote Schuur Hospital, and only had arrangements made for interim care by a district nurse. One of these patients was in the medical casualty ward for days suffering from haemoptysis due to inoperable lung carcinoma and was referred on dis-
4 TABLE I. ADMISSION AND DISCHARGE DISABILITY STATUS RELATED TO LENGTH OF STAY AND DISCHARGE REFERRALS IN WHITES 00 Ul o Diagnosis Metastatic Ca. Metastatic Ca. PVD gangrene leg Fractured hip CVA Metastatic Ca. Sudden onset CVA Laparotomy acute pancreatitis MI, PE CCF, COAD, amputee COAD and infection Fractured hip Complicated hip replacement Aortic valve replacement Pancreatitis (no lap.) Septic hip prosthesis COAD, blind COAD and i'nfection COAD and infection Ca. stomach, gastrectomy Fractured radius and ulna Osteoarthritis right knee Diabetes, CCF Haematemesis CCF, previous valve replacement Ca. ovary Biopsy axillary node Mass right abdomen Ca. uterus Postmenopausal bleeding Age DS on admission DS on discharge Died Died Died Died Died Died Length of stay (days) 9 9 Actual discharge referral Eaton Convalesc. Home Convalesc. home Eva,luation length stay AC = acule pancreatitis; DS = disability status; PVD = peripheral vascular disease; CVA = cerebrovascular accident; MI = myocardial infarction. PE = pulmonary embolism; CCF = con'gestive cardiac fai lure; COAD = chronic obstructive airways disease; ass. = assessment ward; rehab. = rehabilitation ward; DN = district nurse; HH = home help; DH = day hospital; into = intermediate term care ward; GSH OPD = Groote Schuur Hospital Outpatient Department GSH GSH OPD Old-age home Eaton Convalesc. Home OPD Long Short Recommended bridging accommodation or services - ON and HH Rehab. (postop.) Ass. Ass. Rehab. rehab. ON and HH rehab. Rehab. ger. OH Ass. (pre-op.) - rehab. (postop.) Ass. - int. Rehab. - ger. OH Ass. - holiday placement ON and HH Rehab. - ON and HH Ass. - int. OH and HH Ass. - discharge Int. - ON and HH [J) > : m " (j > <' '-< o ::0 > <' w o n0' a ().., \0 -..l \0
5 TABLE. ADMISSION AND DISCHARGE DISABILITY STATUS RELATED TO LENGTH OF STAY AND DISCHARGE REFERRALS IN COLOUREDS \.#.) o :>;" 0-0" (l..., Diagnosis PVD, bilat. amputee CVA Gangrene of the foot CVA CCF, COAD COAD, asthma IHD CCF, COAD Acute cholecystitis PVD, amputee Acute pulmonary oedema Leaking aortic aneurysm PVD, bilat. amputee MI Septicaemia, diabetic MI PVD, bilat. amputee Ca. lung Metastases IHD CCF Ca. lung Herniorrhaphy, leg paresis Ca. cervix Haematemesis/rheumatoid Ca. uterus Mesothelioma Haematemesis Prostatectomy, COAD Cataract extraction Age OS on admission OS on discharge Died Died Died Length of stay (days) 8 4 pre-op DH, DN Actual discharge referral DH, DN Jooste Hospital, Jooste Hospital,, DH, DH, DH, DH Evaluation length stay Long Short Recommended bridging accommodation or services, ger. DH Ass. - into or DH and DN, ger. DH, ger. DH Ass. - Ass. - HH int. surgical ward Rehab. - HH Rehab. - DH - DN - DN Ass. - DN Surgery - rehab. DN - DN Ass. int. Ass. - int. -\,CJ -:l \,CJ C/J > ~ t'lj tj t'lj [J) t'lj - ><: tj [J) ~ :xl... " IHD = ischaemic heart disease; ger. DH geriatric day hospital. For other abbreviations see Table I. 0\ VI -
6 SA MEDICAL JOURNAL October 99 charge to the Outpatient Department. One -year-old male patient was discharged home on his second postoperative day after inguinal herniorrhaphy but had the complicating factor of old-standing paresis of the leg. Three other patients were discharged to their homes in disability status with no referral problems. All surviving patients were discharged to their own homes except the mentioned who went to a convalescent home. In only of these cases were home conditions unsuitable in that the person who was to cope, usually a spouse, was frail and unwell. The overall mean length of hospital stay in the Coloured sample was,8 days. In this Coloured series it was judged that 9 patients occupied 'acute' beds for unduly long periods in terms of other possible facilities, ranging from to 0 days with a mean of 8,88 days. One patient in this group died, was discharged in status. and the remainder in status. It was also judged that 4 patients were discharged rapidly before optimal health could be achieved. One of these was discharged in status (previously mentioned and who refused amputation of a gangrenous leg), and the remainder in disability status. The length of stay ranged from to 8 days with a mean of,4 days. Two of these 4 patients were referred to day hospitals and the remainder to the Outpatient Department of Groote Schuur Hospital after weeks, with no arrangements for interim nursing or medical care. Only of the Coloured patients were believed not to be in need of bridging accommodation or services as previously mentioned. It must again be mentioned that patients were referred to hospital by general practitioners who would be notified of their discharges, but it was very unlikely that this group could afford private medical and nursing attention which would be protracted. Seven Coloured patients had contact with social workers to deal with accommodation problems on discharge. Fourteen patients in the Coloured sample were treated by physiotherapists, but none had contact with occupational therapists, clinical psychologists or speech therapists. There was evidence of contact with relatives by the attending doctor in cases, nursing staff in cases, and social workers in cases. Percentage Bed Occupancy by Geriatric Patients in Multiple Wards In the Coloured medical wards, geriatric patients occupied 0% of the beds on average, % in the surgical and % in the orthopaedic wards. In the White medical wards, geriatric patients occupied 44% of the beds on average, 4 % in the surgical wards and 4% in the orthopaedic wards. The orthopaedic beds were occupied by significantly more White female geriatric patients (%) than males (%). DISCUSSION The large percentage of White beds occupied by geriatric patients is not surprising considering that on the one hand Groote Schuur Hospital is a closed hospital, normally admitting only people of the lower income group (among others, old-aged pensioners), the younger group being largely economically active and mostly on medical aid funds. On the other hand, the demographic age pattern magnifies the problem in the White population and minimizes it in the Coloured. Also, a smaller proportion of Coloureds are in the higher income bracket, which would mean that a higher percentage of the younger groups are admitted. However, the Coloured population of Cape Town (± ) is almost double that of the White (± 0000), and good note will have to be taken of this fact in future hospital planning, especially if the socio-econornic status of the Coloured population improves. (The latter may paradoxically reduce their birth rate.) In 9' the average length of stay in Groote Schuur Hospital for Whites of all ages was 9, days and for Coloureds,88 days. In this geriatric survey, the average length of hospital stay was, days for Whites and,8 days for Coloureds. The mean cost per bed per day at Groote Schuur Hospital was R4 in 9," and is believed to have risen above R0 in 98. It can logically be stated that if methods could be suggested (i) to decrease the length of hospital stay in 'acute' beds of the geriatric population; and (ii) to place geriatric patients in less expensive accommodation with less expensive services at the earliest appropriate time, considerable savings could be anticipated. For example, in 9 8 the mean cost per bed per day at Eaton Convalescent Home was R9,4, at Conradie Hospital R0,94 and at Somerset Hospital R,9. Tt has already been stated that geriatric patients in this survey of 0 occupied 'acute' beds for apparently longer than was warranted by their disability states in terms of other possible facilities. On the other hand, 9 patients out of 0 were discharged rapidly before optimum health could be achieved in the hospital environment. Fourteen of these patients were Coloured. In 9 9 the percentage of medical beds occupied in the White wards of Groote Schuur Hospital was,% and in the non-white section 9,9 %. Surgical bed occupancy was,% in the White section and 89,0% in the Coloured section. In 9 the percentage of White beds occupied in the medical casualty'wards was 94,4'% and 0,% in the non-white section. At the present time (August 98) the latter figure has risen alarmingly to 00% (B. Sundgren - personal communication). The medical casualty wards may be regarded as the assessment wards of Groote Schuur Hospital to which very ill patients are admitted for a limited period. In this series of 0 patients, 4 (9 Coloured and White) were admitted to these wards. Eight were in disability status and in disability status. Two were discharged in disability status and in status. Tt is apparent from the above figures that in the Coloured group these ill patients were discharged because no alternative accommodation was available in the hospital, and the casualty ward was strained beyond its limits. Tt is noted that a considerable proportion of patients in this survey had multiple previous recent admissions. Tt is probable that with more emphasis on preventive,
7 Oktober 99 SA MEDIESE TYDSKRIF rehabilitative and follow-up services, this could be minimized. Preventive services, such as those provided by voluntary organizations, local authority clinics and community health nurses were very seldom used, and it is noteworthy that there was no follow-up service either in the hospital or in discharge referrals by these agencies. Rehabilitation Half of the patients had physiotherapy, and none had occupational or speech therapy while in hospital. There was minimal evidence of follow-up of these services on discharge from hospital in spite of the large proportion of patients with multiple diagnoses. Follow-Up Services on Discharge Five patients in the White group and in the Coloured group were admitted to convalescent or old-age homes. In the White survey, the remainder of the survivors (9) were sent home and referred back to the hospital outpatient department after a varying number of weeks, with no arrangements made for interim medical or nursing care. It is estimated that of these patients needed such care. In the Coloured survey, the remainder of the survivors () were sent home. In cases arrangements were made before discharge for day hospital or district nurse care, and in 9 cases there was no interim medical or nursing care arranged before return to the Outpatient.Department of Groote Schuur Hospital. Only of 9 were judged not to be in need of interim care, as they were discharged in disability status. In view of the fact that there are day hospitals]' in strategic positions in the Cape Peninsula who supply outpatient district nursing and outpatient and domiciliary physiotherapeutic services, it is surprising that only patients in this survey were referred to these facilities on discharge. The Groote Schuur Hospital Outpatient Depart- ment ll is stated to be under considerable pressure, but there is still apparent patient resistance to being referred away from the hospital. It is apparent, therefore, that in view of the fact that many ill patients are discharged rapidly before rehabilitation and optimal health can be achieved, with minimal follow-up services or bridging accommodation (i) chronicity of illnesses will be increased; (h) quality of life for these people will be further impaired; and (iii) more frequent re-admissions to expensive 'acute' beds will be required. This is indeed a very great pity because of the excellent inpatient care received by these geriatric patients, for example, uccessful aortic valve replacement in a woman of 4 years, and successful multiple abdominal surgery including aortic grafting in a man of years. This survey adequately demonstrates that the main areas where facilities are lacking for geriatric patients in Groote Schuur Hospital are: (i) less expensive beds for the patients who require longer hospital stays, particularly for convalescence and rehabilitation; (ii) rehabilitation services; (iii) facilities for follow-up services after discharge; and (iv) liaison between hospital, day hospital and local authority services, and voluntary organizations. REFERENCES I. Van der Merwe. S. W. (9): S. Afr. med. J Droskie, Z. (9): lbid.,, 4.. Anderson, Sir W. F. (9): Practical Matw[lemefJI 0/ Ihe Elderly, rd ed.. p. 44. Oxford: Blad.-well Scientific Publications. 4. Coni,., Davison, W. and Webster, S. (9): Lecture Notes on Geriatrics, op. -. Oxford: BlackwelI Scientific Publications.. Medical Officer of Health, Caoe Town (9): Annual Reoort.. Verrier-Jones, P., Pascoe, F. D., Gillis, L. S. el al. (98): S. Afr. med... 4,.. Groote Schuur Hospital Group (9): Annual Report. 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Dialysis Transplantation Nephrolog)': Proceedings of the Fifteenth Congress of the European Dialysis and Transplant Association, held in Istanbul, Turkey, 98. Ed. by B. H. B. Robinson and J. B. Hawkins. Pp. xvi +. Illustrated. 0,00. Tunbridge Wells, Kent: Pitman Medical Publishing Company. 98. The Singer's and Actor's Throat: The Vocal Mechanism of the Professional Voice User and its Care in Health and Disease. rd ed. By A. Punt. Pp. vi TIlustrated..9. London: William Heinemann Medical Books. 99.