Future Acute Care in Rural General Hospitals in Norway

Professor Tor Ingebrigtsen

CEO

University Hospital of North Norway

April 30, 2008:Therefore managers intend to base the long-awaited service in a "modular" structure fitted out for its needs, and can be transported to another part of the Highlands once it has been replaced by a new hospital in the town.

Hospitals in Norway

• 1998– 56 acute care hospitals

• 2006– 45 (surgery and medicine)

– 5 (medicine only)

• No rural general hospital to be closed• Hospital are important for confidence and feeling of

safety in local communities

• But:– Reconsideration of work share between hospitals

• The chain of acute care

• Clarification

Main conclusions• Rural general hospitals provide important health services

and have specific strengths and advantages– Access and availability

– Broad, general competence

– Local knowledge

• Quality of care must be as good as in larger volume institutions

• The chain of acute care must be strengthened, and the work share changed• Redesigning processes must follow specific procedures

involving all parties of interest

A change in workload…

More– Diagnostic work

– Chronic obstructive lung disease

– Kidney failure – dialyses

– Diabetes

– Stroke and rehabilitation after stroke

– Palliative cancer treatment – chemotherapy

Less– Trauma

– Cancer surgery

Pyramid of HealthUniversity Hospitals

Rural general hospitals

Primary Care: >90% av the health services needed

Nursing homes

General practitioners

Community based services

Main strategies

• Early diagnosis to lead the patient to the into right clinical pathway

• Clinical pathways need to be developed across levels of care and geography

• Implementation of clinical practice guidelines

50 – 70 % of acute care patients can have definitive treatment at rural general hospitals

Bridging the gap

goes two ways…

Acute Coronary Disease

Rural general hospital

Stroke

• CT availability 24/7• <10 % thrombolysis• Few transfers to larger hospitals

Recommendations

• High quality diagnostic equipment– CT and ultrasound 24/7 (teleradiology network)– MRI at daytime

• ER organised in collaboration with local council health services

• Ambulance station and staff organised and localised close to the ER

• Specialists in internal medicine and anaesthesiology on call at all hospitals

Quality of care

• Equal to that achieved at larger hospitals– Availability and access are central aspects of quality– Outcome is, too...

• Service at the lowest effective care level– The volume of elective services must be high

enough to allow comparison with larger volume institutions

– Pragmatic balance between the volume/quality aspect and availability for acute care

Two hospital classes• Acute care hospitals

– Admit and treat all acute care and trauma patients– Physicians on call in general surgery, anaesthesiology and

internal medicine– Sub specialised orthopaedic surgeon not necessary– Radiology, laboratory services– Gynaecology and obstetrics??

• Acute care hospitals with adjusted functions– Admit and treat most cases except surgical emergencies– Physicians on call in internal medicine and anaesthesiology– Elective surgery, surgeon not necessarily on call

Staff recruitment and competence

• Main problem: Invasive emergency procedures

• National and regional training courses• Formal documentation of competence • New specialty in emergency medicine?

– Work group appointed, work in progress– National college of surgeons reconsidering

”common trunk” strategy for general surgery

• 50 mill NOK (£ 5 mill) to redesign projects in district general hospitals

• National committee on hospital economy– Redistribution of 780 mill NOK (£ 78 mill) from

the capital region to the rest of the country– Main reason: Cost of acute services

• Regional strategy in development

• Centralisation of acute surgical care to 7 hospitals?