Levels of care needed by medical inpatients in a teaching hospital

Medical inpatients in a teaching hospital ward were studied daily for 2 weeks. The registrar responsible for each patient decided each day what level of care would be most appropriate, and what elements of care were needed for the patient on that day. From their documented assessments on 308 of 458 recorded days registrars considered that 54.5% of patient-days (168 of 308 days) could appropriately have been spent at a lower of level of care than the academic hospital, had such beds been available. The assessments of the registrars in the study ward were similar to assessments of all medical registrars in all other general medical wards in the hospital. Professional staff in the study ward recorded task duration each time any work was done for a patient. Nurses spent 23.9% more time per patient on those whom registrars thought could be treated at lower levels. Doctors spent 15.0% more time per patient on those whose presence in the hospital registrars considered appropriate. Health care could be provided more economically if more lower-level facilities were available. This could perhaps also be achieved with reorganisation of care within a teaching hospital but steps would have to be taken to ensure maintenance of continuity of care and staff-patient relationships.