Art c e s REFERENCES 1. Report of the CommiuJon of Inquiry into the Responsibility of Mentally Deranged Levels of health care at Persons and Related Matters. Pretoria: Government Printer. 1967. 2. Janofsky JS, Dunn MH, Roskes EJ. Briskln JK. Audolph ML. Insanity defense pleas in Baltimore City: An analysis of outcome. Am J Psychiatry 1996: 153: academic and regional 1464-1468. 3. Nair MG. W~els WHo The insanity defence: a South African ~pectlVe. Med Law 1992; 11: 297·302. hospitals in KwaZulu-Natal ~. Snyman CR. Criminal Law. 3rt! eel. Dutban: 6unerworIh. 1995. 5. Schrtliber J, Roe5oI;h R. Golding S. An evalllation of procedures for asSt!'SSing competency to stand trial. Bull Am Acaa Psychiatry La .... 1987: 15(2): 187-204. KN Vallabhjee. CC Jinabhai. E Gouws, 6. Drab Sl.. Serger RH, Wemstein He. Competency to stand trial: a conceptual model for its propel'" assessment. Bull Am Acad Psychlarry La.... 1987: 1.5(1}: 85-94. Bradshaw. K Naidoo 7. Ciccone JR. Clements C. The insanity cefence: asking and answenng the o ultimate questiOn. Bull Am Acad Psychiatry Law 1987; 15(4): 329-348. 8. Diamond B. Criminal responsibility of the mentally ill. In: Ouen JM, eds. The Psychiarrisr in the Courtroom (Se-lected papers of Bernard t. Diamond. MO). Objective. To assess the levels of health care based on Hillsdale. NJ: The Analytic Press. 1994. g. Stone AA. Law. Psychiatry and MOrTality. Washington: American Psychiatric hosprtal bed utilisation at seven academic and regional Press. 1984. 10. Insanity Defense Work Group. American Psychiatric Association statement 011 the hospitals in Kwazulu-Natal. insanity defense. Am J Psychiatry 1983: 140: 681-68a. Design. A prospective study. The registrar in charge of 11. Report of the Board of Trustees. Insanity defense in criminal trials and limitations of psychiatric testimony. JAMA 1964; 251: 2967·2961. patients documented the level of care needed for each 12. Diea PE. Mentally disordered offenders. Panerns in me relationship between mental disorCer ana crime. Psychiarr Clin North Am 1992: 15: 539-551. patient over 7 consecutive days. Independent assessment 13. Insanity Defence Work Group. Stalement on the Insanity Defence. Am J Psychiarry 1983: 140: 68T. by consuttants was used to validate the results. 14. Perlin ML Myths. realities, and the political worla: the anthropology of insanity defense attitudes. Bull Am Acad Psychiarry Law 1996; 24(1): 5-26. Setting. All wards in public sector regional and tertiary 15. Appelbaum PS. Almost a ReVOlution. MMtal He~ La.... and me limits of Cnange. Oxford: Oxford University Press. 1994-. hosprtals with acute general beds in Durban and Pietennaritzburg. except intensive care, coronary care and Accepled 1 July 1997. respiratory units. Participants. All inpatients present in the wards. The response rate of wards participating in the stUdy varied between hospitals from 32% to 75%. Data on 14 858 patient days were analysed. Outcome measures. Inpatients were classified according to levels of care based on' patient days. Results. The proportion of patients in the tertiary (King Edward) and regional hospitals requiring levels of care below that for which the hosprtal was designated ranged from 54% to 72% of the patient days. Wentworth Hospital, which is a tertiary referral centre, had 30% of its patient days judged to be below the designated level. Patient days below the designated level of care for that hospital were significantly higher in tertiary than in regional hospitals (P < 0.001). Conclusions. All seven hosprtals admitted patients at levels of care below that for which the hosprtal was designated. These findings have important implications for the efficient utilisation and planning of health and hospital services, and for their evaluation and management. S Afr Med J 1997; 87: 1355-1359. Since hospitals dominate the health services and comprise the largest and most costly operational unit of the health system, improving their efficiency may generate additional resources for the expansion and decentralisation of heatth Department of Community Health, University of Natal, Durban KN Vallabhjee. Me GhB. DOH. FFCH~. OHSM CC Jinabhai, BSc, Me 018. MMea \CMl. FFCH lSAl. DOH K Naidoo. Me CnS. MtMId (CM) Medical Research Council E Gouws. BSc. MSc o Bradshaw. BSc. MSc. ~ , SAMJ Volum .. 87 No. 10 Ocrobtr 1997 1355 = services towards a comprehensive PHC-based district The utilisation of hospital beds in regional and tertiary modeL' hospitals in Kwalulu-Natal - according to the different levels Hospital utilisation review programmes to optimise of health care and in terms of the level designated for that efficiency and contain costs have considered appropriate hospital - has not been studied. This study estimated the utilisation of hospital beds with a focus on length of stay hospital bed utilisation by assessing the level of care required and the justification of admission.2-111 The Appropriate by inpatients, on the basis of patient days, at seven tertiary Evaluation Protocol (AEP), developed by the Boston and regional hospitals in Durban and Pietermarilzburg. University Health Care Research Unit,' assesses the medical necessrty of admissions and the appropriateness of patient days in a hospital. However, it is not sensitive to the appropriateness of level of care. No suitable instrument, Definitions internationally recognised or standardised and based on 1. The levels of care used in this study were adapted from objective criteria, was found in the literature. the National Health Expenditure Review12 (Table I). The Given the magnitude of this study (seven hospitals) and classification of the hospitals was based on that used by the numerous clinical disciplines with a wide variety of clinical Department of Health as listed in the Hospital and Nursing conditions, it was not feasible to use a set of objective clinical Yeanbook [Table 11). criteria. which have been found to be 'labour intensive, time consuming and expensive' .11 All studies attempting to Table I. Definition and description of the levels of care categorise patients according to level of care or applying Level objective instruments to assess the appropriateness of of care Description Personal 8efvices hospital admissions rely on subjective opinion to some 1 5etf-eare None extent.'2 Zwarenstein recommends short written guidelines to standardise level of care judgements between observers and 2 Clinic PHC nurses No Iab/X-ray 1 15 16 hospitals. Record reviews )'1. or prospective assessment • of 3 Community-health PHC nurses Basic labIX-ray, patients in hospitals have been used in different studies. centre and doctors casualty Few studies on appropriate utilisation of hospital beds have 4 District hospital Doctors and Basic lab/X:'ray, been undertaken in South Africa. Zwarenstein et al. found that occasional access theatre to specialists in facilities, of patient days justified acute hospital in medical 71 % care major disciplines no ICU wards in a teaching hospital in the Cape.l1 Similar studies in 5 Regional hospital Specialists on Above services, the USA found that 66% of patient days and 75% of ongoing basis in ICU admissionse were justified. These studies did not address major disciplines, whether patients requiring hospitalisation could have been including psychiatry treated at a lower level of care. In 1990, Bachmann et al., and pathology using SUbjective assessments by registrars, found that 14% 6 Tertiary hospital As above + Above services~ of patients should not have been admitted to a tertiary facility experts in scarce, at all, and that 55% of patient days could have been spent at subspecialties + sophisticated a lower level of care.,a Henley et al., applying the Paediatric minor disciplines diagnostic and therapeutic Evaluation Protocol in combination with a subjective measure management of the level of care. found that in 98% of admissions, 79.5% + specialist of patient days were medically justified while 49% of outpatient care admissions required tertiary care at a children's teaching hospital in Cape Town." American studies have found that Table 11. A description of the hospitals participating in the study- 21.4% and 13.3%"'" of patient days did not justify hospital care. In 1992, Schneider and Broekman, using consultants for No. of Ranking Response a retrospective review of patient records in a teaching Hospital beds Departments (LOC) rate hospital in Johannesburg, found that 30%, 45% and 25% of Kin9Edward 1 913 M, S, P. O/G, 0, E, Tertiary 36 inpatients receive a maximum of level 1 (community hospitaO, Ps, U, Op, PI, D, H (6) level 2 (regional hospital) and level 3 (tertiary hospital) care Wentworth 390 Ns, N, C, CT, PI Tertiary 54 dUring hospitalisation. respectively (unpublished data). The (6) resu~s of an unpublished 1992 study of levels of care of Addington 746 M, S. P. O/G, 0, Regional 66 patients at the Wits academic complex showed that 32% and E, Ps, U, Op, PI (5) 50% of beds were used at below level 3 care at RK Khan 684 M, S, P. O/G. 0, Regional 60 Johannesburg General and Baragwanath hospitals, E, Ps, U, Op, PI (5) respectively (R Broekman - report to the Wrtwatersrand Prince 1 010 M, S, P. O/G, 0, Regional 32 Academic SUbcommittee), while a similar study at HF Mshiyeni E, Ps, U, Op, PI (5) Verwoerd Academic Hospital in Pretoria showed that 66.4%, Edandale 1 605 M, S, P, O/G, 0, E, Regional 73 21.7% and 9.9% of patient days required community Ps, U, Op, PI, H (5) hospital, regional hospital and tertiary hospital care. Northdale 385 M, S, P, O/G, 0, Regional 75 respectively (R Broekman - report to the Pretoria Academic E, Ps, U, Op, PI (5) Complex Subcommittee, 1992). • Hospit;JJ 8Jld Nursing Yearbook, 1994. LOC =level of C8I1l, E '" otolaryngology,S =surgery, M = medicine, Ps '" psychiatry, As the definitions and measures of appropriate bed p =paediatrics, U = urology, OIG =obsteuics & gynaecology, er = cardlothoracic swgery, utilisation vary considerably between different studies, PI = plastic surgery, Op = ophttIaImology, 0 '" orthopaedics, 0 (SS) = spinal surgery unit, PSx =padatric SI.:fgefy, 0 ,.