Sample records for acute care patients
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Patient dissatisfaction with acute stroke care.
Asplund, Kjell; Jonsson, Fredrik; Eriksson, Marie; Stegmayr, Birgitta; Appelros, Peter; Norrving, Bo; Terént, Andreas; Asberg, Kerstin Hulter
2009-12-01
Riks-Stroke, the Swedish Stroke Register, was used to explore patient characteristics and stroke services as determinants of patient dissatisfaction with acute in-hospital care. All 79 hospitals in Sweden admitting acute stroke patients participate in Riks-Stroke. During 2001 to 2007, 104,876 patients (87% of survivors) responded to a follow-up questionnaire 3 months after acute stroke; this included questions on satisfaction with various aspects of stroke care. The majority (>90%) were satisfied with acute in-hospital stroke care. Dissatisfaction was closely associated with outcome at 3 months. Patient who were dependent regarding activities of daily living, felt depressed, or had poor self-perceived general health were more likely to be dissatisfied. Dissatisfaction with global acute stroke care was linked to dissatisfaction with other aspects of care, including rehabilitation and support by community services. Patients treated in stroke units were less often dissatisfied than patients in general wards, as were patients who had been treated in a small hospital (vs medium or large hospitals) and patient who had participated in discharge planning. In multivariate analyses, the strongest predictor of dissatisfaction with acute care was poor outcome (dependency regarding activities of daily living, depressed mood, poor self-perceived health). Dissatisfaction with in-hospital acute stroke care is part of a more extensive complex comprising poor functional outcome, depressive mood, poor self-perceived general health, and dissatisfaction not only with acute care but also with health care and social services at large. Several aspects of stroke care organization are associated with a lower risk of dissatisfaction.
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Determining level of care appropriateness in the patient journey from acute care to rehabilitation
2011-01-01
Background The selection of patients for rehabilitation, and the timing of transfer from acute care, are important clinical decisions that impact on care quality and patient flow. This paper reports utilization review data on inpatients in acute care with stroke, hip fracture or elective joint replacement, and other inpatients referred for rehabilitation. It examines reasons why acute level of care criteria are not met and explores differences in decision making between acute care and rehabilitation teams around patient appropriateness and readiness for transfer. Methods Cohort study of patients in a large acute referral hospital in Australia followed with the InterQual utilization review tool, modified to also include reasons why utilization criteria are not met. Additional data on team decision making about appropriateness for rehabilitation, and readiness for transfer, were collected on a subset of patients. Results There were 696 episodes of care (7189 bed days). Days meeting acute level of care criteria were 56% (stroke, hip fracture and joint replacement patients) and 33% (other patients, from the time of referral). Most inappropriate days in acute care were due to delays in processes/scheduling (45%) or being more appropriate for rehabilitation or lower level of care (30%). On the subset of patients, the acute care team and the utilization review tool deemed patients ready for rehabilitation transfer earlier than the rehabilitation team (means of 1.4, 1.3 and 4.0 days from the date of referral, respectively). From when deemed medically stable for transfer by the acute care team, 28% of patients became unstable. From when deemed stable by the rehabilitation team or utilization review, 9% and 11%, respectively, became unstable. Conclusions A high proportion of patient days did not meet acute level of care criteria, due predominantly to inefficiencies in care processes, or to patients being more appropriate for an alternative level of care, including
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Jangland, Eva; Kitson, Alison; Muntlin Athlin, Åsa
2016-04-01
To explore how patients with acute abdominal pain describe their experiences of fundamental care across the acute care episode. Acute abdominal pain is one of the most common conditions to present in the acute care setting. Little is known about how patients' fundamental care needs are managed from presentation to post discharge. A multi-stage qualitative case study using the Fundamentals of Care framework as the overarching theoretical and explanatory mechanism. Repeated reflective interviews were conducted with five adult patients over a 6-month period in 2013 at a university hospital in Sweden. The interviews (n = 14) were analysed using directed content analysis. Patients' experiences across the acute care episode are presented as five patient narratives and synthesized into five descriptions of the entire hospital journey. The patients talked about the fundamentals of care and had vivid accounts of what they meant to them. The experiences of each of the patients were influenced by the extent to which they felt engaged with the health professionals. The ability to engage or build a rapport was identified as a central component across the fundamental care elements, but it varied in visibility. Consistent pain management, comfort, timely and accurate information, choice and dignity and relationships were identified as essential fundamental care needs of patients experiencing acute abdominal pain regardless of setting, diagnosis, or demographic variables. These were variously achieved and the patients' narratives raised areas for improvement in several areas. © 2016 John Wiley & Sons Ltd.
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Pietrantonio, Filomena; Orlandini, Francesco; Moriconi, Luca; La Regina, Micaela
2015-12-01
Chronic diseases are the major cause of death (59%) and disability worldwide, representing 46% of global disease burden. According to the Future Hospital Commission of the Royal College of Physicians, Medical Division (MD) will be responsible for all hospital medical services, from emergency to specialist wards. The Hospital Acute Care Hub will bring together the clinical areas of the MD that focus on the management of acute medical patients. The Chronic Care Model (CCM) places the patient at the center of the care system enhancing the community's social and health support, pathways and structures to keep chronic, frail, poly-pathological people at home or out of the hospital. The management of such patients in the hospital still needs to be solved. Hereby, we propose an innovative model for the management of the hospital's acute complex patients, which is the hospital counterpart of the CCM. The target population are acutely ill complex and poly-pathological patients (AICPPs), admitted to hospital and requiring high technology resources. The mission is to improve the management of medical admissions through pre-defined intra-hospital tracks and a global, multidisciplinary, patient-centered approach. The ACCM leader is an internal medicine specialist (IMS) who summarizes health problems, establishes priorities, and restores health balance in AICPPs. The epidemiological transition leading to a progressive increase in "chronically unstable" and complex patients needing frequent hospital treatment, inevitably enhances the role of hospital IMS in the coordination and delivery of care. ACCM represents a practical response to this epochal change of roles. Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
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Improving patients' and staff's experiences of acute care.
Chaplin, Rob; Crawshaw, Jacob; Hood, Chloe
2015-03-01
The aim of this audit was to assess the effect of the Quality Mark programme on the quality of acute care received by older patients by comparing the experiences of staff and older adults before and after the programme. Data from 31 wards in 12 acute hospitals were collected over two stages. Patients and staff completed questionnaires on the perceived quality of care on the ward. Patients rated improved experiences of nutrition, staff availability and dignity. Staff received an increase in training and reported better access to support, increased time and skill to deliver care and improved morale, leadership and teamwork. Problems remained with ward comfort and mealtimes. Overall, results indicated an improvement in ratings of care quality in most domains during Quality Mark data collection. Further audits need to explore ways of improving ward comfort and mealtime experience.
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Fu, Jack B; Lee, Jay; Shin, Ben C; Silver, Julie K; Smith, Dennis W; Shah, Jatin J; Bruera, Eduardo
2017-06-01
Pancytopenia, immunosuppression, and other factors may place patients with multiple myeloma at risk for medical complications. These patients often require inpatient rehabilitation. No previous studies have looked at risk factors for return to the primary acute care service of this patient population. To determine the percentage of and factors associated with return to the primary acute care service of multiple myeloma rehabilitation inpatients. Retrospective review. Acute inpatient rehabilitation unit within a National Cancer Institute Comprehensive Cancer Center. All patients with multiple myeloma admitted to the inpatient rehabilitation unit between March 1, 2004, and February 28, 2015. Return to the primary acute care service was analyzed with demographic information, multiple myeloma characteristics, medications, laboratory values, and hospital admission characteristics. One hundred forty-three inpatient rehabilitation admissions were found during the study period. After we removed multiple admissions of the same patients and planned transfers to the primary acute care service, 122 admissions were analyzed. Thirty-two (26%) patients transferred back to the primary acute care service for unplanned reasons. Multivariate analysis revealed male gender and thrombocytopenia as significantly associated with return to the primary acute care service. The median survival of patients who transferred back to the inpatient primary acute care service was 180 days versus 550 days for those who did not (P < .001). Because of their medical fragility, clinicians caring for rehabilitation inpatients with multiple myeloma should maintain close contact with the primary oncology service. Factors associated with an increased risk of transfer back to the primary acute care service include male gender and thrombocytopenia. IV. Copyright © 2017 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
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Acute Care Utilization by Patients After Graduation of Their Resident Primary Care Physicians.
Solomon, Sonja R; Gooding, Holly C; Reyes Nieva, Harry; Linder, Jeffrey A
2015-11-01
The disruption in provider continuity caused by medical resident graduation may result in adverse patient outcomes. Our aim was to investigate whether resident graduation was associated with increased acute care utilization by residents' primary care patients. This was a retrospective cohort study of patients cared for by junior and senior residents finishing the academic year in 2010, 2011 and 2012. We compared rates of clinic visits, emergency department (ED) visits, and hospitalizations between transitioning patients whose residents were graduating and non-transitioning patients whose residents were not graduating. Our study population comprised 90 residents, 4018 unique patients, and 5988 resident-patient dyads that transitioned (n = 3136) or did not transition (n = 2852). For transitioning patients, the clinic visit rate per 100 patients in the 4 months before and after graduation was 129 and 102, respectively; for non-transitioning patients, the clinic visit rate was 119 and 94, respectively (difference-in-differences, +2 per 100 patients; p = 0.12). For transitioning patients, the ED visit rate per 100 patients before and after graduation was 29 and 26, respectively; for non-transitioning patients, the ED visit rate was 28 and 25, respectively (difference-in-differences, 0; p = 0.49). For transitioning patients, the hospitalization rate per 100 patients before and after graduation was 14 and 13, respectively; for non-transitioning patients, the hospitalization rate was 15 and 12, respectively (difference-in-differences, -2; p = 0.20). In multivariable modeling there was no increased risk for transitioning patients for clinic visits (adjusted rate ratio [aRR], 1.03; 95 % confidence interval [CI], 0.97 to 1.10), ED visits (aRR, 1.05; 95 % CI, 0.92 to 1.20), or hospitalizations (aRR, 1.04; 95 % CI, 0.83 to 1.31). Acute care utilization by residents' patients did not increase or decrease after graduation. Acute care utilization was high
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Promoting patient-centred fundamental care in acute healthcare systems.
Feo, Rebecca; Kitson, Alison
2016-05-01
Meeting patients' fundamental care needs is essential for optimal safety and recovery and positive experiences within any healthcare setting. There is growing international evidence, however, that these fundamentals are often poorly executed in acute care settings, resulting in patient safety threats, poorer and costly care outcomes, and dehumanising experiences for patients and families. Whilst care standards and policy initiatives are attempting to address these issues, their impact has been limited. This discussion paper explores, through a series of propositions, why fundamental care can be overlooked in sophisticated, high technology acute care settings. We argue that the central problem lies in the invisibility and subsequent devaluing of fundamental care. Such care is perceived to involve simple tasks that require little skill to execute and have minimal impact on patient outcomes. The propositions explore the potential origins of this prevailing perception, focusing upon the impact of the biomedical model, the consequences of managerial approaches that drive healthcare cultures, and the devaluing of fundamental care by nurses themselves. These multiple sources of invisibility and devaluing surrounding fundamental care have rendered the concept underdeveloped and misunderstood both conceptually and theoretically. Likewise, there remains minimal role clarification around who should be responsible for and deliver such care, and a dearth of empirical evidence and evidence-based metrics. In explicating these propositions, we argue that key to transforming the delivery of acute healthcare is a substantial shift in the conceptualisation of fundamental care. The propositions present a cogent argument that counters the prevailing perception that fundamental care is basic and does not require systematic investigation. We conclude by calling for the explicit valuing and embedding of fundamental care in healthcare education, research, practice and policy. Without this
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A patient-centered research agenda for the care of the acutely ill older patient.
Wald, Heidi L; Leykum, Luci K; Mattison, Melissa L P; Vasilevskis, Eduard E; Meltzer, David O
2015-05-01
Hospitalists and others acute-care providers are limited by gaps in evidence addressing the needs of the acutely ill older adult population. The Society of Hospital Medicine sponsored the Acute Care of Older Patients Priority Setting Partnership to develop a research agenda focused on bridging this gap. Informed by the Patient-Centered Outcomes Research Institute framework for identification and prioritization of research areas, we adapted a methodology developed by the James Lind Alliance to engage diverse stakeholders in the research agenda setting process. The work of the Partnership proceeded through 4 steps: convening, consulting, collating, and prioritizing. First, the steering committee convened a partnership of 18 stakeholder organizations in May 2013. Next, stakeholder organizations surveyed members to identify important unanswered questions in the acute care of older persons, receiving 1299 responses from 580 individuals. Finally, an extensive and structured process of collation and prioritization resulted in a final list of 10 research questions in the following areas: advanced-care planning, care transitions, delirium, dementia, depression, medications, models of care, physical function, surgery, and training. With the changing demographics of the hospitalized population, a workforce with limited geriatrics training, and gaps in evidence to inform clinical decision making for acutely ill older patients, the identified research questions deserve the highest priority in directing future research efforts to improve care for the older hospitalized patient and enrich training. © 2015 Society of Hospital Medicine.
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Studying Physician-Patient Communication in the Acute Care Setting: The Hospitalist Rapport Study
Anderson, Wendy G.; Winters, Kathryn; Arnold, Robert M.; Puntillo, Kathleen A.; White, Douglas B.; Auerbach, Andrew D.
2010-01-01
Objective To assess the feasibility of studying physician-patient communication in the acute care setting. Methods We recruited hospitalist physicians and patients from two hospitals within a university system and audio-recorded their first encounter. Recruitment, data collection, and challenges encountered were tracked. Results Thirty-two physicians consented (rate 91%). Between August 2008 and March 2009, 441 patients were referred, 210 (48%) were screened, and 119 (66% of 179 eligible) consented. We audio-recorded encounters of 80 patients with 27 physicians. Physicians’ primary concern about participation was interference with their workflow. Addressing their concerns and building the protocol around their schedules facilitated participation. Challenges unique to the acute care setting were: 1) extremely limited time for patient identification, screening, and enrollment during which patients were ill and busy with clinical care activities, and 2) little advance knowledge of when physician-patient encounters would occur. Employing a full-time study coordinator mitigated these challenges. Conclusion Physician concerns for participating in communication studies are similar in ambulatory and acute care settings. The acute care setting presents novel challenges for patient recruitment and data collection. Practice Implications These methods should be used to study provider-patient communication in acute care settings. Future work should test strategies to increase patient enrollment. PMID:20444569
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Challenges that nurses face in caring for morbidly obese patients in the acute care setting.
Drake, Daniel; Dutton, Kathy; Engelke, Martha; McAuliffe, Maura; Rose, Mary Ann
2005-01-01
Despite increasing numbers of morbidly obese patients admitted to acute care facilities for surgery or treatment of nonsurgical conditions, there is little evidence of the problems nurses face in providing care to these patients. Anecdotal evidence suggests that the care of these patients is more demanding than the care of nonobese patients. The objective of this study was to describe nurses' perceptions of the challenges that they face when caring for morbidly obese patients. Focus groups of nurses from a tertiary care facility were convened. A trained facilitator posed questions to the group concerning various aspects of care for morbidly obese patients. Comments of respondents were categorized using NVIVO software. Nurses reported concerns about the increased staffing needs required for care of these patients and the particular challenges of the physical care. Concerns also included the availability, placement, and use of specialized equipment. Room size and the absence of some equipment were also problematic. Finally, nurses perceived safety issues, both for themselves and their patients. Morbidly obese patients in the acute care setting require specialized nursing care in terms of techniques, levels of staffing required, and the use of specialized equipment.
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Elective course in acute care using online learning and patient simulation.
Seybert, Amy L; Kane-Gill, Sandra L
2011-04-11
To enhance students' knowledge of and critical-thinking skills in the management of acutely ill patients using online independent learning partnered with high-fidelity patient simulation sessions. Students enrolled in the Acute Care Simulation watched 10 weekly Web-based video presentations on various critical care and advanced cardiovascular pharmacotherapy topics. After completing each online module, all students participated in groups in patient-care simulation exercises in which they prepared a pharmacotherapeutic plan for the patient, recommended this plan to the patient's physician, and completed a debriefing session with the facilitator. Students completed a pretest and posttest before and after each simulation exercise, as well as midterm and final evaluations and a satisfaction survey. Pharmacy students significantly improved their scores on 9 of the 10 tests (p ≤ 0.05). Students' performance on the final evaluation improved compared with performance on the midterm evaluation. Overall, students were satisfied with the unique dual approach to learning and enjoyed the realistic patient-care environment that the simulation laboratory provided. Participation in an elective course that combined self-directed Web-based learning and hands-on patient simulation exercises increased pharmacy students' knowledge and critical-thinking skills in acute care.
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Post-acute care and vertical integration after the Patient Protection and Affordable Care Act.
Shay, Patrick D; Mick, Stephen S
2013-01-01
The anticipated changes resulting from the passage of the Patient Protection and Affordable Care Act-including the proposed adoption of bundled payment systems and the promotion of accountable care organizations-have generated considerable controversy as U.S. healthcare industry observers debate whether such changes will motivate vertical integration activity. Using examples of accountable care organizations and bundled payment systems in the American post-acute healthcare sector, this article applies economic and sociological perspectives from organization theory to predict that as acute care organizations vary in the degree to which they experience environmental uncertainty, asset specificity, and network embeddedness, their motivation to integrate post-acute care services will also vary, resulting in a spectrum of integrative behavior.
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Penney, Christine; Henry, Effie
2008-01-01
The public, providers and policy-makers are interested in a service continuum where care is provided in the appropriate place. Alternate level of care is used to define patients who no longer need acute care but remain in an acute care bed. Our aims were to determine how subacute care and convalescent care should be defined in British Columbia (BC); how these care levels should be aligned with existing legislation to provide more consistent service standards to patients and what reporting requirements were needed for system planning and performance management. A literature review was conducted to understand the international trends in performance management, care delivery models and change management. A Canada-wide survey was carried out to determine the directions of other provinces on the defined issues and a BC survey provided a current state analysis of programming within the five regional health authorities (HAs). A provincial policy framework for subacute and convalescent care has been developed to begin to address the concerns raised and provide a base for performance measurement. The policy has been approved and disseminated to BC HAs for implementation. An implementation plan has been developed and implementation activities have been integrated into the work of existing provincial committees. Evaluation will occur through performance measurement. The benefits anticipated include: clear policy guidance for programme development; improved comparability of performance information for system monitoring, planning and integrity of the national acute care Discharge Abstracting Database; improved efficiency in acute care bed use; and improved equity of access, insurability and quality for patients requiring subacute and convalescent care. While a national reporting system exists for acute care in Canada, this project raises questions about the implications for this system, given the shifting definition of acute care as other care levels emerge. Questions are also
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Chi, Shu-Ching; Yeh, Lily; Lu, Meei-Shiow; Lin, Pei-Yu
2015-12-01
Post-acute care (PAC) service is becoming increasingly important in Taiwan as a core focus of government policies that are designed to ensure continuity of care. In order to improve PAC nursing education and quality of care, the present study applies a modified Delphi method to identify the core competences of nurses who provide PAC services to acute stroke patients. We surveyed 18 experts in post-acute care and long-term care anonymously using a 29-question questionnaire in order to identify the essential professional skills that are required to perform PAC effectively. The results of this survey indicate that the core competences of PAC may be divided into two categories: Case Management and Care Management. Case Management includes Direct Care, Communication, Health Care Education, Nursing Consulting, and Family Assessment & Health Care. Care Management includes Interdisciplinary Teamwork, Patient Care Management, and Resource Integration. The importance and practicality of each item was evaluated using a 7-point Likert scale. The experts required 2 rounds to reach a consensus about the importance and 3 rounds to determine the practicality of PAC core competences. This process highlighted the differing points of view that are held by professionals in the realms of nursing, medicine, and national health policy. The PAC in-job training program in its current form inadequately cul-tivates core competence in Care Management. The results of the present study may be used to inform the development of PAC nurse orientation training programs and continuing education courses.
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Safe patient handling perceptions and practices: a survey of acute care physical therapists.
Olkowski, Brian F; Stolfi, Angela M
2014-05-01
Acute care physical therapists are at risk for developing work-related musculoskeletal disorders (WMSDs) due to manual patient handling. Safe patient handling (SPH) reduces WMSDs caused by manual handling. The purpose of this study was to describe the patient handling practices of acute care physical therapists and their perceptions regarding SPH. Additionally, this study determined whether an SPH program influences the patient handling practices and perceptions regarding SPH of acute care physical therapists. Subscribers to the electronic discussion board of American Physical Therapy Association's Acute Care Section were invited to complete a survey questionnaire. The majority of respondents used SPH equipment and practices (91.1%), were confident using SPH equipment and practices (93.8%), agreed that evidence supports the use of SPH equipment and practices (87.0%), and reported the use of SPH equipment and practices is feasible (92.2%). Respondents at a facility with an SPH program were more likely to use SPH equipment and practices, have received training in the use of SPH equipment and practices, agree that the use of SPH equipment and practices is feasible, and feel confident using SPH equipment and practices. The study might not reflect the perceptions and practices of the population of acute care physical therapists. Acute care physical therapists are trained to use SPH equipment and practices, use SPH equipment and practices, and have positive perceptions regarding SPH. Acute care physical therapists in a facility with an SPH program are more likely to use SPH equipment and practices, receive training in SPH equipment and practices, and have positive perceptions regarding SPH. Quasi-regulatory organizations should incorporate SPH programs into their evaluative standards.
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Utilization of acute care among patients with ESRD discharged home from skilled nursing facilities.
Hall, Rasheeda K; Toles, Mark; Massing, Mark; Jackson, Eric; Peacock-Hinton, Sharon; O'Hare, Ann M; Colón-Emeric, Cathleen
2015-03-06
Older adults with ESRD often receive care in skilled nursing facilities (SNFs) after an acute hospitalization; however, little is known about acute care use after SNF discharge to home. This study used Medicare claims for North and South Carolina to identify patients with ESRD who were discharged home from a SNF between January 1, 2010 and August 31, 2011. Nursing Home Compare data were used to ascertain SNF characteristics. The primary outcome was time from SNF discharge to first acute care use (hospitalization or emergency department visit) within 30 days. Cox proportional hazards models were used to identify patient and facility characteristics associated with the outcome. Among 1223 patients with ESRD discharged home from a SNF after an acute hospitalization, 531 (43%) had at least one rehospitalization or emergency department visit within 30 days. The median time to first acute care use was 37 days. Characteristics associated with a shorter time to acute care use were black race (hazard ratio [HR], 1.25; 95% confidence interval [95% CI], 1.04 to 1.51), dual Medicare-Medicaid coverage (HR, 1.24; 95% CI, 1.03 to 1.50), higher Charlson comorbidity score (HR, 1.07; 95% CI, 1.01 to 1.12), number of hospitalizations during the 90 days before SNF admission (HR, 1.12; 95% CI, 1.03 to 1.22), and index hospital discharge diagnoses of cellulitis, abscess, and/or skin ulcer (HR, 2.59; 95% CI, 1.36 to 4.45). Home health use after SNF discharge was associated with a lower rate of acute care use (HR, 0.72; 95% CI, 0.59 to 0.87). There were no statistically significant associations between SNF characteristics and time to first acute care use. Almost one in every two older adults with ESRD discharged home after a post-acute SNF stay used acute care services within 30 days of discharge. Strategies to reduce acute care utilization in these patients are needed. Copyright © 2015 by the American Society of Nephrology.
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Fukuda, Risa; Shimizu, Yasuko
2015-01-01
Objective Dementia is a major public health problem. More and more patients with dementia are being admitted to acute care hospitals for treatment of comorbidities. Issues associated with care of patients with dementia in acute care hospitals have not been adequately clarified. This study aimed to explore the challenges nurses face in providing care to patients with dementia in acute care hospitals in Japan. Methods This was a qualitative study using focus group interviews (FGIs). The setting was six acute hospitals with surgical and medical wards in the western region of Japan. Participants were nurses in surgical and internal medicine wards, excluding intensive care units. Nurses with less than 3 years working experience, those without experience in dementia patient care in their currently assigned ward, and head nurses were excluded from participation. FGIs were used to collect data from February to December 2008. Interviews were scheduled for 1–1.5 h. The qualitative synthesis method was used for data analysis. Results In total, 50 nurses with an average experience of 9.8 years participated. Eight focus groups were formed. Issues in administering care to patients with dementia at acute care hospitals were divided into seven groups. Three of these groups, that is, problematic patient behaviors, recurrent problem, and problems affecting many people equally, interact to result in a burdensome cycle. This cycle is exacerbated by lack of nursing experience and lack of organization in hospitals. In coping with this cycle, the nurses develop protection plans for themselves and for the hospital. Conclusions The two main issues experienced by nurses while administering care to patients with dementia in acute care hospitals were as follows: (a) the various problems and difficulties faced by nurses were interactive and caused a burdensome cycle, and (b) nurses do their best to adapt to these conditions despite feeling conflicted. PMID:25716983
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Aigner, R; Meier Fedeler, T; Eschbach, D; Hack, J; Bliemel, C; Ruchholtz, S; Bücking, B
2016-12-01
The aim of the present study was to identify patient factors associated with higher costs in hip fracture patients. The mean costs of a prospectively observed sample of 402 patients were 8853 €. The ASA score, Charlson comorbidity index, and fracture location were associated with increased costs. Fractures of the proximal end of the femur (hip fractures) are of increasing incidence due to demographic changes. Relevant co-morbidities often present in these patients cause high complication rates and prolonged hospital stays, thus leading to high costs of acute care. The aim of this study was to perform a precise cost analysis of the actual hospital costs of hip fractures and to identify patient factors associated with increased costs. The basis of this analysis was a prospectively observed single-center trial, which included 402 patients with fractures of the proximal end of the femur. All potential cost factors were recorded as accurately as possible for each of the 402 patients individually, and statistical analysis was performed to identify associations between pre-existing patient factors and acute care costs. The mean total acute care costs per patient were 8853 ± 5676 € with ward costs (5828 ± 4294 €) and costs for surgical treatment (1972 ± 956 €) representing the major cost factors. The ASA score, Charlson comorbidity index, and fracture location were identified as influencing the costs of acute care for hip fracture treatment. Hip fractures are associated with high acute care costs. This study underlines the necessity of sophisticated risk-adjusted payment models based on specific patient factors. Economic aspects should be an integral part of future hip fracture research due to limited health care resources.
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Fu, Jack Brian; Lee, Jay; Smith, Dennis W.; Bruera, Eduardo
2012-01-01
Objective To assess the frequency and reasons for return to the primary acute care service among leukemia patients undergoing inpatient rehabilitation. Design Retrospective study of all patients with leukemia, myelodysplastic syndrome, aplastic anemia, or myelofibrosis admitted to inpatient rehabilitation at a tertiary referral-based cancer center between January 1, 2005, and April 10, 2012. Items analyzed from patient records included return to the primary acute care service with demographic information, leukemia characteristics, medications, hospital admission characteristics, and laboratory values. Results 225 patients were admitted a total of 255 times. 93/255 (37%) of leukemia inpatient rehabilitation admissions returned to the primary acute care service. 18/93 (19%) and 42/93 (45%) of these patients died in the hospital and were discharged home respectively. Statistically significant factors (p<.05) associated with return to the primary acute care service include peripheral blast percentage and the presence of an antifungal agent on the day of inpatient rehabilitation transfer. Using an additional two factors (platelet count and the presence of an antiviral agent both with a p<.11), a Return To Primary (RTP) - Leukemia index was formulated. Conclusions Leukemia patients with the presence of circulating peripheral blasts and/or antifungal agent may be at increased risk of return to the primary acute care service. The RTP-Leukemia index should be tested in prospective studies to determine its usefulness. PMID:23117267
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Soares, Luiz Guilherme L; Japiassu, André M; Gomes, Lucia C; Pereira, Rogéria
2018-02-01
Patients with complex palliative care needs can experience delayed discharge, which causes an inappropriate occupancy of hospital beds. Post-acute care facilities (PACFs) have emerged as an alternative discharge destination for some of these patients. The aim of this study was to investigate the frequency of admissions and characteristics of palliative care patients discharged from hospitals to a PACF. We conducted a retrospective analysis of PACF admissions between 2014 and 2016 that were linked to hospital discharge reports and electronic health records, to gather information about hospital-to-PACF transitions. In total, 205 consecutive patients were discharged from 6 different hospitals to our PACF. Palliative care patients were involved in 32% (n = 67) of these discharges. The most common conditions were terminal cancer (n = 42, 63%), advanced dementia (n = 17, 25%), and stroke (n = 5, 8%). During acute hospital stays, patients with cancer had significant shorter lengths of stay (13 vs 99 days, P = .004), a lower use of intensive care services (2% vs 64%, P < .001) and mechanical ventilation (2% vs 40%, P < .001), when compared to noncancer patients. Approximately one-third of discharges from hospitals to a PACF involved a heterogeneous group of patients in need of palliative care. Further studies are necessary to understand the trajectory of posthospitalized patients with life-limiting illnesses and what factors influence their decision to choose a PACF as a discharge destination and place of death. We advocate that palliative care should be integrated into the portfolio of post-acute services.
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Design Considerations for Post-Acute Care mHealth: Patient Perspectives.
Sanger, Patrick; Hartzler, Andrea; Lober, William B; Evans, Heather L; Pratt, Wanda
2014-01-01
Many current mobile health applications ("apps") and most previous research have been directed at management of chronic illnesses. However, little is known about patient preferences and design considerations for apps intended to help in a post-acute setting. Our team is developing an mHealth platform to engage patients in wound tracking to identify and manage surgical site infections (SSI) after hospital discharge. Post-discharge SSIs are a major source of morbidity and expense, and occur at a critical care transition when patients are physically and emotionally stressed. Through interviews with surgical patients who experienced SSI, we derived design considerations for such a post-acute care app. Key design qualities include: meeting basic accessibility, usability and security needs; encouraging patient-centeredness; facilitating better, more predictable communication; and supporting personalized management by providers. We illustrate our application of these guiding design considerations and propose a new framework for mHealth design based on illness duration and intensity.
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Characteristics of Inpatient Care and Rehabilitation for Acute First-Ever Stroke Patients
Chang, Won Hyuk; Shin, Yong-Il; Lee, Sam-Gyu; Oh, Gyung-Jae; Lim, Young Shil
2015-01-01
Purpose The purpose of this study was to analyze the status of inpatient care for acute first-ever stroke at three general hospitals in Korea to provide basic data and useful information on the development of comprehensive and systematic rehabilitation care for stroke patients. Materials and Methods This study conducted a retrospective complete enumeration survey of all acute first-ever stroke patients admitted to three distinct general hospitals for 2 years by reviewing medical records. Both ischemic and hemorrhagic strokes were included. Survey items included demographic data, risk factors, stroke type, state of rehabilitation treatment, discharge destination, and functional status at discharge. Results A total of 2159 patients were reviewed. The mean age was 61.5±14.4 years and the ratio of males to females was 1.23:1. Proportion of ischemic stroke comprised 54.9% and hemorrhagic stroke 45.1%. Early hospital mortality rate was 8.1%. Among these patients, 27.9% received rehabilitation consultation and 22.9% underwent inpatient rehabilitation treatment. The mean period from admission to rehabilitation consultation was 14.5 days. Only 12.9% of patients were transferred to a rehabilitation department and the mean period from onset to transfer was 23.4 days. Improvements in functional status were observed in the patients who had received inpatient rehabilitation treatment after acute stroke management. Conclusion Our analysis revealed that a relatively small portion of patients who suffered from an acute first-ever stroke received rehabilitation consultation and inpatient rehabilitation treatment. Thus, applying standardized clinical practice guidelines for post-acute rehabilitation care is needed to provide more effective and efficient rehabilitation services to patients with stroke. PMID:25510773
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Incidence, care quality and outcomes of patients with acute kidney injury in admitted hospital care.
Medcalf, J F; Davies, C; Hollinshead, J; Matthews, B; O'Donoghue, D
2016-12-01
Acute kidney injury (AKI) is common in acute hospital admission and associated with worse patient outcomes. To measure incidence, care quality and outcome of AKI in admitted hospital care. Forty-six of 168 acute NHS healthcare trusts in UK caring for 2 million acute hospital admissions per annum collected information on adults identified with AKI stage 3 (3-fold rise in serum creatinine or creatinine >354 µmol/l) through routine biochemical testing over a 5-month period in 2012. Information was collected on patient and care characteristics. Primary outcomes were survival and recovery of kidney function at 1 month. A total of 15 647 patients were identified with biochemical AKI stage 3. Case note reviews were available for 7726 patients. In 80%, biochemical AKI stage 3 was confirmed clinically. Among this group, median age was 75 years, median length of stay was 12 days and the overall mortality within 1 month was 38%. Significant factors in a multivariable model predicting survival included age and some causes of AKI. Dipstick urinalysis, medication review, discussion with a nephrologist and acceptance for transfer to a renal unit were also associated with higher survival, but not early review by a senior doctor, acceptance for transfer to critical care or requirement for renal replacement therapy. Eighteen percent of people did not have their kidney function checked 1 month after the episode had resolved. This large study of in-hospital AKI supports the efficacy of biochemical detection of AKI in common usage. AKI mortality remains substantial, length of stay comparable with single-centre studies, and much of the variation is poorly explained (model Cox and Snell R 2 = 0.131) from current predictors. © The Author 2016. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oup.com.
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Emotions delay care-seeking in patients with an acute myocardial infarction.
Nymark, Carolin; Mattiasson, Anne-Cathrine; Henriksson, Peter; Kiessling, Anna
2014-02-01
In acute myocardial infarction the risk of death and loss of myocardial tissue is at its highest during the first few hours. However, the process from symptom onset to the decision to seek medical care can take time. To comprehend patients' pre-hospital delay, attention must be focused on the circumstances preceding the decision to seek medical care. To add a deeper understanding of patients' thoughts, feelings and actions that preceded the decision to seek medical care when afflicted by an acute myocardial infarction. Fourteen men and women with a first or second acute myocardial infarction were interviewed individually in semi-structured interviews. Data were analysed by qualitative content analysis. Four themes were conceptualized: 'being incapacitated by fear, anguish and powerlessness', 'being ashamed of oneself', 'fear of losing a healthy identity' and 'striving to avoid fear by not interacting with others'. Patients were torn between feelings such as anguish, fear, shame and powerlessness. They made an effort to uphold their self-image as being a healthy person thus affected by an unrecognized discomfort. This combined with a struggle to protect others from involvement, strengthened the barriers to seeking care. The present study indicates that emotional reactions are important and influence patients' pre-hospital behaviour. Being ashamed of oneself stood out as a novel finding. Emotions might be an important explanation of undesired and persisting patient delays. However, our findings have to and should be evaluated quantitatively. Such a study is in progress.
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Wiese, Christoph H R; Barrels, Utz E; Graf, Bernhard M; Hanekop, Gerd G
2009-01-01
Prehospital emergency physicians (EP) are often confronted with the acute care of palliative care patients. Dyspnoea is a frequent acute symptom and its causes often differ from the generally known emergency medical causes. Till now, there have been no relevant concepts for emergency care of palliative care patients for their specific symptoms. Over a 24-month period, the authors retrospectively investigated all out-of-hospital emergency medical services for palliative care patients with acute dyspnoea at four emergency physician support points. The evaluation of these services was followed retrospectively on the basis of the therapy carried out by the EP (Group 1: therapy with morphine and oxygen; Group 2: therapy with morphine, bronchodilator effective drugs and oxygen; Group 3: therapy with bronchodilator effective drugs and oxygen; Group 4: therapy with oxygen; Group 5: no medical treatment). Moreover, EPs were interviewed about their actions and their uncertainties in the treatment of palliative care patients. The diagnosis of acute dyspnoea in palliative care patients occurred 121 times (116 patients were integrated in the present investigation) within the defined period. In total, 116 patients were included (Group 1: 21, Group 2: 29, Group 3: 31, Group 4: 28, and Group 5: 7). Dyspnoea was satisfactorily treated in 41 percent of the patients (Group 1: 67 percent, Group 2: 52 percent, Group 3: 22 percent, Group 4: 18 percent, and Group 5: 71 percent). Most EPs (70 percent) revealed uncertainties in emergency medical therapy for patients at the end of life. The current investigation showed a significant relief of acute dyspnoea when using opioids, in contrast with the established out-of-hospital emergency medical therapy for acute dyspnoea. Therefore, opioids should be recommended for emergency medical therapy of dyspnoea in palliative care patients. Clinical studies that recommend the use of effective opioids for the treatment of dyspnoea in palliative care
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[Patient-related complexity in nursing care - Collective case studies in the acute care hospital].
Gurtner, Caroline; Spirig, Rebecca; Staudacher, Diana; Huber, Evelyn
2018-06-04
Patient-related complexity in nursing care - Collective case studies in the acute care hospital Abstract. Patient-related complexity of nursing is defined by the three characteristics "instability", "uncertainty", and "variability". Complexity increased in the past years, due to reduced hospital length of stay and a growing number of patients with chronic and multiple diseases. We investigated the phenomenon of patient-related complexity from the point of view of nurses and clinical nurse specialists in an acute care hospital. In the context of a collective case study design, nurses and clinical nurse specialists assessed the complexity of nursing situations with a questionnaire. Subsequently, we interviewed nurses and clinical nurse specialists about their evaluation of patient-related complexity. In a within-case-analysis we summarized data inductively to create case narratives. By means of a cross-case-analysis we compared the cases with regard to deductively derived characteristics. The four cases exemplarily showed that the degree of complexity depends on the controllability and predictability of clinical problems. Additionally, complexity increases or decreases, according to patients' individual resources. Complex patient situations demand professional expertise, experience, communicative competencies and the ability for reflection. Beginner nurses would benefit from support and advice by experienced nurses to develop these skills.
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Huber, Evelyn; Kleinknecht-Dolf, Michael; Müller, Marianne; Kugler, Christiane; Spirig, Rebecca
2017-06-01
To define the concept of patient-related complexity of nursing care in acute care hospitals and to operationalize it in a questionnaire. The concept of patient-related complexity of nursing care in acute care hospitals has not been conclusively defined in the literature. The operationalization in a corresponding questionnaire is necessary, given the increased significance of the topic, due to shortened lengths of stay and increased patient morbidity. Hybrid model of concept development and embedded mixed-methods design. The theoretical phase of the hybrid model involved a literature review and the development of a working definition. In the fieldwork phase of 2015 and 2016, an embedded mixed-methods design was applied with complexity assessments of all patients at five Swiss hospitals using our newly operationalized questionnaire 'Complexity of Nursing Care' over 1 month. These data will be analysed with structural equation modelling. Twelve qualitative case studies will be embedded. They will be analysed using a structured process of constructing case studies and content analysis. In the final analytic phase, the quantitative and qualitative data will be merged and added to the results of the theoretical phase for a common interpretation. Cantonal Ethics Committee Zurich judged the research programme as unproblematic in December 2014 and May 2015. Following the phases of the hybrid model and using an embedded mixed-methods design can reach an in-depth understanding of patient-related complexity of nursing care in acute care hospitals, a final version of the questionnaire and an acknowledged definition of the concept. © 2016 John Wiley & Sons Ltd.
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Walz, Stacy E; Smith, Maureen; Cox, Elizabeth; Sattin, Justin; Kind, Amy J H
2011-04-01
Previous studies have noted a high (41%) prevalence and poor discharge summary communication of pending laboratory (lab) tests at the time of hospital discharge for general medical patients. However, the prevalence and communication of pending labs within a high-risk population, specifically those patients discharged to sub-acute care (i.e., skilled nursing, rehabilitation, long-term care), remains unknown. To determine the prevalence and nature of lab tests pending at hospital discharge and their inclusion within hospital discharge summaries, for common sub-acute care populations. Retrospective cohort study. Stroke, hip fracture, and cancer patients discharged from a single large academic medical center to sub-acute care, 2003-2005 (N = 564) Pending lab tests were abstracted from the laboratory information system (LIS) and from each patient's discharge summary, then grouped into 14 categories and compared. Microbiology tests were sub-divided by culture type and number of days pending prior to discharge. Of sub-acute care patients, 32% (181/564) were discharged with pending lab tests per the LIS; however, only 11% (20/181) of discharge summaries documented these. Patients most often left the hospital with pending microbiology tests (83% [150/181]), particularly blood and urine cultures, and reference lab tests (17% [30/181]). However, 82% (61/74) of patients' pending urine cultures did not have 24-hour preliminary results, and 19% (13/70) of patients' pending blood cultures did not have 48-hour preliminary results available at the time of hospital discharge. Approximately one-third of the sub-acute care patients in this study had labs pending at discharge, but few were documented within hospital discharge summaries. Even after considering the availability of preliminary microbiology results, these omissions remain common. Future studies should focus on improving the communication of pending lab tests at discharge and evaluating the impact that this improved
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Visser, Philip; Dwyer, Alison; Moran, Juli; Britton, Mary; Heland, Melodie; Ciavarella, Filomena; Schutte, Sandy; Jones, Daryl
2014-05-01
To assess the frequency, characteristics and outcomes of medical emergency response (MER) calls in a sub-acute hospital setting. The present study was a retrospective observational study in a sub-acute hospital providing aged care, palliative care, rehabilitation, veteran's mental health and elective surgical services. We assessed annual MER call numbers between 2005 and 2011 in the context of contemporaneous changes to hospital services. We also assessed MER calls over a 12-month period in detail using standardised case report forms and the scanned medical record. There were 2285 multiday admissions in the study period where 141 MER calls were triggered in 132 patients (61.7 calls per 1000 admissions). The median patient age was 83.0 years, and 55.3% of patients were men. Most calls occurred on weekdays and during the daytime, and were triggered by altered conscious state, low oxygen saturations and hypotension. Documentation of escalation of care before the MER call was not present in 99 of 141 (70.2%) calls. Following the call, in 70 of 141 (49.6%) cases, the patient was transferred to the acute campus, where 52 (74.2%) and 14 (20%) patients required ward and intensive care level treatment, respectively. Thirty-seven of 132 (28%) patients died. A palliative care physician adjudicated that most of these patients who died (24/37; 64.9%) were appropriate for a call, but that 19 (51.4%) should have received palliation at the time of the call. Compared with survivors, patients who died after the MER call were more likely originally admitted from supported accommodation. MER calls in our sub-acute hospital occurred in elderly patients and are associated with an in-hospital mortality of 28%. A small proportion of patients required intensive care level treatment. There is a need to improve processes involving escalation of care before MER call activation and to revise advance care directives. What is known about this topic? Rapid response team (RRT) activation has been
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Santry, Heena P; Janjua, Sumbal; Chang, Yuchiao; Petrovick, Laurie; Velmahos, George C
2011-12-01
Patients with major nontraumatic surgical emergencies (NTSEs) are commonly transferred from small hospitals to tertiary care centers. We hypothesized that transferred patients (TRANS) have worse outcomes than patients with similar diagnoses admitted directly to a tertiary center (DIRECT). We reviewed all patients admitted to the acute care surgery service of our tertiary center (September 1, 2006-October 31, 2009) with one of eight diagnoses indicating a major NTSE. Patients transferred for reasons other than the severity of illness were excluded. Univariate and multivariable analyses compared TRANS and DIRECT patients. Of 319 patients eligible for analysis, 103 (34%) were TRANS and averaged 3.8 days in the referring hospital before transfer. Compared to DIRECT patients, TRANS patients were more likely to be obese (18.5 vs. 8.0%, P = 0.006) and have cardiac (24 vs. 14%, P = 0.022) or pulmonary (25 vs. 12%, P = 0.003) co-morbidities. TRANS patients were also more likely to present to the tertiary center with hypotension (9 vs. 2%, P = 0.021), tachycardia (20 vs. 13%, P = 0.036), anemia (83 vs. 58%, P < 0.001), and hypoalbuminemia (50 vs. 14%, P < 0.001). TRANS patients had higher mortality (4.9 vs. 0.9%, P = 0.038) and longer hospital stay (8 with 5-13 days vs. 5 with 3-8 days, P < 0.001). TRANS patients comprised a significant portion of the population with major NTSEs admitted to the acute care surgery service of our tertiary center. They presented with greater physiologic derangement and had worse outcomes than DIRECT patients. As is currently established for trauma care, regionalization of care for NTSEs should be considered.
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Acute care research: is it ethical?
Iserson, K V; Mahowald, M B
1992-07-01
Research in acute care is a troubling area for Institutional Review Board (IRB) approval and informed consent. Confusion about ethical and legal requirements has hampered research efforts and subsequent patient benefits. Acute care patients are the relatively few critical care patients who have suffered unexpected events that carry a high probability of mortality or severe morbidity unless immediate medical intervention is provided. We argue that acute care research is justified if the usual ethical requirements for research are modified to reflect the uniqueness of the situation. Our recommendations are to: a) use an explicit definition of acute care as distinct from other modes of critical care; b) eliminate the requirement for informed consent (as it is usually understood); and c) require stringent IRB oversight, regarding the unique ethical problems raised by this area of research. We further suggest that IRB oversight includes review of the protocol by a panel of individuals who represent possible enrollees in the proposed study.
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Preparing Nursing and Social Work Students to Care for Patients in Acute Alcohol Withdrawal.
Gates, Sharon A; Brown, James R
Alcohol and other drug abuse has become a national crisis with approximately 26% of general medical patients having alcohol-related problems. New nurses and social workers are often not prepared to care for patients with severe alcohol withdrawal symptoms because they lack experience in actual crisis situations. The purpose of this study was to prepare nursing and social work students to care for a patient undergoing an acute alcohol withdrawal process. Nine groups of 8-10 students participated in a 2.5-hour simulation event that included an alcohol withdrawal seizure, team meeting, and discharge of the patient. Students recognized the importance of all the professional roles and how each professional benefits patient care. Before the simulation, students thought they were prepared to care for patients experiencing alcohol withdrawal; however, the crisis of an alcohol seizure decreased the student's ability to perform skills and communicate effectively. These findings suggest that new nurses and social workers may not be prepared to care for the acute alcohol withdrawal patient.
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Using discrete event computer simulation to improve patient flow in a Ghanaian acute care hospital.
Best, Allyson M; Dixon, Cinnamon A; Kelton, W David; Lindsell, Christopher J; Ward, Michael J
2014-08-01
Crowding and limited resources have increased the strain on acute care facilities and emergency departments worldwide. These problems are particularly prevalent in developing countries. Discrete event simulation is a computer-based tool that can be used to estimate how changes to complex health care delivery systems such as emergency departments will affect operational performance. Using this modality, our objective was to identify operational interventions that could potentially improve patient throughput of one acute care setting in a developing country. We developed a simulation model of acute care at a district level hospital in Ghana to test the effects of resource-neutral (eg, modified staff start times and roles) and resource-additional (eg, increased staff) operational interventions on patient throughput. Previously captured deidentified time-and-motion data from 487 acute care patients were used to develop and test the model. The primary outcome was the modeled effect of interventions on patient length of stay (LOS). The base-case (no change) scenario had a mean LOS of 292 minutes (95% confidence interval [CI], 291-293). In isolation, adding staffing, changing staff roles, and varying shift times did not affect overall patient LOS. Specifically, adding 2 registration workers, history takers, and physicians resulted in a 23.8-minute (95% CI, 22.3-25.3) LOS decrease. However, when shift start times were coordinated with patient arrival patterns, potential mean LOS was decreased by 96 minutes (95% CI, 94-98), and with the simultaneous combination of staff roles (registration and history taking), there was an overall mean LOS reduction of 152 minutes (95% CI, 150-154). Resource-neutral interventions identified through discrete event simulation modeling have the potential to improve acute care throughput in this Ghanaian municipal hospital. Discrete event simulation offers another approach to identifying potentially effective interventions to improve patient
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Williams, Allison; Botti, Mari
2002-10-01
Advances in medical science and improved lifestyles have reduced mortality rates in Australia and most western countries. This has resulted in an ageing population with a concomitant growth in the number of people who are living with chronic illnesses. Indeed a significant number of younger people experience more than one chronic illness. Large numbers of these may require repeated admissions to hospital for acute or episodic care that is superimposed upon the needs of their chronic conditions. To explore the issues that circumscribe the complexities of caring for people with concurrent chronic illnesses, or comorbidities, in the acute care setting and postdischarge. A literature review to examine the issues that impact upon the provision of comprehensive care to patients with comorbidities in the acute care setting and postdischarge. Few studies have investigated this subject. From an Australian perspective, it is evident that the structure of the current health care environment has made it difficult to meet the needs of patients with comorbidities in the acute care setting and postdischarge. This is of major concern for nurses attempting to provide comprehensive care to an increasingly prevalent group of chronically ill people. Further research is necessary to explore how episodic care is integrated into the on-going management of patients with comorbidities and how nurse clinicians can better use an episode of acute illness as an opportunity to review their overall management.
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Urinary NGAL in patients with and without acute kidney injury in a cardiology intensive care unit
Watanabe, Mirian; Silva, Gabriela Fulan e; da Fonseca, Cassiane Dezoti; Vattimo, Maria de Fatima Fernandes
2014-01-01
Objective To assess the diagnostic and prognostic efficacy of urine neutrophil gelatinase-associated lipocalin in patients admitted to an intensive care unit. Methods Longitudinal, prospective cohort study conducted in a cardiology intensive care unit. The participants were divided into groups with and without acute kidney injury and were followed from admission to the intensive care unit until hospital discharge or death. Serum creatinine, urine output and urine neutrophil gelatinase-associated lipocalin were measured 24 and 48 hours after admission. Results A total of 83 patients admitted to the intensive care unit for clinical reasons were assessed, most being male (57.8%). The participants were divided into groups without acute kidney injury (N=18), with acute kidney injury (N=28) and with severe acute kidney injury (N=37). Chronic diseases, mechanical ventilation and renal replacement therapy were more common in the groups with acute kidney injury and severe acute kidney injury, and those groups exhibited longer intensive care unit stay and hospital stay and higher mortality. Serum creatinine did not change significantly in the group with acute kidney injury within the first 24 hours of admission to the intensive care unit, although, urine neutrophil gelatinase-associated lipocalin was high in the groups with acute kidney injury and severe acute kidney injury (p<0.001). Increased urine neutrophil gelatinase-associated lipocalin was associated with death. Conclusion An increase in urine neutrophil gelatinase-associated lipocalin precedes variations in serum creatinine in patients with acute kidney injury and may be associated with death. PMID:25607262
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Koenig, Helen C; Finkel, Barbara B; Khalsa, Satjeet S; Lanken, Paul N; Prasad, Meeta; Urbani, Richard; Fuchs, Barry D
2011-01-01
Lung protective ventilation reduces mortality in patients with acute lung injury, but underrecognition of acute lung injury has limited its use. We recently validated an automated electronic acute lung injury surveillance system in patients with major trauma in a single intensive care unit. In this study, we assessed the system's performance as a prospective acute lung injury screening tool in a diverse population of intensive care unit patients. Patients were screened prospectively for acute lung injury over 21 wks by the automated system and by an experienced research coordinator who manually screened subjects for enrollment in Acute Respiratory Distress Syndrome Clinical Trials Network (ARDSNet) trials. Performance of the automated system was assessed by comparing its results with the manual screening process. Discordant results were adjudicated blindly by two physician reviewers. In addition, a sensitivity analysis using a range of assumptions was conducted to better estimate the system's performance. The Hospital of the University of Pennsylvania, an academic medical center and ARDSNet center (1994-2006). Intubated patients in medical and surgical intensive care units. None. Of 1270 patients screened, 84 were identified with acute lung injury (incidence of 6.6%). The automated screening system had a sensitivity of 97.6% (95% confidence interval, 96.8-98.4%) and a specificity of 97.6% (95% confidence interval, 96.8-98.4%). The manual screening algorithm had a sensitivity of 57.1% (95% confidence interval, 54.5-59.8%) and a specificity of 99.7% (95% confidence interval, 99.4-100%). Sensitivity analysis demonstrated a range for sensitivity of 75.0-97.6% of the automated system under varying assumptions. Under all assumptions, the automated system demonstrated higher sensitivity than and comparable specificity to the manual screening method. An automated electronic system identified patients with acute lung injury with high sensitivity and specificity in diverse
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Weight Bias and Psychosocial Implications for Acute Care of Patients With Obesity.
Smigelski-Theiss, Rachel; Gampong, Malisa; Kurasaki, Jill
2017-01-01
Obesity is a complex medical condition that has psychosocial and physiological implications for those suffering from the disease. Factors contributing to obesity such as depression, childhood experiences, and the physical environment should be recognized and addressed. Weight bias and stigmatization by health care providers and bedside clinicians negatively affect patients with obesity, hindering those patients from receiving appropriate care. To provide optimal care of patients with obesity or adiposity, health care providers must understand the physiological needs and requirements of this population while recognizing and addressing their own biases. The authors describe psychosocial and environmental factors that contribute to obesity, discuss health care providers' weight biases, and highlight implications for acute care of patients suffering from obesity. ©2017 American Association of Critical-Care Nurses.
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Patient advocacy and advance care planning in the acute hospital setting.
Seal, Marion
2007-01-01
The aim of this study was to explain the role of patient advocacy in the Advance Care Planning (ACP-ing) process. Nurses rate prolonging the dying process with inappropriate measures as their most disturbing ethical issue and protecting patients' rights to be of great concern (Johnston et al 2002). Paradoxically ethical codes assume nurses have the autonomy to uphold patients' health-care choices. Advance Directives (AD) designed to improve end-of-life care are poorly taken up and acute hospitals are generally not geared for the few they receive. The Respecting Patient Choices Program (RPCP) improves AD utilisation through providing a supportive framework for ACP-ing and primarily equipping nurses as RPC consultants. Assisting patients with this process requires attributes consistent with patient advocacy arising out of nursing's most basic tenet, the care of others. Likert Scales survey administered pre and six months post-intervention to pilot and control groups, with coinciding focus groups. Selected wards in an acute care public hospital in South Australia. Nurses on the palliative care, respiratory, renal and colo-rectal pilot wards and the haem-oncology, coronary care, cardiology and neurology/geriatric control wards. The RPCP during the 2004-2005 South Australian pilot of the (RPCP). The organisational endorsement of ACP-ing gave nurses the autonomy to be patient advocates with respect to end-of-life care, reconciling clinical practice to their code of ethics and easing distress about prolonging the dying process inappropriately. Statistically significant survey results in the post-intervention group showed nurses experienced: encouragement to ensure patients could make informed choices about their end-of-life treatment (84%); the ability to uphold these wishes in practice (73%); and job satisfaction from delivering appropriate end-of-life care (67%); compared to approximately half (42-55%) of respondents in the pre-intervention and control groups. Focus
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Patient Nonadherence to Guideline-Recommended Care in Acute Low Back Pain.
Bier, Jasper D; Kamper, Steven J; Verhagen, Arianne P; Maher, Christopher G; Williams, Christopher M
2017-12-01
To describe the magnitude of patient-reported nonadherence with guideline-recommended care for acute low back pain. Secondary analysis of data from participants enrolled in the Paracetamol for Acute Low Back Pain study trial, a randomized controlled trial evaluating the effectiveness of paracetamol for acute low back pain. Primary care, general practitioner. Data from participants with acute low back pain (N=1643). Guideline-recommended care, including reassurance, simple analgesia, and the advice to stay active and avoid bed rest. Also, advice against additional treatments and referral for imaging. Proportion of nonadherence with guideline-recommended care. Nonadherence was defined as (1) failure to consume the advised paracetamol dose, or (2) receipt of additional health care, tests, or medication during the trial treatment period (4wk). Multivariable logistic regression analysis was performed to determine the factors associated with nonadherence. In the first week of treatment, 39.7% of participants were classified as nonadherent. Over the 4-week treatment period, 70.0% were nonadherent, and 57.5% did not complete the advised paracetamol regimen. Higher perceived risk of persistent pain, lower level of disability, and not claiming workers' compensation were associated with nonadherence, with odds ratios ranging from .46 to 1.05. Adherence to guideline-recommended care for acute low back pain was poor. Most participants do not complete the advised paracetamol regimen. Higher perceived risk of persistence of complaints, lower baseline disability, and participants not claiming workers' compensation were independently associated with nonadherence. Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
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Acute care patient portals: a qualitative study of stakeholder perspectives on current practices.
Collins, Sarah A; Rozenblum, Ronen; Leung, Wai Yin; Morrison, Constance Rc; Stade, Diana L; McNally, Kelly; Bourie, Patricia Q; Massaro, Anthony; Bokser, Seth; Dwyer, Cindy; Greysen, Ryan S; Agarwal, Priyanka; Thornton, Kevin; Dalal, Anuj K
2017-04-01
To describe current practices and stakeholder perspectives of patient portals in the acute care setting. We aimed to: (1) identify key features, (2) recognize challenges, (3) understand current practices for design, configuration, and use, and (4) propose new directions for investigation and innovation. Mixed methods including surveys, interviews, focus groups, and site visits with stakeholders at leading academic medical centers. Thematic analyses to inform development of an explanatory model and recommendations. Site surveys were administered to 5 institutions. Thirty interviews/focus groups were conducted at 4 site visits that included a total of 84 participants. Ten themes regarding content and functionality, engagement and culture, and access and security were identified, from which an explanatory model of current practices was developed. Key features included clinical data, messaging, glossary, patient education, patient personalization and family engagement tools, and tiered displays. Four actionable recommendations were identified by group consensus. Design, development, and implementation of acute care patient portals should consider: (1) providing a single integrated experience across care settings, (2) humanizing the patient-clinician relationship via personalization tools, (3) providing equitable access, and (4) creating a clear organizational mission and strategy to achieve outcomes of interest. Portals should provide a single integrated experience across the inpatient and ambulatory settings. Core functionality includes tools that facilitate communication, personalize the patient, and deliver education to advance safe, coordinated, and dignified patient-centered care. Our findings can be used to inform a "road map" for future work related to acute care patient portals. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com
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Roberts, Pamela S; DiVita, Margaret A; Riggs, Richard V; Niewczyk, Paulette; Bergquist, Brittany; Granger, Carl V
2014-01-01
To identify medical and functional health risk factors for being discharged directly to an acute-care hospital from an inpatient rehabilitation facility among patients who have had a stroke. Retrospective cohort study. Academic medical center. A total of 783 patients with a primary diagnosis of stroke seen from 2008 to 2012; 60 were discharged directly to an acute-care hospital and 723 were discharged to other settings, including community and other institutional settings. Logistic regression analysis. Direct discharge to an acute care hospital compared with other discharge settings from the inpatient rehabilitation unit. No significant differences in demographic characteristics were found between the 2 groups. The adjusted logistic regression model revealed 2 significant risk factors for being discharged to an acute care hospital: admission motor Functional Independence Measure total score (odds ratio 0.97, 95% confidence interval 0.95-0.99) and enteral feeding at admission (odds ratio 2.87, 95% confidence interval 1.34-6.13). The presence of a Centers for Medicare and Medicaid-tiered comorbidity trended toward significance. Based on this research, we identified specific medical and functional health risk factors in the stroke population that affect the rate of discharge to an acute-care hospital. With active medical and functional management, early identification of these critical components may lead to the prevention of stroke patients from being discharged to an acute-care hospital from the inpatient rehabilitation setting. Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
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Understanding the bereavement care roles of nurses within acute care: a systematic review.
Raymond, Anita; Lee, Susan F; Bloomer, Melissa J
2017-07-01
To investigate nurses' roles and responsibilities in providing bereavement care during the care of dying patients within acute care hospitals. Bereavement within acute care hospitals is often sudden, unexpected and managed by nurses who may have limited access to experts. Nurses' roles and experience in the provision of bereavement care can have a significant influence on the subsequent bereavement process for families. Identifying the roles and responsibilities, nurses have in bereavement care will enhance bereavement supports within acute care environments. Mixed-methods systematic review. The review was conducted using the databases Cumulative Index Nursing and Allied Health Literature Plus, Embase, Ovid MEDLINE, PsychINFO, CareSearch and Google Scholar. Included studies published between 2006-2015, identified nurse participants, and the studies were conducted in acute care hospitals. Seven studies met the inclusion criteria, and the research results were extracted and subjected to thematic synthesis. Nurses' role in bereavement care included patient-centred care, family-centred care, advocacy and professional development. Concerns about bereavement roles included competing clinical workload demands, limitations of physical environments in acute care hospitals and the need for further education in bereavement care. Further research is needed to enable more detailed clarification of the roles nurse undertake in bereavement care in acute care hospitals. There is also a need to evaluate the effectiveness of these nursing roles and how these provisions impact on the bereavement process of patients and families. The care provided by acute care nurses to patients and families during end-of-life care is crucial to bereavement. The bereavement roles nurses undertake are not well understood with limited evidence of how these roles are measured. Further education in bereavement care is needed for acute care nurses. © 2016 John Wiley & Sons Ltd.
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Patient Perspectives on Accessing Acute Illness Care
Finta, Mary K.; Borkenhagen, Amy; Werner, Nicole E.; Duckles, Joyce; Sellers, Craig R.; Seshadri, Sandhya; Lampo, Denise; Shah, Manish N.
2017-01-01
Introduction Older adults use the emergency department (ED) at high rates, including for illnesses that could be managed by their primary care providers (PCP). Policymakers have implemented barriers and incentives, often financial, to try to modify use patterns but with limited success. This study aims to understand the factors that influence older adults’ decision to obtain acute illness care from the ED rather than from their PCPs. Methods We performed a qualitative study using a directed content analysis approach from February to October 2013. Fifteen community-dwelling older adults age≥65 years who presented to the ED of an academic medical center hospital for care and who were discharged home were enrolled. Semi-structured interviews were conducted initially in the ED and subsequently in patients’ homes over the following six weeks. All interviews were audio-recorded, transcribed, verified, and coded. The study team jointly analyzed the data and identified themes that emerged from the interviews. Results The average age of study participants was 74 years (standard deviation ±7.2 years); 53% were female; 80% were white. We found five themes that influenced participants’ decisions to obtain acute illness care from the ED: limited availability of PCP-based care, variable interactions with healthcare providers and systems, limited availability of transportation for illness care, desire to avoid burdening friends and family, and previous experiences with illnesses. Conclusion Community-dwelling older adults integrate multiple factors when deciding to obtain care from an ED rather than their PCPs. These factors relate to personal and social considerations, practical issues, and individual perceptions based on previous experiences. If these findings are validated in confirmatory studies, policymakers wishing to modify where older adults receive care should consider person-centered interventions at the system and individual level, such as decision support
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Yu, Tiffany; Campbell, Timothy; Ciuffetelli, Isabella; Haywood, Carlton; Carroll, C. Patrick; Resar, Linda M.S.; Strouse, John J.; Lanzkron, Sophie
2016-01-01
Objectives Sickle cell disease (SCD) is associated with high healthcare utilization rates and poor outcomes in a subset of patients, although the underlying factors that predict this phenotype are poorly understood. Prior studies suggest that comorbid avascular necrosis (AVN) contributes to high healthcare utilization. We sought to clarify whether AVN independently predicts acute care utilization in adults with SCD and to identify characteristics of those with AVN that predict higher utilization. Methods We reviewed the medical records of 87 patients with SCD with symptomatic AVN and compared acute care utilization and clinical characteristics with 87 sex- and age-matched patients with SCD without symptomatic AVN. Patients with ≥2 years of follow-up were included. Outcomes were compared using bivariate analysis and multivariate regression. Results Our study included 1381 follow-up years, with a median of 7 years per patient. The AVN cohort had greater median rates of urgent care visits (3.2/year vs 1.3/year; P = 0.0155), admissions (1.3/year vs 0.4/year; P = 0.0002), and admission days (5.1 days/year vs 1.8 days/year; P = 0.0007). History of high utilization (odds ratio [OR] 4.28; P = 0.001), acute chest syndrome (OR 3.12; P = 0.005), pneumonia (OR 3.20; P = 0.023), hydroxyurea therapy (OR 2.23; P = 0.0136), and long-term transfusion (OR 2.33; P = 0.014) were associated with AVN. In a median regression model, AVN, acute chest syndrome, and pneumonia were independently associated with greater urgent care visits and admissions. Conclusions Symptomatic AVN was found to be an independent risk factor for acute care utilization in patients with SCD. Because this is a potentially modifiable factor, further studies are urgently needed to determine whether AVN prevention/early treatment interventions will alter utilization and improve outcomes for patients with SCD. PMID:27598353
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Yu, Tiffany; Campbell, Timothy; Ciuffetelli, Isabella; Haywood, Carlton; Carroll, Christopher Patrick; Resar, Linda; Strouse, John J; Lanzkron, Sophie
2016-09-01
Sickle cell disease (SCD) is associated with high healthcare utilization rates and poor outcomes in a subset of patients, although the underlying factors that predict this phenotype are poorly understood. Prior studies suggest that comorbid avascular necrosis (AVN) contributes to high healthcare utilization. We sought to clarify whether AVN independently predicts acute care utilization in adults with SCD and to identify characteristics of those with AVN that predict higher utilization. We reviewed the medical records of 87 patients with SCD with symptomatic AVN and compared acute care utilization and clinical characteristics with 87 sex- and age-matched patients with SCD without symptomatic AVN. Patients with ≥2 years of follow-up were included. Outcomes were compared using bivariate analysis and multivariate regression. Our study included 1381 follow-up years, with a median of 7 years per patient. The AVN cohort had greater median rates of urgent care visits (3.2/year vs 1.3/year; P = 0.0155), admissions (1.3/year vs 0.4/year; P = 0.0002), and admission days (5.1 days/year vs 1.8 days/year; P = 0.0007). History of high utilization (odds ratio [OR] 4.28; P = 0.001), acute chest syndrome (OR 3.12; P = 0.005), pneumonia (OR 3.20; P = 0.023), hydroxyurea therapy (OR 2.23; P = 0.0136), and long-term transfusion (OR 2.33; P = 0.014) were associated with AVN. In a median regression model, AVN, acute chest syndrome, and pneumonia were independently associated with greater urgent care visits and admissions. Symptomatic AVN was found to be an independent risk factor for acute care utilization in patients with SCD. Because this is a potentially modifiable factor, further studies are urgently needed to determine whether AVN prevention/early treatment interventions will alter utilization and improve outcomes for patients with SCD.
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Segaric, Cheryl Ann; Hall, Wendy A
2015-02-01
In this grounded theory study, informed by symbolic interactionism, we explain how nurses, patients, and family members construct relationships in acute care settings, including managing effects of work environments. We recruited participants from 10 acute care units across four community hospitals in a Western Canadian city. From 33 hr of participant observation and 40 interviews with 13 nurses, 17 patients, and 10 family members, we constructed the basic social-psychological process of progressively engaging. Nurses, patients, and family members approached constructing relationships through levels of engagement, ranging from perspectives about "just doing the job" to "doing the job with heart." Progressively engaging involved three stages: focusing on tasks, getting acquainted, and building rapport. Workplace conditions and personal factors contributed or detracted from participants' movement through the stages of the process; with higher levels of engagement, participants experienced greater satisfaction and cooperation. Progressively engaging provides direction for how all participants in care can invest in relationships. © The Author(s) 2014.
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Acute care teaching in the undergraduate nursing curriculum.
McGaughey, Jennifer
2009-01-01
To incorporate basic aspects of acute care into the undergraduate nursing programme by providing an opportunity for the development of knowledge and skills in the early recognition and assessment of deteriorating patients on general hospital wards. Acute care initiatives implemented in the hospital setting to improve the identification and management of 'at risk' patients have focused on the provision of education for trained or qualified staff. However, to ensure student nurses are 'fit to practice' at the point of registration, it has been recommended that acute care theory and skills are incorporated into the undergraduate nursing curriculum. PRACTICE DEVELOPMENT INITIATIVE: An 'Integrated Nursing Care' module was incorporated into year 3 of the undergraduate nursing programme to introduce students to acute care theory and practice. Module content focuses on the early detection and management of acute deterioration in patients with respiratory, cardiac, neurological or renal insufficiencies. We used a competency-based framework to ensure the application of theory to practice through the use of group seminars. High-fidelity patient-simulated clinical scenarios were a key feature. The United Kingdom Resuscitation Council Intermediate Life Support course is also an important component of the module. Incorporating the Integrated Nursing Care module into the undergraduate nursing curriculum provides pre-registration students the opportunity to develop their knowledge and skills in acute care. The provision of undergraduate education in care of the acutely ill patient in hospital is essential to improve nurses' competence and confidence in assessing and managing deteriorating patients in general wards at the point of registration.
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Bowers, L; Simpson, A; Nijman, H; Hall, C
2008-04-01
Psychiatric care units provide care to disturbed patients in a context of higher security and staffing levels. Although such units are numerous, few systematic comparisons have been made, and there are indications that ethnic minority groups may be over-represented. The aim of this study was to compare the rates of adverse incidents and patterns of usage of three psychiatric intensive care units. The study used a triangulation or multi-method design, bringing together data from official statistics, local audit and interviews conducted with staff. Intensive care patients were more likely to be young, male and suffering a psychotic disorder, as compared with general acute ward patients. Caribbean patients were twice as likely, and Asian patients half as likely, to receive intensive care (age, gender and diagnosis controlled). There were large differences in service levels, staffing, team functioning and adverse incidents between the three units. Various aspects of physical security were important in preventing absconds. More evaluative research is required in order to define effective service levels, and to explore the nature of the interaction between ethnicity and inpatient care provision during acute illness.
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Chiovitti, Rosalina F
2008-02-01
The concept of caring is described as intangible, abstract, and invisible in nursing practice. This has translated into a view of caring as a personal choice or natural obligation rather than a deliberate process. While there has been movement to delineate caring within nursing in general, the psychiatric nurse's perspective on caring has been absent from theoretical works and measures constructed to describe nurse's work. To develop a substantive grounded theory of caring from the perspective of Registered Nurses working with patients in three Canadian acute psychiatric hospital settings. The qualitative research design of grounded theory methodology was used to develop a theory of caring. Three urban, acute psychiatric hospital settings in Canada. Two were general hospitals and one was a psychiatric hospital. Registered Nurses (N=17) licensed with the College of Nurses of Ontario. In-depth interviews with Registered Nurses were conducted using theoretical sampling. The data were analysed using constant comparative analysis. Protective empowering is the basic social psychological process that represents Registered Nurses' caring with patients in acute psychiatric hospital settings. Nurses accomplish protective empowering through six main categories of: (1) respecting the patient; (2) not taking the patient's behaviour personally; (3) keeping the patient safe; (4) encouraging the patient's health; (5) authentic relating; and (6) interactive teaching. The six main categories were accomplished through 27 subcategories. In the theory of protective empowering, the goal is to help patients participate in activities contributing to convalescence, health, and/or quality of life. The theory of protective empowering provides six main categories and 27 subcategories that can be transferred to funding formulas, patient health record documentation systems, nurse orientation and education programs, nurse role descriptions, and used in guiding discussions about organizational
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Jefferis, Joanna; Perera, Rafael; Everitt, Hazel; van Weert, Henk; Rietveld, Remco; Glasziou, Paul; Rose, Peter
2011-01-01
Background Acute infective conjunctivitis is a common problem in primary care, traditionally managed with topical antibiotics. A number of clinical trials have questioned the benefit of topical antibiotics for patients with acute infective conjunctivitis Aim To determine the benefit of antibiotics for the treatment of acute infective conjunctivitis in primary care and which subgroups benefit most Design An individual patient data meta-analysis Method Relevant trials were identified and individual patient data gathered for meta-analysis and subgroup analysis Results Three eligible trials were identified. Individual patient data were available from all primary care trials and data were available for analysis in 622 patients. Eighty per cent (246/308) of patients who received antibiotics and 74% (233/314) of controls were cured at day 7. There was a significant benefit of antibiotics versus control for cure at seven days in all cases combined (risk difference 0.08, 95% confidence interval (CI) = 0.01 to 0.14). Subgroups that showed a significant benefit from antibiotics were patients with purulent discharge (risk difference 0.09, 95% CI = 0.01 to 0.17) and patients with mild severity of red eye (risk difference 0.10, 95% CI = 0.02 to 0.18), while the type of control used (placebo drops versus nothing) showed a statistically significant interaction (P=0.03) Conclusion Acute conjunctivitis seen in primary care can be thought of as a self-limiting condition, with most patients getting better regardless of antibiotic therapy. Patients with purulent discharge or a mild severity of red eye may have a small benefit from antibiotics. Prescribing practices need to be updated, taking into account these results PMID:22152728
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Perspectives of Post-Acute Transition of Care for Cardiac Surgery Patients
Stoicea, Nicoleta; You, Tian; Eiterman, Andrew; Hartwell, Clifton; Davila, Victor; Marjoribanks, Stephen; Florescu, Cristina; Bergese, Sergio Daniel; Rogers, Barbara
2017-01-01
Post-acute care (PAC) facilities improve patient recovery, as measured by activities of daily living, rehabilitation, hospital readmission, and survival rates. Seamless transitions between discharge and PAC settings continue to be challenges that hamper patient outcomes, specifically problems with effective communication and coordination between hospitals and PAC facilities at patient discharge, patient adherence and access to cardiac rehabilitation (CR) services, caregiver burden, and the financial impact of care. The objective of this review is to examine existing models of cardiac transitional care, identify major challenges and social factors that affect PAC, and analyze the impact of current transitional care efforts and strategies implemented to improve health outcomes in this patient population. We intend to discuss successful methods to address the following aspects: hospital-PAC linkages, improved discharge planning, caregiver burden, and CR access and utilization through patient-centered programs. Regular home visits by healthcare providers result in decreased hospital readmission rates for patients utilizing home healthcare while improved hospital-PAC linkages reduced hospital readmissions by 25%. We conclude that widespread adoption of improvements in transitional care will play a key role in patient recovery and decrease hospital readmission, morbidity, and mortality. PMID:29230400
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Perspectives of Post-Acute Transition of Care for Cardiac Surgery Patients.
Stoicea, Nicoleta; You, Tian; Eiterman, Andrew; Hartwell, Clifton; Davila, Victor; Marjoribanks, Stephen; Florescu, Cristina; Bergese, Sergio Daniel; Rogers, Barbara
2017-01-01
Post-acute care (PAC) facilities improve patient recovery, as measured by activities of daily living, rehabilitation, hospital readmission, and survival rates. Seamless transitions between discharge and PAC settings continue to be challenges that hamper patient outcomes, specifically problems with effective communication and coordination between hospitals and PAC facilities at patient discharge, patient adherence and access to cardiac rehabilitation (CR) services, caregiver burden, and the financial impact of care. The objective of this review is to examine existing models of cardiac transitional care, identify major challenges and social factors that affect PAC, and analyze the impact of current transitional care efforts and strategies implemented to improve health outcomes in this patient population. We intend to discuss successful methods to address the following aspects: hospital-PAC linkages, improved discharge planning, caregiver burden, and CR access and utilization through patient-centered programs. Regular home visits by healthcare providers result in decreased hospital readmission rates for patients utilizing home healthcare while improved hospital-PAC linkages reduced hospital readmissions by 25%. We conclude that widespread adoption of improvements in transitional care will play a key role in patient recovery and decrease hospital readmission, morbidity, and mortality.
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Vora, Amit N; Peterson, Eric D; Hellkamp, Anne S; Sutton, Nadia R; Panacek, Edward; Thomas, Laine; de Lemos, James A; Wang, Tracy Y
2016-03-01
Many patients in the United States require transfer from one hospital to another for acute myocardial infarction (MI) care. How well these transferred-in patients are transitioned back to their local community is unknown. We used linked Medicare claims data to examine postdischarge outcomes of 39 136 patients with acute MI aged ≥65 years discharged alive from 451 US hospitals in Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines. Multivariable Cox modeling was used to compare the likelihood of outpatient clinic follow-up and risks of all-cause mortality and all-cause or cardiovascular readmission at 30 days post MI between transferred-in and direct-arrival patients. From 2007 to 2010, 14 060 of 39 136 patients (36%) required interhospital transfer for acute MI care, traveling a median of 43 miles (interquartile range, 27-68 miles; 77.6 km [interquartile range, 48.2-122.6 km]). Compared with those arriving directly, transferred-in patients with MI were slightly younger (median age, 73 versus 74; P<0.01) but less likely to have previous MI, heart failure, and previous revascularization than direct-arrival patients. Relative to direct-arrival patients, those transferred-in had a lower likelihood of outpatient follow-up within 30 days post discharge (risk-adjusted incidence, 69.9% versus 78.2%; hazard ratio [HR], 0.90; 95% confidence interval, 0.87-0.92) and higher adjusted 30-day all-cause and cardiovascular readmission risks (14.5% versus 14.0%; HRall-cause, 1.08; 95% confidence interval, 1.01-1.15 and 9.5% versus 9.1%; HRcardiovascular, 1.13; 95% confidence interval, 1.04-1.22). In contrast, risk-adjusted 30-day mortality was similar between transferred-in and direct arrivals (1.6% versus 1.6%; HR, 1.05; 95% confidence interval, 0.86-1.27). Transferred-in patients with acute MI are less likely to have outpatient clinic follow-up within 30 days and more likely to be readmitted within the first 30 days post discharge compared
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Vincent, Heather K; Vasilopoulos, Terrie; Zdziarski-Horodyski, Laura Ann; Sadasivan, Kalia K; Hagen, Jennifer; Guenther, Robert; McClelland, JoAnna; Horodyski, MaryBeth
2018-02-01
Pre-existing psychiatric illness, illicit drug use, and alcohol abuse adversely impact patients with orthopaedic trauma injuries. Obesity is an independent factor associated with poorer clinical outcomes and discharge disposition, and higher hospital resource use. It is not known whether interactions exist between pre-existing illness, illicit drug use and obesity on acute trauma care outcomes. This cohort study is from orthopaedic trauma patients prospectively measured over 10 years (N = 6353). Psychiatric illness, illicit drug use and alcohol were classified by presence or absence. Body mass index (BMI) was analyzed as both a continuous and categorical measure (<30 kg/m 2 [non-obese], 30-39.9 kg/m 2 [obese] and ≥40 kg/m 2 [morbidly obese]). Main outcomes were the number of acute care services provided, length of stay (LOS), discharge home, hospital readmissions, and mortality in the hospital. Statistically significant BMI by pre-existing condition (psychiatric illness, illicit drug use) interactions existed for LOS and number of acute care services provided (β values 0.012-0.098; all p < 0.05). The interaction between BMI and psychiatric illness was statistically significant for discharge to locations other than home (β = 0.023; p = 0.001). Obese patients with orthopaedic trauma, particularly with preexisting mental health conditions, will require more hospital resources and longer care than patients without psychiatric illness. Early identification of these patients through screening for psychiatric illness and history of illicit drug use at admission is imperative to mobilize the resources and provide psychosocial support to facilitate the recovery trajectory of affected obese patients. Copyright © 2017 Elsevier Ltd. All rights reserved.
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Sidani, Souraya; Reeves, Scott; Hurlock-Chorostecki, Christina; van Soeren, Mary; Fox, Mary; Collins, Laura
2018-06-01
There is limited evidence of the extent to which Healthcare professionals implement patient-centered care (PCC) and of the factors influencing their PCC practices in acute care organizations. This study aimed to (1) examine the practices reported by health professionals (physicians, nurses, social workers, other healthcare providers) in relation to three PCC components (holistic, collaborative, and responsive care), and (2) explore the association of professionals' characteristics (gender, work experience) and a contextual factor (caseload), with the professionals' PCC practices. Data were obtained from a large scale cross-sectional study, conducted in 18 hospitals in Ontario, Canada. Consenting professionals (n = 382) completed a self-report instrument assessing the three PCC components and responded to standard questions inquiring about their characteristics and workload. Small differences were found in the PCC practices across professional groups: (1) physicians reported higher levels of enacting the holistic care component; (2) physicians, other healthcare providers, and social workers reported implementing higher levels of the collaborative care component; and (3) physicians, nurses, and other healthcare providers reported higher levels of providing responsive care. Caseload influenced holistic care practices. Interprofessional education and training strategies are needed to clarify and address professional differences in valuing and practicing PCC components. Clinical guidelines can be revised to enable professionals to engage patients in care-related decisions, customize patient care, and promote interprofessional collaboration in planning and implementing PCC. Additional research is warranted to determine the influence of professional, patient, and other contextual factors on professionals' PCC practices in acute care hospitals.
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Roe, Matthew T; Chen, Anita Y; Mehta, Rajendra H; Li, Yun; Brindis, Ralph G; Smith, Sidney C; Rumsfeld, John S; Gibler, W Brian; Ohman, E Magnus; Peterson, Eric D
2007-09-04
Since the broad dissemination of practice guidelines, the association of specialty care with the treatment of patients with acute coronary syndromes has not been studied. We evaluated 55 994 patients with non-ST-segment elevation acute coronary syndromes (ischemic ST-segment changes and/or positive cardiac markers) included in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Quality Improvement Initiative from January 2001 through September 2003 at 301 tertiary US hospitals with full revascularization capabilities. We compared baseline characteristics, the use of American College of Cardiology/American Heart Association guidelines class I recommendations, and in-hospital outcomes by the specialty of the primary in-patient service (cardiology versus noncardiology). A total of 35 374 patients (63.2%) were primarily cared for by a cardiology service, and these patients had lower-risk clinical characteristics, but they more commonly received acute (Acute care processes were improved when care was provided by a cardiology service regardless of the propensity to receive cardiology care. The adjusted risk of in-hospital mortality was lower with care provided by a cardiology service (adjusted odds ratio 0.80, 95% confidence interval 0.73 to 0.88), and adjustment for differences in the use of acute medications and invasive procedures partially attenuated this mortality difference (adjusted odds ratio 0.92, 95% confidence interval 0.83 to 1.02). Non-ST-segment elevation acute coronary syndrome patients primarily cared for by a cardiology inpatient service more commonly received evidence-based treatments and had a lower risk of mortality, but these patients had lower-risk clinical characteristics. Results from the present analysis highlight the difficulties with
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Dostálová, G; Bělohlávek, J; Vítek, L; Muchová, L; Skvařilová, M; Karetová, D; Jirátová, K; Kvasnička, J; Vondráková, D; Toman, O; Linhart, A
2012-10-01
The incidence of cardiovascular (CV) diseases and acute myocardial infarction (AMI) in Czech Republic is de-clining. In spite of this in a proportion of patients AMI occurs in young age. The aim of our project was to assess the character of risk factors, precipitating diseases and the quality of care in young AMI survivors. We included 132 patients (97 men and 35 women) in whom AIM with ST elevations occurred before age of 45 years in men and age of 50 years in women. Several results were compared to a control group composed of 84 healthy volunteers of comparable age. We assessed the course of the disease, extent of coronary involvement, subsequent therapy and control of risk factors after 3 years from the index event. Smoking represented the main risk factor - 85% patents were active smokers at the time of AMI and 9% were former smokers, 64% patients had a positive family history of CV disease. We found a higher prevalence of dyslipidemia history in men. In spite of high rate of statin use, laboratory examination during follow-up revealed higher triglyceride values and low levels of HDL-cholesterol in both genders. All together 23% of patients had a history of provoking underlying disease or precipitating factors (inflammatory diseases, malignancies, combined thrombophilias, drug abuse). In total 95% of patients underwent coronary angiography during the acute phase of AMI, the median time from pain onset to intervention was 9 hours. Most patients had single vessel disease, 14% had even coronary angiogram without clinically significant stenosis. The subsequent care was satisfactory concerning the rate of drug prescriptions. However, target lipid values were not reached in 78% patients and blood pressure targets in 37%. In patients who suffered AMI in young age, risk factors are dominated by smoking and positive family history of CV diseases. One fifth of patients suffer from other underlying disease (inflammatory disease, malignancies, combined thrombophilia) or
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Pediatric thermal injury: acute care and reconstruction update.
Armour, Alexis D; Billmire, David A
2009-07-01
The acute and reconstructive care of each pediatric burn patient presents unique challenges to the plastic surgeon and the burn care team. : The purpose of this review article is to highlight the interdependence between the acute and reconstructive needs of pediatric burn patients as it pertains to each anatomical site. Relevant principles of acute pediatric burn care and burn reconstruction are outlined, based on the authors' experience and review of the literature. The need for late reconstruction in pediatric burn survivors is significantly influenced by the acute surgical and rehabilitative treatments. With their vulnerability to airway swelling, hypothermia, pulmonary edema, and ischemia-reperfusion injury, pediatric patients with large burns require precise, life-saving treatment in the acute phase. Decision-making in pediatric burn reconstruction must take into account the patient's future growth, maturity, and often lack of suitable donor sites. Appropriately selected reconstructive techniques are essential to optimize function, appearance, and quality of life in pediatric burn survivors.
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[Implementation of a palliative care concept in a geriatric acute care hospital].
Hagg-Grün, U; Lukas, A; Sommer, B-N; Klaiber, H-R; Nikolaus, T
2010-12-01
To integrate palliative care patients into an acute geriatric ward requires extensive and continuous education and preparation of all participating professionals. It can be a lengthy process to integrate palliative care concepts despite cooperation of the hospital administration. The group of patients to be integrated differs from the patients of regular geriatric wards because of a higher percentage of relatively young oncologic patients and they differ from a regular palliative ward because about 50% are non-oncologic patients, while the average age is much higher than in normal palliative care. It is possible to integrate specialized palliative care into a regular geriatric ward. Patients admitted without palliative intention will benefit the most from ward-integrated palliative care if the treatment aim turns this way. Ward-integrated palliative care can be an integral part of treating geriatric patients in addition to acute geriatric medicine, rehabilitation, and prevention. It can also provide caretakers and patients with the benefits from continuity of treatment and care.
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Medicare's bundling pilot: including post-acute care services.
Dummit, Laura A
2011-03-28
Fee-for-service Medicare, in which a separate payment is made for each service, rewards health care providers for delivering more services, but not necessarily coordinating those services over time or across settings. To help address these concerns, the Patient Protection and Affordable Care Act of 2010 requires Medicare to experiment with making a bundled payment for a hospitalization plus post-acute care, that is, the recuperative or rehabilitative care following a hospital discharge. This bundled payment approach is intended to promote more efficient care across the acute/post-acute episode because the entity that receives the payment has financial incentives to keep episode costs below the payment. Although the entity is expected to control costs through improved care coordination and efficiency, it could stint on care or avoid expensive patients instead. This issue brief focuses on the unique challenges posed by the inclusion of post-acute care services in a payment bundle and special considerations in implementing and evaluating the episode payment approach.
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Implementing a resident acute care surgery service: Improving resident education and patient care.
Kantor, Olga; Schneider, Andrew B; Rojnica, Marko; Benjamin, Andrew J; Schindler, Nancy; Posner, Mitchell C; Matthews, Jeffrey B; Roggin, Kevin K
2017-03-01
To simulate the duties and responsibilities of an attending surgeon and allow senior residents more intraoperative and perioperative autonomy, our program created a new resident acute care surgery consult service. We structured resident acute care surgery as a new admitting and inpatient consult service managed by chief and senior residents with attending supervision. When appropriate, the chief resident served as a teaching assistant in the operation. Outcomes were recorded prospectively and reviewed at weekly quality improvement conferences. The following information was collected: (1) teaching assistant case logs for senior residents preimplentation (n = 10) and postimplementation (n = 5) of the resident acute care surgery service; (2) data on the proportion of each case performed independently by residents; (3) resident evaluations of the resident acute care surgery versus other general operative services; (4) consult time for the first 12 months of the service (June 2014 to June 2015). During the first year after implementation, the number of total teaching assistant cases logged among graduating chief residents increased from a mean of 13.4 ± 13.0 (range 4-44) for preresident acute care surgery residents to 30.8 ± 8.8 (range 27-36) for postresident acute care surgery residents (P < .01). Of 323 operative cases, the residents performed an average of 82% of the case independently. There was a significant increase in the satisfaction with the variety of cases (mean 5.08 vs 4.52, P < .01 on a 6-point Likert scale) and complexity of cases (mean 5.35 vs 4.94, P < .01) on service evaluations of resident acute care surgery (n = 27) in comparison with other general operative services (n = 127). In addition, creation of a 1-team consult service resulted in a more streamlined consult process with average consult time of 22 minutes for operative consults and 25 minutes for nonoperative consults (range 5-90 minutes). The implementation of a
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Bachnick, Stefanie; Ausserhofer, Dietmar; Baernholdt, Marianne; Simon, Michael
2018-05-01
Patient-centered care is a key element of high-quality healthcare and determined by individual, structural and process factors. Patient-centered care is associated with improved patient-reported, clinical and economic outcomes. However, while hospital-level characteristics influence patient-centered care, little evidence is available on the association of patient-centered care with characteristic such as the nurse work environment or implicit rationing of nursing care. The aim of this study was to describe patient-centered care in Swiss acute care hospitals and to explore the associations with nurse work environment factors and implicit rationing of nursing care. This is a sub-study of the cross-sectional multi-center "Matching Registered Nurse Services with Changing Care Demands" study. We included 123 units in 23 acute care hospitals from all three of Switzerland's language regions. The sample consisted of 2073 patients, hospitalized for at least 24 h and ≥18 years of age. From the same hospital units, 1810 registered nurses working in direct patient care were also included. Patients' perceptions of patient-centered care were assessed using four items from the Generic Short Patient Experiences Questionnaire. Nurses completed questionnaires assessing perceived staffing and resource adequacy, adjusted staffing, leadership ability and level of implicit rationing of nursing care. We applied a Generalized Linear Mixed Models for analysis including individual-level patient and nurse data aggregated to the unit level. Patients reported high levels of patient-centered care: 90% easily understood nurses, 91% felt the treatment and care were adapted for their situation, 82% received sufficient information, and 70% felt involved in treatment and care decisions. Higher staffing and resource adequacy was associated with higher levels of patient-centered care, e.g., sufficient information (β 0.638 [95%-CI: 0.30-0.98]). Higher leadership ratings were associated with
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Utilization of Post-Acute Care following Distal Radius Fracture among Medicare Beneficiaries
Zhong, Lin; Mahmoudi, Elham; Giladi, Aviram M.; Shauver, Melissa; Chung, Kevin C.; Waljee, Jennifer F.
2016-01-01
Purpose To examine the utilization and cost of post-acute care following isolated distal radius fractures (DRF) among Medicare beneficiaries. Methods We examined utilization of post-acute care among Medicare beneficiaries who experienced an isolated DRF (n=38,479) during 2007 using 100% Medicare claims data. We analyzed the effect of patient factors on hospital admission following DRF and the receipt of post-acute care delivered by skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), home healthcare agencies (HHAs), and outpatient OT/PT for the recovery of DRF. Results In this cohort of isolated DRF patients, 1,694 (4.4%) were admitted to hospitals following DRF, and 20% received post-acute care. Women and patients with more comorbid conditions were more likely to require hospital admission. The utilization of post-acute care was higher among women, patients who resided in urban areas, and patients of higher socioeconomic status. The average cost per patient of post-acute care services from IRFs and SNFs ($15,888/patient) was significantly higher than the average cost other aspects of DRF care and accounted for 69% of the total DRF-related expenditure among patients who received inpatient rehabilitation. Conclusions Sociodemographic factors, including sex, socioeconomic status, and age, were significantly correlated with the use of post-acute care following isolated DRFs, and post-acute care accounted for a substantial proportion of the total expenditures related to these common injuries among the elderly. Identifying patients who will derive the greatest benefit from post-acute care can inform strategies to improve the cost-efficiency of rehabilitation and optimize scarce healthcare resources. Level of evidence Therapeutic, III PMID:26527599
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De Rosa, Silvia; Samoni, Sara; Villa, Gianluca; Ronco, Claudio
2017-01-01
Patients with chronic kidney disease (CKD) are at high risk for developing critical illness and for admission to intensive care units (ICU). 'Critically ill CKD patients' frequently develop an acute worsening of renal function (i.e. acute-on-chronic, AoC) that contributes to long-term kidney dysfunction, potentially leading to end-stage kidney disease (ESKD). An integrated multidisciplinary effort is thus necessary to adequately manage the multi-organ damage of those kidney patients and contemporaneously reduce the progression of kidney dysfunction when they are critically ill. The aim of this review is to describe (1) the pathophysiological mechanisms underlying the development of AoC kidney dysfunction and its role in the progression toward ESKD; (2) the most common clinical presentations of critical illness among CKD/ESKD patients; and (3) the continuum of care for CKD/ESKD patients from maintenance hemodialysis/peritoneal dialysis to acute renal replacement therapy performed in ICU and, vice-versa, for AoC patients who develop ESKD. © 2017 S. Karger AG, Basel.
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Brooke, Joanne; Manneh, Claire
2018-03-12
To explore the lived experience of caring for a patient during an acute episode of delirium by nurses working in cardiology, elderly care, renal, or respiratory specialities. A missed or delayed diagnosis of delirium in an acute hospital setting adversely impacts on patient outcomes. Nurses are the best placed health care professionals to identify a change in patient's cognitive status but struggle to do so. Inductive interpretative phenomenology. Semi-structured interviews with nurses working in an acute hospital in England between November 2016 and March 2017 (n = 23). Interviews were transcribed verbatim and analysed using thematic analysis. Three themes were identified: (i) "sometimes delirium is confusing", difficultly in differentiating between delirium and dementia; (ii) "everyone in the ward was looking after him", a need for collaborative working to provide harm free care; and (iii) "he was aggressive with us, but after treatment he was a gentleman", acceptance and tolerance of aggression. The need for education across specialities, with a combination of classroom and simulation teaching. Alongside, the development of structures to support the development of nursing teamwork and reporting of near miss incidents that occur with patients during an episode of delirium. © 2018 John Wiley & Sons Australia, Ltd.
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Hospital-based, acute care after ambulatory surgery center discharge.
Fox, Justin P; Vashi, Anita A; Ross, Joseph S; Gross, Cary P
2014-05-01
As a measure of quality, ambulatory surgery centers have begun reporting rates of hospital transfer at discharge. This process, however, may underestimate the acute care needs of patients after care. We conducted this study to determine rates and evaluate variation in hospital transfer and hospital-based, acute care within 7 days among patients discharged from ambulatory surgery centers. Using data from the Healthcare Cost and Utilization Project, we identified adult patients who underwent a medical or operative procedure between July 2008 and September 2009 at ambulatory surgery centers in California, Florida, and Nebraska. The primary outcomes were hospital transfer at the time of discharge and hospital-based, acute care (emergency department visits or hospital admissions) within 7-days expressed as the rate per 1,000 discharges. At the ambulatory surgery center level, rates were adjusted for age, sex, and procedure-mix. We studied 3,821,670 patients treated at 1,295 ambulatory surgery centers. At discharge, the hospital transfer rate was 1.1 per 1,000 discharges (95% confidence interval 1.1-1.1). Among patients discharged home, the hospital-based, acute care rate was 31.8 per 1,000 discharges (95% confidence interval 31.6-32.0). Across ambulatory surgery centers, there was little variation in adjusted hospital transfer rates (median = 1.0/1,000 discharges [25th-75th percentile = 1.0-2.0]), whereas substantial variation existed in adjusted, hospital-based, acute care rates (28.0/1,000 [21.0-39.0]). Among adult patients undergoing ambulatory care at surgery centers, hospital transfer at time of discharge from the ambulatory care center is a rare event. In contrast, the rate of need for hospital-based, acute care in the first week afterwards is nearly 30-fold greater, varies across centers, and may be a more meaningful measure for discriminating quality. Published by Mosby, Inc.
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Ekerstad, Niklas; Karlson, Björn W; Andersson, David; Husberg, Magnus; Carlsson, Per; Heintz, Emelie; Alwin, Jenny
2018-05-18
The objective of this study was to estimate the 3-month within-trial cost-effectiveness of comprehensive geriatric assessment (CGA) in acute medical care for frail elderly patients compared to usual medical care, by estimating health-related quality of life and costs from a societal perspective. Clinical, prospective, controlled, 1-center intervention trial with 2 parallel groups. Structured, systematic interdisciplinary CGA-based care in an acute elderly care unit. If the patient fulfilled the inclusion criteria, and there was a bed available at the CGA unit, the patient was included in the intervention group. If no bed was available at the CGA unit, the patient was included in the control group and admitted to a conventional acute medical care unit. A large county hospital in western Sweden. The trial included 408 frail elderly patients, 75 years or older, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n = 206) or control group (n = 202). Mean age of the patients was 85.7 years, and 56% were female. The primary outcome was the adjusted incremental cost-effectiveness ratio associated with the intervention compared to the control at the 3-month follow-up. We undertook cost-effectiveness analysis, adjusted by regression analyses, including hospital, primary, and municipal care costs and effects. The difference in the mean adjusted quality-adjusted life years gained between groups at 3 months was 0.0252 [95% confidence interval (CI): 0.0082-0.0422]. The incremental cost, that is, the difference between the groups, was -3226 US dollars (95% CI: -6167 to -285). The results indicate that the care in a CGA unit for acutely ill frail elderly patients is likely to be cost-effective compared to conventional care after 3 months. Copyright © 2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.
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Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care.
Burke, Robert E; Jones, Jacqueline; Lawrence, Emily; Ladebue, Amy; Ayele, Roman; Leonard, Chelsea; Lippmann, Brandi; Matlock, Daniel D; Allyn, Rebecca; Cumbler, Ethan
2018-05-01
Despite a national focus on post-acute care brought about by recent payment reforms, relatively little is known about how hospitalized older adults and their caregivers decide whether to go to a skilled nursing facility (SNF) after hospitalization. We sought to understand to what extent hospitalized older adults and their caregivers are empowered to make a high-quality decision about utilizing an SNF for post-acute care and what contextual or process elements led to satisfaction with the outcome of their decision once in SNF. Qualitative inquiry using the Ottawa Decision Support Framework (ODSF), a conceptual framework that describes key components of high-quality decision-making. Thirty-two previously community-dwelling older adults (≥ 65 years old) and 22 caregivers interviewed at three different hospitals and three skilled nursing facilities. We used key components of the ODSF to identify elements of context and process that affected decision-making and to what extent the outcome was characteristic of a high-quality decision: informed, values based, and not associated with regret or blame. The most important contextual themes were the presence of active medical conditions in the hospital that made decision-making difficult, prior experiences with hospital readmission or SNF, relative level of caregiver support, and pressure to make a decision quickly for which participants felt unprepared. Patients described playing a passive role in the decision-making process and largely relying on recommendations from the medical team. Patients commonly expressed resignation and a perceived lack of choice or autonomy, leading to dissatisfaction with the outcome. Understanding and intervening to improve the quality of decision-making regarding post-acute care supports is essential for improving outcomes of hospitalized older adults. Our results suggest that simply providing information is not sufficient; rather, incorporating key contextual factors and improving the
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The Australian National Sub-Acute and Non-Acute Patient casemix classification.
Eagar, K
1999-01-01
The Australian National Sub-Acute and Non-Acute Patient (AN-SNAP) Version 1 casemix classification was completed in 1997. AN-SNAP is designed for the classification of sub-acute and non-acute care provided in both inpatient and ambulatory settings and is intended to be useful for both funding and clinical management purposes. The National Sub-Acute and Non-Acute Casemix Classification study has produced the first version of a national classification of sub-acute and non-acute care. Ongoing refinement (leading to Version 2) will be possible through further analysis of the existing data set in combination with analysis of the results of a carefully planned and phased implementation.
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Fox, Mary T; Persaud, Malini; Maimets, Ilo; O'Brien, Kelly; Brooks, Dina; Tregunno, Deborah; Schraa, Ellen
2012-01-01
Objectives To compare the effectiveness of acute geriatric unit care, based on all or part of the Acute Care for Elders (ACE) model and introduced in the acute phase of illness or injury, with that of usual care. Design Systematic review and meta-analysis of 13 randomized controlled and quasi-experimental trials with parallel comparison groups retrieved from multiple sources. Setting Acute care geriatric and nongeriatric hospital units. Participants Acutely ill or injured adults (N = 6,839) with an average age of 81. Interventions Acute geriatric unit care characterized by one or more ACE components: patient-centered care, frequent medical review, early rehabilitation, early discharge planning, prepared environment. Measurements Falls, pressure ulcers, delirium, functional decline at discharge from baseline 2-week prehospital and hospital admission statuses, length of hospital stay, discharge destination (home or nursing home), mortality, costs, and hospital readmissions. Results Acute geriatric unit care was associated with fewer falls (risk ratio (RR) = 0.51, 95% confidence interval (CI) = 0.29–0.88), less delirium (RR = 0.73, 95% CI = 0.61–0.88), less functional decline at discharge from baseline 2-week prehospital admission status (RR = 0.87, 95% CI = 0.78–0.97), shorter length of hospital stay (weighted mean difference (WMD) = −0.61, 95% CI = −1.16 to −0.05), fewer discharges to a nursing home (RR = 0.82, 95% CI = 0.68–0.99), lower costs (WMD = −$245.80, 95% CI = −$446.23 to −$45.38), and more discharges to home (RR = 1.05, 95% CI = 1.01–1.10). A nonsignificant trend toward fewer pressure ulcers was observed. No differences were found in functional decline between baseline hospital admission status and discharge, mortality, or hospital readmissions. Conclusion Acute geriatric unit care, based on all or part of the ACE model and introduced during the acute phase of older adults' illness or injury, improves patient- and system
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Romeyke, Tobias; Nöhammer, Elisabeth; Scheuer, Hans Christoph; Stummer, Harald
2017-08-01
The integration of naturopathic methods into acute inpatient care has been the subject of very few scientific studies. Patient expectations of the service received in hospital are increasing, and the integration of naturopathy into clinical practice can serve as Unique Selling Proposition. The present study was conducted over a period of two years. In total, over 1700 patients were included in the study. The setting is an acute hospital specialising in a multimodal, patient-centred approach to treatment. Patient satisfaction with the use of holistic care, patient perception of adherence to treatment and the amount of time care staff spend with patients were all investigated. The patients' principal diagnoses were also recorded using the DRG classification system, as were the number of concomitant diseases and the length of their stay in hospital. The majority of patients rate the integration of complementary care in the acute hospital very positively. The effects on patient perception of adherence to treatment and the amount of time care staff spend with patients are also assessed positively. At the same time, we can see that patients who receive patient-centred care in this study predominantly suffer from diseases and disorders of the musculoskeletal system and connective tissue, diseases of the nervous system and mental diseases and disorders. They also have numerous concomitant diseases. It could be shown that patients are very satisfied with the combination of naturopathy and academic medicine and with approaches that take patient preferences into account. Integrating naturopathy can be considered for multimorbid patients, in particular. Moreover, patient-centred care can improve staff satisfaction levels. Copyright © 2017 Elsevier Ltd. All rights reserved.
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Salonga-Reyes, Armi; Scott, Ian A
2017-03-01
Objectives The aims of the present study were to identify causes of prolonged discharge delays among non-acute in-patients admitted to a tertiary general medicine service, quantify occupied bed days (OBDs) and propose strategies for eliminating avoidable delays. Methods A retrospective study was performed of patients admitted between 1 January 2012 and 31 May 2015 and discharged as non-acute cases requiring maintenance care and who incurred a total non-acute length of stay (LOS) >7 days and total hospital LOS >14 days. Long-stay patients with non-acute LOS ≥28 days were subject to chart review in ascertaining serial causes of discharge delay and their attributable OBDs. Literature reviews and staff feedback identified potential strategies for minimising delays. Results Of the 406 patients included in the present study, 131 incurred long-stays; for these 131 patients, delays were identified that accounted for 5420 of 6033 (90%) non-acute OBDs. Lack of available residential care beds was most frequent, accounting for 44% of OBDs. Waits for outcomes of guardianship applications accounted for 13%, whereas guardian appointments, Public Trustee applications and funding decisions for equipment or care packages each consumed between 4% and 5% of OBDs. Family and/or carer refusal of care accounted for 7%. Waits for aged care assessment team (ACAT) assessments, social worker reports, geriatrician or psychiatrist reviews and confirmation of enduring power of attorney each accounted for between 1% and 3% of OBDs. Of 30 proposed remedial strategies, those rated as high priority were: greater access to interim care or respite care beds or supported accommodation, especially for patients with special needs; dedicated agency officers for hospital guardianship applications and greater interagency collaboration and harmonisation of assessment and decision processes; and formal requests from hospital administrators to patients and family to accept care options and attend mediation
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Bundling Post-Acute Care Services into MS-DRG Payments
Vertrees, James C.; Averill, Richard F.; Eisenhandler, Jon; Quain, Anthony; Switalski, James
2013-01-01
Objective A bundled hospital payment system that encompasses both acute and post-acute care has been proposed as a means of creating financial incentives in the Medicare fee-for-service system to foster care coordination and to improve the current disorganized system of post care. The objective of this study was to evaluate the statistical stability of alternative designs of a hospital payment system that includes post-acute care services to determine the feasibility of using a combined hospital and post-acute care bundle as a unit of payment. Methods The Medicare Severity-Diagnosis Related Groups (MS-DRGs) were subdivided into clinical subclasses that measured a patient's chronic illness burden to test whether a patient's chronic illness burden had a substantial impact on post-acute care expenditures. Using Medicare data the statistical performance of the MS-DRGs with and without the chronic illness subclasses was evaluated across a wide range of post-acute care windows and combinations of post-acute care service bundles using both submitted charges and Medicare payments. Results The statistical performance of the MS-DRGs as measured by R2 was consistently better when the chronic illness subclasses are included indicating that MS-DRGs by themselves are an inadequate unit of payment for post-acute care payment bundles. In general, R2 values increased as the post-acute care window length increased and decreased as more services were added to the post-acute care bundle. Discussion The study results suggest that it is feasible to develop a payment system that incorporates significant post-acute care services into the MS-DRG inpatient payment bundle. This expansion of the basic DRG payment approach can provide a strong financial incentive for providers to better coordinate care potentially leading to improved efficiency and outcome quality. PMID:24753970
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Lim, Jia Xu; King, Nicolas; Low, Sharon; Ng, Wai Hoe
2015-01-01
Readmission of patients to acute hospitals contributes significantly toward inefficient utilization of healthcare resources, with studies quoting up to 90% being preventable. We aim to report and analyze the factors involved in the readmission of neurosurgical patients who had been previously transferred to an intermediate step-down care facility, and explore possible predictive markers for such readmissions. We conducted a retrospective analysis of all 129 neurosurgical patients who were transferred from out acute tertiary hospital to an intermediate care facility. The cases were segregated into those who were readmitted and those who were not readmitted back to our acute center. The demographic data, clinical features, diagnoses, treatment modalities, pretransfer laboratory findings, and inpatient complications were compared with readmission rate. There were 23 patients (17.8%) who were readmitted to our acute hospital. The most common causes of readmission was infection (n = 12, 52.2%). We found a statistically significant correlation between the higher pretransfer procalcitonin levels with the readmission of our patients (P = 0.037). There was also a significant difference noted between ethnic groups (P = 0.026) and having no complications of disease or treatment (P = 0.008), with readmission. Procalcitonin is a pro-hormone known to correlate with infection and poor neurological status. We have found that its serum values correlate significantly with the readmission rates of neurosurgical patients in our study. We postulate that by ensuring normality in procalcitonin levels prior to transfer to an intermediate care facility, potentially half of neurosurgical readmissions can be prevented.
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Lim, Jia Xu; King, Nicolas; Low, Sharon; Ng, Wai Hoe
2015-01-01
Background: Readmission of patients to acute hospitals contributes significantly toward inefficient utilization of healthcare resources, with studies quoting up to 90% being preventable. We aim to report and analyze the factors involved in the readmission of neurosurgical patients who had been previously transferred to an intermediate step-down care facility, and explore possible predictive markers for such readmissions. Methods: We conducted a retrospective analysis of all 129 neurosurgical patients who were transferred from out acute tertiary hospital to an intermediate care facility. The cases were segregated into those who were readmitted and those who were not readmitted back to our acute center. The demographic data, clinical features, diagnoses, treatment modalities, pretransfer laboratory findings, and inpatient complications were compared with readmission rate. Results: There were 23 patients (17.8%) who were readmitted to our acute hospital. The most common causes of readmission was infection (n = 12, 52.2%). We found a statistically significant correlation between the higher pretransfer procalcitonin levels with the readmission of our patients (P = 0.037). There was also a significant difference noted between ethnic groups (P = 0.026) and having no complications of disease or treatment (P = 0.008), with readmission. Conclusion: Procalcitonin is a pro-hormone known to correlate with infection and poor neurological status. We have found that its serum values correlate significantly with the readmission rates of neurosurgical patients in our study. We postulate that by ensuring normality in procalcitonin levels prior to transfer to an intermediate care facility, potentially half of neurosurgical readmissions can be prevented. PMID:26430533
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Vincent, Heather K.; Haupt, Edward; Tang, Sonya; Egwuatu, Adaeze; Vlasak, Richard; Horodyski, MaryBeth; Carden, Donna; Sadisivan, Kalia K.
2014-01-01
Background Controversy exists regarding obesity-related injury severity and clinical outcomes after orthopedic trauma. Purpose The purposes of this study were to expand our understanding of the effect of morbid obesity on perioperative and acute care outcomes after acetabular fracture. Methods This was a retrospective review of patients with acetabular fracture after trauma. Non-morbidly obese (BMI < 35 kg/m2) and morbidly obese (BMI ≥ 35 kg/m2; N = 81). Injury severity scores and Glasgow Coma Scale scores (GCS) were collected. Perioperative and acute care outcomes were positioning and operative time, extra fractures, estimated blood loss, complications, hospital charges, ventilator days, transfusions, length of stay (LOS) and discharge destination. Positioning and operative times were longer in morbidly obese patients (p < 0.05). No other differences existed between groups. Conclusions Orthopedic trauma surgeons and care teams can expect similar acute care outcomes in morbidly obese and non-morbidly obese patients with acetabular fracture. PMID:25104886
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Bridges, Jackie; Nicholson, Caroline; Maben, Jill; Pope, Catherine; Flatley, Mary; Wilkinson, Charlotte; Meyer, Julienne; Tziggili, Maria
2013-01-01
Aims To synthesize evidence and knowledge from published research about nurses' experiences of nurse-patient relationships with adult patients in general, acute inpatient hospital settings. Background While primary research on nurses' experiences has been reported, it has not been previously synthesized. Design Meta-ethnography. Data sources Published literature from Australia, Europe, and North America, written in English between January 1999–October 2009 was identified from databases: CINAHL, Medline, British Nursing Index and PsycINFO. Review methods Qualitative studies describing nurses' experiences of the nurse-patient relationship in acute hospital settings were reviewed and synthesized using the meta-ethnographic method. Results Sixteen primary studies (18 papers) were appraised as high quality and met the inclusion criteria. The findings show that while nurses aspire to develop therapeutic relationships with patients, the organizational setting at a unit level is strongly associated with nurses' capacity to build and sustain these relationships. The organizational conditions of critical care settings appear best suited to forming therapeutic relationships, while nurses working on general wards are more likely to report moral distress resulting from delivering unsatisfactory care. General ward nurses can then withdraw from attempting to emotionally engage with patients. Conclusion The findings of this meta-ethnography draw together the evidence from several qualitative studies and articulate how the organizational setting at a unit level can strongly influence nurses' capacity to build and sustain therapeutic relationships with patients. Service improvements need to focus on how to optimize the organizational conditions that support nurses in their relational work with patients. PMID:23163719
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Fakhry, Samir M; Martin, Brad; Al Harakeh, Hasan; Norcross, E Douglas; Ferguson, Pamela L
2013-04-01
Controlling inpatient costs is increasingly important. Identifying proportionately larger cost categories may help focus cost control efforts. The purpose of this study was to identify proportionate patient cost categories in trauma and acute care surgery (TACS) patients and determine subgroups in which the largest opportunities for cost savings might exist. Administrative data from our academic, urban, level I trauma center were used to identify all adult TACS patients from FY07 through FY11. We determined, on average, what proportion of the whole each cost category contributed to patients' total costs and examined the same proportions for subgroups of patients. We identified 6,008 TACS patients. Trauma patients (n = 3,904) made up 65% of the cohort (mean Injury Severity Score 13.2). Payers were: 22% government (Medicare, Medicaid, Champus), 27% private, 43% self-pay/indigent, 3% other, and 5% workers compensation. Nontrauma (general surgery) patients (n = 2,104) made up 35% of the cohort. Payers were: 44% government, 24% private, 29% self-pay/indigent, 2% other, and 1% workers compensation. Total inpatient costs were $141,304,993. Per patient costs rose from $17,245 in FY07 to $26,468 in FY11. In the aggregate, supplies, ICU stays, and ward stays represented the largest proportionate cost categories. On a per patient basis, however, ICU stays were by far the largest cost. Patients with ICU stay greater than 10 days were only 7% of all patients but accounted for 41% of total costs. Trauma and acute care surgery patients represent a significant and increasing institutional cost. Per patient ICU costs were the largest single category, suggesting that cost control efforts should focus heavily on critically ill patients. Nontrauma patients who require critical care have the highest per patient ICU costs and may represent a previously underappreciated opportunity for cost control. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights
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Agarwal, Ekta; Ferguson, Maree; Banks, Merrilyn; Bauer, Judith; Capra, Sandra; Isenring, Elisabeth
2012-02-01
One aim of the Australasian Nutrition Care Day Survey was to determine the nutritional status and dietary intake of acute care hospital patients. Dietitians from 56 hospitals in Australia and New Zealand completed a 24-h survey of nutritional status and dietary intake of adult hospitalised patients. Nutritional risk was evaluated using the Malnutrition Screening Tool. Participants 'at risk' underwent nutritional assessment using Subjective Global Assessment. Based on the International Classification of Diseases (Australian modification), participants were also deemed malnourished if their body mass index was <18.5 kg/m(2). Dietitians recorded participants' dietary intake at each main meal and snacks as 0%, 25%, 50%, 75%, or 100% of that offered. 3122 patients (mean age: 64.6 ± 18 years) participated in the study. Forty-one percent of the participants were "at risk" of malnutrition. Overall malnutrition prevalence was 32%. Fifty-five percent of malnourished participants and 35% of well-nourished participants consumed ≤50% of the food during the 24-h audit. "Not hungry" was the most common reason for not consuming everything offered during the audit. Malnutrition and sub-optimal food intake is prevalent in acute care patients across hospitals in Australia and New Zealand and warrants appropriate interventions. Copyright © 2011 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
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Rivera-Hernandez, Maricruz; Rahman, Momotazur; Mukamel, Dana B; Mor, Vincent; Trivedi, Amal N
2018-04-25
Understanding and addressing racial and ethnic disparities in the quality of post-acute care in skilled nursing facilities is an important health policy issue, particularly as the Medicare program initiates value-based payments for these institutions. Our final cohort included 649,187 Medicare beneficiaries in either the fee-for-service or Medicare Advantage programs, who were 65 and older and were admitted to a skilled nursing facility following an acute hospital stay, from 8,375 skilled nursing facilities. We examined the quality of care in skilled nursing facilities that disproportionately serve minority patients compared to non-Hispanic whites. Three measures, all calculated at the level of the facility, were used to assess quality of care in skilled nursing facilities: 1) 30-day rehospitalization rate; 2) successful discharge from the facility to the community; and 3) Medicare five-star quality ratings. We found that African-American post-acute patients are highly concentrated in a small number of institutions, with 28% of facilities accounting for 80% of all post-acute admissions for African-American patients. Similarly, just 20% of facilities accounted for 80% of all admissions for Hispanics. Skilled nursing facilities with higher fractions of African-American patients had worse performance for three publicly-reported quality measures: rehospitalization, successful discharge to the community, and the star rating indicator. Efforts to address disparities should focus attention on institutions that disproportionately serve minority patients and monitor unintended consequences of value-based payments to skilled nursing facilities.
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Chambers, Rachel; Bryan, Joanna; Jannat-Khah, Deanna; Russo, Emily; Merriman, Louise; Gupta, Renuka
2018-04-27
As described in detail in the literature, patients identified with malnutrition are at increased risk for poor clinical outcomes. Despite this knowledge, malnourished patients do not always receive optimal nutrition management while admitted into a hospital because of what we describe as gaps in care throughout their admission. We hypothesized that the 3 main gaps in care were poor dietitian-doctor communication, excessive time spent nil per os (NPO) for procedures and testing, and/or inaccurate or incomplete dietary discharge instructions. The objectives of this study were to determine and to characterize gaps in nutrition care after a malnutrition diagnosis. This retrospective study involved postdischarge chart reviews of malnourished adult medicine patients admitted to an acute care facility from September 1, 2014, to November 30, 2014 (n = 242). Of the malnourished patients, 76% had at least 1 gap in care. The most prevalent gap (68%) involved discharge diet instructions, most often because of the omission of the dietitian recommendation for oral supplementation. Thirty-five percent of malnourished patients had a gap in care because of procedures or testing extending the period held NPO, and 13% had a gap in care because of poor communication, thus delaying orders and/or interventions. This is the first study to evaluate gaps in care of patients diagnosed with malnutrition. Identification of these gaps allows us the opportunity to develop strategies for this vulnerable population to improve areas such as discharge documentation and time spent NPO to provide the best and safest nutrition care. © 2018 American Society for Parenteral and Enteral Nutrition.
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Study protocol: The Improving Care of Acute Lung Injury Patients (ICAP) study
Needham, Dale M; Dennison, Cheryl R; Dowdy, David W; Mendez-Tellez, Pedro A; Ciesla, Nancy; Desai, Sanjay V; Sevransky, Jonathan; Shanholtz, Carl; Scharfstein, Daniel; Herridge, Margaret S; Pronovost, Peter J
2006-01-01
Introduction The short-term mortality benefit of lower tidal volume ventilation (LTVV) for patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS) has been demonstrated in a large, multi-center randomized trial. However, the impact of LTVV and other critical care therapies on the longer-term outcomes of ALI/ARDS survivors remains uncertain. The Improving Care of ALI Patients (ICAP) study is a multi-site, prospective cohort study that aims to evaluate the longer-term outcomes of ALI/ARDS survivors with a particular focus on the effect of LTVV and other critical care therapies. Methods Consecutive mechanically ventilated ALI/ARDS patients from 11 intensive care units (ICUs) at four hospitals in the city of Baltimore, MD, USA, will be enrolled in a prospective cohort study. Exposures (patient-based, clinical management, and ICU organizational) will be comprehensively collected both at baseline and throughout patients' ICU stay. Outcomes, including mortality, organ impairment, functional status, and quality of life, will be assessed with the use of standardized surveys and testing at 3, 6, 12, and 24 months after ALI/ARDS diagnosis. A multi-faceted retention strategy will be used to minimize participant loss to follow-up. Results On the basis of the historical incidence of ALI/ARDS at the study sites, we expect to enroll 520 patients over two years. This projected sample size is more than double that of any published study of long-term outcomes in ALI/ARDS survivors, providing 86% power to detect a relative mortality hazard of 0.70 in patients receiving higher versus lower exposure to LTVV. The projected sample size also provides sufficient power to evaluate the association between a variety of other exposure and outcome variables, including quality of life. Conclusion The ICAP study is a novel, prospective cohort study that will build on previous critical care research to improve our understanding of the longer-term impact of ALI/ARDS, LTVV and
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Surgical rescue: The next pillar of acute care surgery.
Kutcher, Matthew E; Sperry, Jason L; Rosengart, Matthew R; Mohan, Deepika; Hoffman, Marcus K; Neal, Matthew D; Alarcon, Louis H; Watson, Gregory A; Puyana, Juan Carlos; Bauzá, Graciela M; Schuchert, Vaishali D; Fombona, Anisleidy; Zhou, Tianhua; Zolin, Samuel J; Becher, Robert D; Billiar, Timothy R; Forsythe, Raquel M; Zuckerbraun, Brian S; Peitzman, Andrew B
2017-02-01
The evolving field of acute care surgery (ACS) traditionally includes trauma, emergency general surgery, and critical care. However, the critical role of ACS in the rescue of patients with a surgical complication has not been explored. We here describe the role of "surgical rescue" in the practice of ACS. A prospective, electronic medical record-based ACS registry spanning January 2013 to May 2014 at a large urban academic medical center was screened by ICD-9 codes for acute surgical complications of an operative or interventional procedure. Long-term outcomes were derived from the Social Security Death Index. Of 2,410 ACS patients, 320 (13%) required "surgical rescue": most commonly, from wound complications (32%), uncontrolled sepsis (19%), and acute obstruction (15%). The majority of complications (85%) were related to an operation; 15% were related to interventional procedures. The most common rescue interventions required were bowel resection (23%), wound debridement (18%), and source control of infection (17%); 63% of patients required operative intervention, and 22% required surgical critical care. Thirty-six percent of complications occurred in ACS primary patients ("local"), whereas 38% were referred from another surgical service ("institutional") and 26% referred from another institution ("regional"). Hospital length of stay was longer, and in-hospital and 1-year mortalities were higher in rescue patients compared with those without a complication. Outcomes were equivalent between "local" and "institutional" patients, but hospital length of stay and discharge to home were significantly worse in "institutional" referrals. We here describe the distinct role of the acute care surgeon in the surgical management of complications; this is an additional pillar of ACS. In this vital role, the acute care surgeon provides crucial support to other providers as well as direct patient care in the "surgical rescue" of surgical and procedural complications
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Effects of Payment Changes on Trends in Post-Acute Care
Buntin, Melinda Beeuwkes; Colla, Carrie Hoverman; Escarce, José J
2009-01-01
Objective To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies. Data Sources Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data. Study Design We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems. Data Extraction Methods A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement. Principal Findings Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill. Conclusions Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites. PMID:19490159
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Effects of payment changes on trends in post-acute care.
Buntin, Melinda Beeuwkes; Colla, Carrie Hoverman; Escarce, José J
2009-08-01
To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies. Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data. We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems. A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement. Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill. Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites.
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Smartphone Use by Nurses in Acute Care Settings.
Flynn, Greir Ander Huck; Polivka, Barbara; Behr, Jodi Herron
2018-03-01
The use of smartphones in acute care settings remains controversial due to security concerns and personal use. The purposes of this study were to determine (1) the current rates of personal smartphone use by nurses in acute care settings, (2) nurses' preferences regarding the use of smartphone functionality at work, and (3) nurse perceptions of the benefits and drawbacks of smartphone use at work. An online survey of nurses from six acute care facilities within one healthcare system assessed the use of personal smartphones in acute care settings and perceptions of the benefits and drawbacks of smartphone use at work. Participants (N = 735) were primarily point-of-care nurses older than 31 years. Most participants (98%) used a smartphone in the acute care setting. Respondents perceived the most common useful and beneficial smartphone functions in acute care settings as allowing them to access information on medications, procedures, and diseases. Participants older than 50 years were less likely to use a smartphone in acute care settings and to agree with the benefits of smartphones. There is a critical need for recognition that smartphones are used by point-of-care nurses for a variety of functions and that realistic policies for smartphone use are needed to enhance patient care and minimize distractions.
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Post-Acute Home Care and Hospital Readmission of Elderly Patients with Congestive Heart Failure
ERIC Educational Resources Information Center
Li, Hong; Morrow-Howell, Nancy; Proctor, Enola K.
2004-01-01
After inpatient hospitalization, many elderly patients with congestive heart failure (CHF) are discharged home and receive post-acute home care from informal (family) caregivers and formal service providers. Hospital readmission rates are high among elderly patients with CHF, and it is thought that use of informal and formal services may reduce…
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Pre-operative patient teaching in an acute care ward in Hong Kong: a case study.
Lee, David S; Chien, W T
2002-10-01
Many nurses have acknowledged that adequate pre-operative teaching can alleviate patients' anxiety, increase patient participation in their own care, and minimize post-operative complications. However, the organization and degree to which pre-operative patient teachingfeatured in nurses' practice varies in different acute care settings. A case study design was used to explore the practice of pre-operative teaching in a surgical ward of an acute general hospital in Hong Kong. Seventeen registered nurses working on the ward were interviewed and observed in order to explore how they conduct a pre-operative teaching program and the difficulties encountered by them in carrying out pre-operative teaching on this acute care setting. Thefindings of this study indicate that pre-operative teaching workshops are organized and conducted by nursesfrom the operating theatre, in the day surgery center. Ward nurses were not actively involved in this pre-operative teaching. The results of this study present some similarities to a study with the similar design in Australia. There are also issues unique to the Hong Kong context. This case study was to review Hong Kong nurses' current practices of pre-operative teaching and to understand the cultural, conceptual and managementfactors influencing the practice in pre-operative teaching.
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Insurance and Quality of Care for Adults with Acute Asthma
Ferris, Timothy G; Blumenthal, David; Woodruff, Prescott G; Clark, Sunday; Camargo, Carlos A
2002-01-01
OBJECTIVE The relationship between health care insurance and quality of medical care remains incompletely studied. We sought to determine whether type of patient insurance is related to quality of care and subsequent outcomes for patients who arrive in the emergency department (ED) for acute asthma. DESIGN Using prospectively collected data from the Multicenter Airway Research Collaboration, we compared measures of quality of pre-ED care, acute severity, and short-term outcomes across 4 insurance categories: managed care, indemnity, Medicaid, and uninsured. SETTING AND PARTICIPANTS Emergency departments at 57 academic medical centers enrolled 1,019 adults with acute asthma. RESULTS Patients with managed care ranked first and uninsured patients ranked last on all 7 unadjusted quality measures. After controlling for covariates, uninsured patients had significantly lower quality of care than indemnity patients for 5 of 7 measures and had lower initial peak expiratory flow rates than indemnity insured patients. Patients with managed care insurance were more likely than indemnity-insured patients to identify a primary care physician and report using inhaled steroids in the month prior to arrival in the ED. Patients with Medicaid insurance were more likely than indemnity-insured patients to use the ED as their usual source of care for problems with asthma. We found no differences in patient outcomes among the insurance categories we studied. CONCLUSIONS Uninsured patients had consistently poorer quality of care and than insured patients. Despite differences in indicators of quality of care between types of insurance, we found no differences in short-term patient outcomes by type of insurance. PMID:12472926
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Zarian, D. A.; Peter, S. A.; Lee, S.; Kleinfeld, M.
1989-01-01
A retrospective study of 81 patients with dementia in a long-term care facility was conducted to determine the causes and frequency of acute hospitalization and the cause of death in the patients who succumbed during the acute hospital admission. Pneumonia and urinary tract infections were the most frequent causes of acute hospitalization; septicemia and respiratory failure were the most frequent causes of death. These results suggest that patients with dementia are prone to acquire life-threatening infections. Preventive measures to decrease the incidence of these complications are discussed. PMID:2500533
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Cardiovascular genomics: implications for acute and critical care nurses.
Quinn Griffin, Mary T; Klein, Deborah; Winkelman, Chris
2013-01-01
As genomic health care becomes commonplace, nurses will be asked to provide genomic care in all health care settings including acute care and critical care. Three common cardiac conditions are reviewed, Marfan syndrome, bicuspid aortic valve, and hypertrophic cardiomyopathy, to provide acute care and critical care nurses with an overview of these pathologies through the lens of genomics and relevant case studies. This information will help critical care nursing leaders become familiar with genetics related to common cardiac conditions and prepare acute care and critical care nurses for a new phase in patient diagnostics, with greater emphasis on early diagnosis and recognition of conditions before sudden cardiac death.
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[Consensus on improving the care integrated of patients with acute heart failure].
Llorens, Pere; Manito Lorite, Nicolás; Manzano Espinosa, Luis; Martín-Sánchez, Francisco Javier; Comín Colet, Josep; Formiga, Francesc; Jacob, Javier; Delgado Jiménez, Juan; Montero-Pérez-Barquero, Manuel; Herrero, Pablo; López de Sá Areses, Esteban; Pérez Calvo, Juan Ignacio; Masip, Josep; Miró, Òscar
2015-01-01
Acute heart failure (AHF) requires considerable use of resources, is an economic burden, and is associated with high complication and mortality rates in emergency departments, on hospital wards, or outpatient care settings. Diagnosis, treatment, and continuity of care are variable at present, leading 3 medical associations (for cardiology, internal medicine, and emergency medicine) to undertake discussions and arrive at a consensus on clinical practice guidelines to support those who manage AHF and encourage standardized decision making. These guidelines, based on a review of the literature and clinical experience with AHF, focus on critical points in the care pathway. Regarding emergency care, the expert participants considered the initial evaluation of patients with signs and symptoms that suggest AHF, the initial diagnosis, first decisions about therapy, monitoring, assessment of prognosis, and referral criteria. For care of the hospitalized patient, the group developed a protocol for essential treatment. Objectives for the management and treatment of AHF on discharge were also covered through the creation or improvement of multidisciplinary care systems to provide continuity of care.
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Maeng, Daniel D; Khan, Nazmul; Tomcavage, Janet; Graf, Thomas R; Davis, Duane E; Steele, Glenn D
2015-04-01
Early evidence suggests that the patient-centered medical home has the potential to improve patient outcomes while reducing the cost of care. However, it is unclear how this care model achieves such desirable results, particularly its impact on cost. We estimated cost savings associated with Geisinger Health System's patient-centered medical home clinics by examining longitudinal clinic-level claims data from elderly Medicare patients attending the clinics over a ninety-month period (2006 through the first half of 2013). We also used these data to deconstruct savings into its main components (inpatient, outpatient, professional, and prescription drugs). During this period, total costs associated with patient-centered medical home exposure declined by approximately 7.9 percent; the largest source of this savings was acute inpatient care ($34, or 19 percent savings per member per month), which accounts for about 64 percent of the total estimated savings. This finding is further supported by the fact that longer exposure was also associated with lower acute inpatient admission rates. The results of this study suggest that patient-centered medical homes can lead to sustainable, long-term improvements in patient health outcomes and the cost of care. Project HOPE—The People-to-People Health Foundation, Inc.
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Chavez, Laura J; Liu, Chuan-Fen; Tefft, Nathan; Hebert, Paul L; Devine, Beth; Bradley, Katharine A
2017-10-01
Hospital readmissions and emergency department (ED) visits within 30 days of discharge are costly. Heavy alcohol use could predict increased risk for post-discharge acute care. This study assessed 30-day acute care utilization and expenditures for different categories of alcohol use. Veterans Affairs (VA) patients age ≥65 years with past-year alcohol screening, hospitalized for a medical condition, were included. VA and Medicare health care utilization data were used. Two-part models adjusted for patient demographics. Among 416,050 hospitalized patients, 25% had 30-day acute care use. Nondrinking patients (n = 267,746) had increased probability of acute care use, mean utilization days, and expenditures (difference of $345; 95% CI $268-$423), relative to low-risk drinkers (n = 105,023). High-risk drinking patients (n = 5,300) had increased probability of acute care use and mean utilization days, but not expenditures. Although these patients did not have greater acute care expenditures than low-risk drinking patients, they may nevertheless be vulnerable to poor post-discharge outcomes.
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Rape, Cyndy; Mann, Tammy; Schooley, John; Ramey, Jana
2015-01-01
With a recent decrease in community resources for the mental health population, acute care facilities must seek creative, cost-effective ways to protect and care for these vulnerable individuals. This article describes 1 facility's journey to maintaining patient and staff safety while reducing cost. Success factors of this program include staff engagement, environmental modifications, and a nurse-driven, sitter-reduction process.
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Muntlin Athlin, Åsa; Juhlin, Claes; Jangland, Eva
2017-02-01
Evidence-informed healthcare is the fundament for practice, whereby guidelines based on the best available evidence should assist health professionals in managing patients. Patients seeking care for acute abdominal pain form a common group in acute care settings worldwide, for whom decision-making and timely treatment are of paramount importance. There is ambiguity about the existence, use and content of guidelines for patients with acute abdomen. The objective was to describe and compare guidelines and management of patients with acute abdomen in different settings across the acute care delivery chain in Sweden. A national cross-sectional design was used. Twenty-nine ambulance stations, 17 emergency departments and 33 surgical wards covering all six Swedish health regions were included, and 23 guidelines were quality appraised using the validated Appraisal of Guidelines for Research & Evaluation II tool. There is a lack of guidelines in use for the management of this large group of patients between and within different healthcare areas across the acute care delivery chain. The quality appraisal identified that several guidelines were of poor quality, especially the in-hospital ones. Further, range orders for analgesics are common in the ambulance services and the surgical wards, but are seldom present in the emergency departments. Also, education in pain management is more common in the ambulance services. These findings are noteworthy as, hypothetically, the same patient could be treated in three different ways during the same care episode. There is an urgent need to develop high-quality evidence-based clinical guidelines for this patient group, with the entire care process in focus. © 2016 John Wiley & Sons, Ltd.
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Quality of Acute Care for Patients With Urinary Stones in the United States.
Scales, Charles D; Bergman, Jonathan; Carter, Stacey; Jack, Gregory; Saigal, Christopher S; Litwin, Mark S
2015-11-01
To describe guideline adherence for patients with suspected upper tract stones. We performed a cross-sectional analysis of visits recorded by the National Hospital Ambulatory Medical Care Survey (emergency department [ED] component) in 2007-2010 (most recent data). We assessed adherence to clinical guidelines for diagnostic laboratory testing, imaging, and pharmacologic therapy. Multivariable regression models controlled for important covariates. An estimated 4,956,444 ED visits for patients with suspected kidney stones occurred during the study period. Guideline adherence was highest for diagnostic imaging, with 3,122,229 (63%) visits providing optimal imaging. Complete guideline-based laboratory testing occurred in only 2 of every 5 visits. Pharmacologic therapy to facilitate stone passage was prescribed during only 17% of eligible visits. In multivariable analysis of guideline adherence, we found little variation by patient, provider, or facility characteristics. Guideline-recommended care was absent from a substantial proportion of acute care visits for patients with suspected kidney stones. These failures of care delivery likely increase costs and temporary disability. Targeted interventions to improve guideline adherence should be designed and evaluated to improve care for patients with symptomatic kidney stones. Published by Elsevier Inc.
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Quality of Acute Care for Patients with Urinary Stones in the United States
Scales, Charles D.; Bergman, Jonathan; Carter, Stacey; Jack, Gregory; Saigal, Christopher S.; Litwin, Mark S.
2015-01-01
Objective To describe guideline adherence for patients with suspected upper tract stones. Methods We performed a cross-sectional analysis of visits recorded by the National Hospital Ambulatory Medical Care Survey (ED component) in 2007–2010 (most recent data). We assessed adherence to clinical guidelines for diagnostic laboratory testing, imaging, and pharmacologic therapy. Multivariable regression models controlled for important covariates. Results An estimated 4,956,444 ED visits for patients with suspected kidney stones occurred during the study period. Guideline adherence was highest for diagnostic imaging, with 3,122,229 (63%) visits providing optimal imaging. Complete guideline-based laboratory testing occurred in only 2 of every 5 visits. Pharmacologic therapy to facilitate stone passage was prescribed during only 17% of eligible visits. In multivariable analysis of guideline adherence, we found little variation by patient, provider or facility characteristics. Conclusions Guideline-recommended care was absent from a substantial proportion of acute care visits for patients with suspected kidney stones. These failures of care delivery likely increase costs and temporary disability. Targeted interventions to improve guideline adherence should be designed and evaluated to improve care for patients with symptomatic kidney stones. PMID:26335495
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The delivery of clinical preventive services: acute care intervention.
Hahn, D L
1999-10-01
. Evidence-based clinical preventive services are underutilized. We explored the major factors associated with delivery of these services in a large physician-owned community-based group practice that provided care for both fee-for-service (FFS) and health maintenance organization (HMO) patient populations. We performed a cross-sectional audit of the computerized billing data of all adult outpatients seen at least once by any primary care provider in 1995 (N = 75,621). Delivery of preventive services was stratified by age, sex, visit frequency, insurance status (FFS or HMO), and visit type (acute care only or scheduled preventive visit). Insurance status and visit type were the strongest predictors of clinical preventive service delivery. Patients with FFS coverage received 6% to 13% (absolute difference) fewer of these services than HMO patients. Acute-care-only patients received 9% to 45% fewer services than patients who scheduled preventive visits. The combination of these factors was associated with profound differences. Having insurance to pay for preventive services is an important factor in the delivery of such care. Encouraging all patients to schedule preventive visits has been suggested as a strategy for increasing delivery, but that is not practical in this setting. Assessing the need for preventive services and offering them during acute care visits has equal potential for increasing delivery.
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Design characteristics of acute care units in china.
Lu, Yi; Wang, Yijia
2014-01-01
To describe the current state of design characteristics of acute care units in China's public hospitals and compare these with characteristics with acute care units in the United States. The healthcare construction industry in China is one of the fastest growing sectors in China and, arguably, in the world. Understanding the physical design of acute care units in China is of great importance because it will influence a large population. Descriptive study was performed of unit configuration, size, patient visibility, distance to nursing station and supplies, and lighting conditions in 25 units in 19 public hospitals built after 2003. Data and information were collected based on spatial and visibility analysis. The study identified major design characteristics of the recently built (from 2003 onward) acute care units in China, comparing them, where appropriate, with those in U.S. It found there are three dominant types of unit layout: single-corridor (52%), triangular (36%), and double-corridor (12%). The number of private rooms is very low (11%), compared with two- or three-bed rooms. Centralized nursing stations are the only type of nurses' working area. China also has a large unit size in terms of number of patient beds. The average number of patient beds in a unit is 40.6 in China (versus 32.9 in U.S.). The care units in China have longer walking distance from nursing station to patient bedside. The percentage of beds visible from a nursing station is lower in China than in the U.S. The access to natural light and direct sunlight in patient rooms is greater in China compared with those in U.S.-100% of patient rooms in China have natural lighting. A majority of them face south or southeast and thus receiving direct sunlight (91.4%). Because of the differences in economies and building codes, there are dramatic differences between the spatial characteristics of acute care units in China and the United States. © 2014 Vendome Group, LLC.
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Patel, Payal K; Mantey, Julia; Mody, Lona
2017-09-01
We assessed multidrug-resistant organism (MDRO) patient hand colonization in relation to the environment in post-acute care to determine risk factors for MDRO hand colonization. Patient hand colonization was significantly associated with environmental contamination. Risk factors for hand colonization included disability, urinary catheter, recent antibiotic use, and prolonged hospital stay. Infect Control Hosp Epidemiol 2017;38:1110-1113.
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Maggio, Marcello; Corsonello, Andrea; Ceda, Gian Paolo; Cattabiani, Chiara; Lauretani, Fulvio; Buttò, Valeria; Ferrucci, Luigi; Bandinelli, Stefania; Abbatecola, Angela Marie; Spazzafumo, Liana; Lattanzio, Fabrizia
2013-04-08
The use of proton pump inhibitors (PPIs) has rapidly increased during the past several years. However, concern remains about risks associated with their long-term use in older populations. To investigate the relationship between the use of PPIs and the risk of death or the combined end point of death or rehospitalization in older patients discharged from acute care hospitals. We investigated the relationship between PPI use and study outcomes using time-dependent Cox proportional hazards regression in patients 65 years or older discharged from acute care medical wards from April 1 to June 30, 2007. Eleven acute care medical wards. Four hundred ninety-one patients (mean [SD] age, 80.0 [5.9] years). Mortality and the combined end point of death or rehospitalization. RESULTS The use of PPIs was independently associated with mortality (hazard ratio, 1.51 [95% CI, 1.03-2.77]) but not with the combined end point (1.49 [0.98-2.17]). An increased risk of mortality was observed among patients exposed to high-dose PPIs vs none (hazard ratio, 2.59 [95% CI, 1.22-7.16]). In older patients discharged from acute care hospitals, the use of high-dose PPIs is associated with increased 1-year mortality. Randomized controlled studies including older frail patients are needed. In the meantime, physicians need to use caution and balance benefits and harms in long-term prescription of high-dose PPIs.
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Inpatient palliative care for patients with acute heart failure: outcomes from a randomized trial.
Sidebottom, Abbey C; Jorgenson, Ann; Richards, Hallie; Kirven, Justin; Sillah, Arthur
2015-02-01
Heart failure (HF) is associated with a high symptom burden and reduced quality of life (QOL). Models integrating palliative care (PC) into HF care have been proposed, but limited research is available on the outcomes of such models. Our aim was to assess if inpatient PC for HF patients is associated with improvements in symptom burden, depressive symptoms, QOL, or differential use of services. Patients hospitalized with acute HF were randomized to receive a PC consult with follow-up as determined by provider or standard care. Two hundred thirty-two patients (116 intervention/116 control) from a large tertiary-care urban hospital were recruited over a 10-month period. Primary outcomes were symptom burden, depressive symptoms, and QOL measured at baseline, 1, and 3 months. Secondary outcomes included advance care planning (ACP), inpatient 30-day readmission, hospice use, and death. Improvements were greater at both 1 and 3 months in the intervention group for primary outcome summary measures after adjusting for age, gender, and marital status differences between study groups. QOL scores increased by 12.92 points in the intervention and 8 points in the control group at 1 month (difference+4.92, p<0.001). Improvement in symptom burden was 8.39 in the intervention group and 4.7 in the control group at 1 month (+3.69, p<0.001). ACP was the only secondary outcome associated with the intervention (hazard ratio [HR] 2.87, p=0.033). An inpatient PC model for patients with acute HF is associated with short-term improvement in symptom burden, QOL, and depressive symptoms.
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Zabawa, Claire; Cottenet, Jonathan; Zeller, Marianne; Mercier, Grégoire; Rodwin, Victor G; Cottin, Yves; Quantin, Catherine
2018-06-01
Rehospitalization after acute myocardial infarction (AMI) is common in elderly patients. It increases morbimortality and health care expenditures. The association between ambulatory care after discharge for AMI and rehospitalization has never been studied in France. We analyzed the impact of ambulatory care on rehospitalization of elderly patients (≥65 years) within 30 days after hospital discharge.We conducted a nationwide population-based study of elderly patients hospitalized with a main diagnosis of AMI in France between 2011 and 2013. We excluded patients hospitalized for AMI in the previous year and those who died during the index hospitalization or within 30 days after discharge. The primary outcome was the first all-cause 30-day rehospitalization in an acute care hospital. Individual and neighborhood-level variables were compared among rehospitalized and nonrehospitalized patients. Determinants of 30-day rehospitalization were identified using logistic regression models.Among the 624 eligible patients, 137 (22.0%) were rehospitalized within 30 days after discharge. In multivariate analyses, chronic kidney failure (odds ratio [OR] 1.88; 95% confidence interval [CI], 1.01-3.53) was an independent predictor of 30-day rehospitalization. We found no association among deprivation and spatial accessibility measures and 30-day rehospitalization. The purchase of lipid-lowering drugs prescription within 7 days after discharge was associated with a reduced risk of 30-day rehospitalization (OR 0.53; 95% CI, 0.36-0.79).This study highlights the role of coordination among hospital and primary care physicians in post-AMI discharge and follow-up among elderly patients. Specifically, targeted interventions to reduce 30-day rehospitalizations should focus on patients with comorbidities and use of prescription drugs after hospital discharge.
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Zagidullin, B I; Khairullin, I I; Stanichenko, N S; Zagidullin, I M; Zagidullin, N Sh
2016-01-01
In Naberezhnye Chelny, a number of structural and technological reformations of service of emergency medical care was implemented in 2009-2012. The reformation manifested in organization of unified emergency center of medical care of patients with acute coronary syndrome; joining up of cardiological departments of two hospitals; organization of X-ray surgical department; enhancement of logistics of admission department and interaction with emergency medical care; optimization of mode of medical care rendering at pre-hospital and hospital stages. The implemented reforms permitted increasing accessibility and timeliness of reperfusion therapy under acute coronary syndrome; to implement transcutaneous coronary interventions into practice and increase their number annually; to decrease “door-balloon” index up to 30-40%. As a result, lethality of acute myocardium infarction decreased from 12 to 3 to 5.8% in 2010-2014.
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General and acute care surgical procedures in patients with left ventricular assist devices.
Arnaoutakis, George J; Bittle, Gregory J; Allen, Jeremiah G; Weiss, Eric S; Alejo, Jennifer; Baumgartner, William A; Shah, Ashish S; Wolfgang, Christopher L; Efron, David T; Conte, John V
2014-04-01
Left ventricular assist devices (LVADs) have become common as a bridge to heart transplant as well as destination therapy. Acute care surgical (ACS) problems in this population are prevalent but remain ill-defined. Therefore, we reviewed our experience with ACS interventions in LVAD patients. A total of 173 patients who received HeartMate(®) XVE or HeartMate(®) II (HMII) LVADs between December 2001 and March 2010 were studied. Patient demographics, presentation of ACS problem, operative intervention, co-morbidities, transplantation, complications, and survival were analyzed. A total of 47 (27 %) patients underwent 67 ACS procedures at a median of 38 days after device implant (interquartile range 15-110), with a peri-operative mortality rate of 5 % (N = 3). Demographics, device type, and acuity were comparable between the ACS and non-ACS groups. A total of 21 ACS procedures were performed emergently, eight were urgent, and 38 were elective. Of 29 urgent and emergent procedures, 28 were for abdominal pathology. In eight patients, the cause of the ACS problem was related to LVADs or anticoagulation. Cumulative survival estimates revealed no survival differences if patients underwent ACS procedures (p = 0.17). Among HMII patients, transplantation rates were unaffected by an ACS intervention (p = 0.2). ACS problems occur frequently in LVAD patients and are not associated with adverse outcomes in HMII patients. The acute care surgeon is an integral member of a comprehensive approach to effective LVAD management.
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Initiating and optimizing acute therapy for migraine: the role of patient-centered stratified care.
Diamond, Merle; Cady, Roger
2005-03-01
Migraine is a chronic, intermittently disabling condition that affects physical, mental, and social aspects of health-related quality of life. Because patients seeking assistance with migraine most often present to primary care providers, these healthcare professionals play critical roles in the diagnosis and treatment process. A comprehensive migraine management plan involves a partnership between the patient and healthcare professional where treatment goals and strategies are established. Elements of such a plan should include preventive strategies to reduce the frequency and effects of future attacks as well as the use of acute treatments to address the immediate need for relief during an attack. Approaches to prevention include education, lifestyle modification, and, often, appropriate medication. Many medications have been used for acute treatment. Nonspecific agents include nonsteroidal anti-inflammatory drugs (NSAIDs), single or combination analgesics (sometimes including antiemetics or caffeine), and narcotics. Migraine-specific medications include ergot alkaloids and triptans (5-hydroxytryptamine(1B/1D) agonists). Various professional organizations have created guidelines to help providers in choosing appropriate management interventions. Clinical approaches to the patient with migraine include step care, whereby all patients begin on a simple or nonspecific treatment, stepping up to the next level of therapy if treatment is unsuccessful; or stratified care, whereby first-line therapy is tailored to the severity of the patient's pattern of headache. Studies have demonstrated that for more disabled headache patients, the stratified-care approach results in more robust headache response with less disability and greater cost-effectiveness than step care. Patient satisfaction studies demonstrate that the use of migraine-specific abortive medications (triptans) is associated with a higher satisfaction rate than over-the-counter preparations, NSAIDs, and
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Costs of terminal patients who receive palliative care or usual care in different hospital wards.
Simoens, Steven; Kutten, Betty; Keirse, Emmanuel; Berghe, Paul Vanden; Beguin, Claire; Desmedt, Marianne; Deveugele, Myriam; Léonard, Christian; Paulus, Dominique; Menten, Johan
2010-11-01
In addition to the effectiveness of hospital care models for terminal patients, policy makers and health care payers are concerned about their costs. This study aims to measure the hospital costs of treating terminal patients in Belgium from the health care payer perspective. Also, this study compares the costs of palliative and usual care in different types of hospital wards. A multicenter, retrospective cohort study compared costs of palliative care with usual care in acute hospital wards and with care in palliative care units. The study enrolled terminal patients from a representative sample of hospitals. Health care costs included fixed hospital costs and charges relating to medical fees, pharmacy and other charges. Data sources consisted of hospital accountancy data and invoice data. Six hospitals participated in the study, generating a total of 146 patients. The findings showed that palliative care in a palliative care unit was more expensive than palliative care in an acute ward due to higher staffing levels in palliative care units. Palliative care in an acute ward is cheaper than usual care in an acute ward. This study suggests that palliative care models in acute wards need to be supported because such care models appear to be less expensive than usual care and because such care models are likely to better reflect the needs of terminal patients. This finding emphasizes the importance of the timely recognition of the need for palliative care in terminal patients treated in acute wards.
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Acute care hospitals' accountability to provincial funders.
Kromm, Seija K; Ross Baker, G; Wodchis, Walter P; Deber, Raisa B
2014-09-01
Ontario's acute care hospitals are subject to a number of tools, including legislation and performance measurement for fiscal accountability and accountability for quality. Examination of accountability documents used in Ontario at the government, regional and acute care hospital levels reveals three trends: (a) the number of performance measures being used in the acute care hospital sector has increased significantly; (b) the focus of the health system has expanded from accountability for funding and service volumes to include accountability for quality and patient safety; and (c) the accountability requirements are misaligned at the different levels. These trends may affect the success of the accountability approach currently being used. Copyright © 2014 Longwoods Publishing.
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[Detection of palliative care needs in an acute care hospital unit. Pilot study].
Rodríguez-Calero, Miguel Ángel; Julià-Mora, Joana María; Prieto-Alomar, Araceli
2016-01-01
Previous to wider prevalence studies, we designed the present pilot study to assess concordance and time invested in patient evaluations using a palliative care needs assessment tool. We also sought to estimate the prevalence of palliative care needs in an acute care hospital unit. A cross-sectional study was carried out, 4 researchers (2 doctors and 2 nurses) independently assessed all inpatients in an acute care hospital unit in Manacor Hospital, Mallorca (Spain), using the validated tool NECPAL CCOMS-ICO©, measuring time invested in every case. Another researcher revised clinical recordings to analise the sample profile. Every researcher assessed 29 patients, 15 men and 14 women, mean age 74,03 ± 10.25 years. 4-observer concordance was moderate (Kappa 0,5043), tuning out to be higher between nurses. Mean time per patient evaluation was 1.9 to 7.72 minutes, depending on researcher. Prevalence of palliative care needs was 23,28%. Moderate concordance lean us towards multidisciplinary shared assessments as a method for future research. Avarage of time invested in evaluations was less than 8 minutes, no previous publications were identified regarding this variable. More than 20% of inpatients of the acute care unit were in need of palliative care. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.
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An analysis of clinical outcomes and costs of a long term acute care hospital.
Votto, John J; Scalise, Paul J; Barton, Randall W; Vogel, Cristine A
2011-01-01
Compare clinical outcomes and costs in a study group of long-term acute care hospital (LTCH) patients with a control group of LTCH-eligible patients in an acute care hospital. LTCHs were created to provide post-acute care services not available at other post-acute settings. This is based on the premise that these patients would otherwise have stayed at acute care hospitals as high-cost outliers. The LTCH hospital is intended to deliver care to patients more efficiently, however, there are little documented clinical and financial data regarding the comparative clinical outcomes and costs for patients. Retrospective medical and billing record review of patients from the following groups: (1) LTCH study comprising patients admitted directly from an acute care hospital to the study LTCH and discharged from the LTCH from September 2004 through August 2006; (2) a control group of LTCH-eligible, medically complex patients treated and discharged from an acute care hospital in FY 2002. The control group was selected from approximately 500 patients who had at least one of the ten most common principle diagnosis DRGs of the study LTCH with >30-day length of stay at the referring hospital and met NALTH admitting guidelines. Discharge disposition is an important outcome measure of the quality of care of medically complex patients. The in-hospital mortality rate trended lower and home discharge was 3 times higher for the LTCH study group than for the control group. As a possible result, SNF discharge of LTCH patients was approximately half that of the control group. Both mean patient cost per day and mean total cost per patient were significantly higher in the control group than in the LTCH study group. The patients in the LTCH study group had both better clinical outcomes and lower cost of care than the control group.
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Examination of the Use of Healing Touch by Registered Nurses in the Acute Care Setting.
Anderson, Joel G; Friesen, Mary Ann; Swengros, Diane; Herbst, Anna; Mangione, Lucrezia
2017-03-01
Acute care nursing is currently undergoing unprecedented change, with health systems becoming more open to nonpharmacological approaches to patient care. Healing Touch (HT) may be a valuable intervention for acute care patients. Research has shown that HT helps both the patient and the caregiver; however, no study to date has examined the impact that the education of nurses in and their use of HT have on daily care delivery in the acute care setting. The purpose of the current qualitative study was to examine the use of HT by registered nurses in the acute care setting during their delivery of patient care, as well as the impact of education in and use of HT on the nurses themselves. Five themes were identified: (1) use of HT techniques, processes, and sequence; (2) outcomes related to HT; (3) integration of HT into acute care nursing practice; (4) perceptions of HT, from skepticism to openness; and (5) transformation through HT. Education in HT and delivery of this modality by nurses in the acute care setting provide nurses with a transformative tool to improve patient outcomes.
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Murata, Kyoko; Hinotsu, Shiro; Sadamasa, Nobutake; Yoshida, Kazumichi; Yamagata, Sen; Asari, Shoji; Miyamoto, Susumu; Kawakami, Koji
2017-02-01
To investigate healthcare resource utilization and changes in functional status in stroke patients during hospitalization in an acute hospital and a rehabilitation hospital. Retrospective cohort study. One acute and one rehabilitation hospital in Japan. Patients who were admitted to the acute hospital due to stroke onset and then transferred to the rehabilitation hospital (n = 263, 56% male, age 70 ± 12 years). Hospitalization costs and functional independence measure (FIM) were evaluated according to stroke subtype and severity of disability at discharge from the acute hospital. Median (IQR) costs at the acute hospital were dependent on the length of stay (LOS) and implementation of neurosurgery, which resulted in higher costs in subarachnoid hemorrhage [$52 413 ($49 166-$72 606) vs $14 129 ($11 169-$19 459) in cerebral infarction; and vs $15 035 ($10 920-$21 864) in intracerebral hemorrhage]. The costs at the rehabilitation hospital were dependent on LOS, and higher in patients with moderate disability than in those with mild disability [$30 026 ($18 419-$39 911) vs $18 052 ($10 631-$24 384)], while those with severe disability spent $25 476 ($13 340-$43 032). Patients with moderate disability gained the most benefits during hospitalization in the rehabilitation hospital, with a median (IQR) total FIM gain of 16 (5-24) points, compared with a modest improvement in patients with mild (6, 2-14) or severe disability (0, 0-5). The costs for in-hospital stroke care were substantial and the improvement in functional status varied by severity of disability. Our findings would be valuable to organize efficient post-acute stroke care. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
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Hutchinson, A; Brand, C; Irving, L; Roberts, C; Thompson, P; Campbell, D
2010-05-01
In 2003, chronic obstructive pulmonary disease (COPD) accounted for 46% of the burden of chronic respiratory disease in the Australian community. In the 65-74-year-old age group, COPD was the sixth leading cause of disability for men and the seventh for women. To measure the influence of disease severity, COPD phenotype and comorbidities on acute health service utilization and direct acute care costs in patients admitted with COPD. Prospective cohort study of 80 patients admitted to the Royal Melbourne Hospital in 2001-2002 for an exacerbation of COPD. Patients were followed for 12 months and data were collected on acute care utilization. Direct hospital costs were derived using Transition II, an activity-based costing system. Individual patient costs were then modelled to ascertain which patient factors influenced total direct hospital costs. Direct costs were calculated for 225 episodes of care, the median cost per admission was AU$3124 (interquartile range $1393 to $5045). The median direct cost of acute care management per patient per year was AU$7273 (interquartile range $3957 to $14 448). In a multivariate analysis using linear regression modelling, factors predictive of higher annual costs were increasing age (P= 0.041), use of domiciliary oxygen (P= 0.008) and the presence of chronic heart failure (P= 0.006). This model has identified a number of patient factors that predict higher acute care costs and awareness of these can be used for service planning to meet the needs of patients admitted with COPD.
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Evaluation of Patient and Proxy Responses on the Activity Measure for Post Acute Care
Jette, Alan M.; Ni, Pengsheng; Rasch, Elizabeth K.; Appelman, Jed; Sandel, M. Elizabeth; Terdiman, Joseph; Chan, Leighton
2012-01-01
Background and Purpose Our objective was to examine the agreement between adult patients with stroke and family member or clinician proxies in Activity Measure for Post Acute Care (AM-PAC) summary scores for daily activity, basic mobility, and applied cognitive function. Methods This study involved 67 patients with stroke admitted to a hospital within the Kaiser Permanente of Northern California system and were participants in a parent study on stroke outcomes. Each participant and proxy respondent completed the AM-PAC by personal or telephone interview at the point of hospital discharge and/or during one or more transitions to different post-acute care settings. Results The results suggest that for patients with a stroke proxy AM-PAC data are robust for family or clinician proxy assessment of basic mobility function, clinician proxy assessment of daily activity function, but less robust for family proxy assessment of daily activity function and for all proxy groups’ assessment of applied cognitive function. The pattern of disagreement between patient and proxy was, on average, relatively small and random. There was little evidence of systematic bias between proxy and patient reports of their functional status. The degree of concordance between patient and proxy was similar for those with moderate to severe strokes compared with mild strokes. Conclusions Patient and proxy ratings on the AM-PAC achieved adequate agreement for use in stroke research where using proxy respondents could reduce sample selection bias. The AM-PAC data can be implemented across institutional as well as community care settings while achieving precision and reducing respondent burden. PMID:22343646
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Why do patients in acute care hospitals fall? Can falls be prevented?
Dykes, Patricia C; Carroll, Diane L; Hurley, Ann C; Benoit, Angela; Middleton, Blackford
2009-06-01
Obtain the views of nurses and assistants as to why patients in acute care hospitals fall. Despite a large quantitative evidence base for guiding fall risk assessment and not needing highly technical, scarce, or expensive equipment to prevent falls, falls are serious problems in hospitals. Basic content analysis methods were used to interpret descriptive data from 4 focus groups with nurses (n = 23) and 4 with assistants (n = 19). A 2-person consensus approach was used for analysis. Positive and negative components of 6 concepts-patient report, information access, signage, environment, teamwork, and involving patient/family-formed 2 core categories: knowledge/ communication and capability/actions that are facilitators or barriers, respectively, to preventing falls. Two conditions are required to reduce patient falls. A patient care plan including current and accurate fall risk status with associated tailored and feasible interventions needs to be easily and immediately accessible to all stakeholders (entire healthcare team, patients, and family). Second, stakeholders must use that information plus their own knowledge and skills and patient and hospital resources to carry out the plan.
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Cooke, Mary; Hurley, Ciarán
2008-05-01
We aimed to identify policy, process and ethical issues related to allocation of National Health Service resources when patients with end-of-life illness are referred to acute care services. Sharing healthcare decisions denotes a different partnership between professionals and patients when patients are empowered to define their needs. Implementation of a transition from professional to patient decision-making appears to be dependent upon its interpretation by personnel delivering care using the local trust policy. The outcome of this is a reformation of responsibility for budget allocation, choice of acute care provider and selecting services, currently in the realm of primary care; be it the general practitioner, community practitioners, or the patient. We used a 'lens' approach to case study analysis in which the lens is constructed of a model of policy analysis and four principles of biomedical ethics. A patient's decision to decline care proposed by an Accident and Emergency department nurse and the nurse's response to that decision expose a policy that restricts the use of ambulance transport and with that, flexibility in responses to patients' decisions. End-of-life care partnership decisions require sensitivity and flexibility from all healthcare practitioners. We found that policy-based systems currently used to deliver care across the primary care - hospital care border are far from seamless and can lead to foreseeable problems. Health professionals responsible for the care of a patient at the end of life should consider the holistic outcomes of resource allocation decisions for patients. Government and health professional agenda suggest that patients should be given a greater element of control over their healthcare than has historically been the case. When patients take responsibility for their decisions, healthcare personnel should recognize that this signals a shift in the nature of the professional-patient relationship to one of partnership.
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A Conceptual Model for Episodes of Acute, Unscheduled Care.
Pines, Jesse M; Lotrecchiano, Gaetano R; Zocchi, Mark S; Lazar, Danielle; Leedekerken, Jacob B; Margolis, Gregg S; Carr, Brendan G
2016-10-01
We engaged in a 1-year process to develop a conceptual model representing an episode of acute, unscheduled care. Acute, unscheduled care includes acute illnesses (eg, nausea and vomiting), injuries, or exacerbations of chronic conditions (eg, worsening dyspnea in congestive heart failure) and is delivered in emergency departments, urgent care centers, and physicians' offices, as well as through telemedicine. We began with a literature search to define an acute episode of care and to identify existing conceptual models used in health care. In accordance with this information, we then drafted a preliminary conceptual model and collected stakeholder feedback, using online focus groups and concept mapping. Two technical expert panels reviewed the draft model, examined the stakeholder feedback, and discussed ways the model could be improved. After integrating the experts' comments, we solicited public comment on the model and made final revisions. The final conceptual model includes social and individual determinants of health that influence the incidence of acute illness and injury, factors that affect care-seeking decisions, specific delivery settings where acute care is provided, and outcomes and costs associated with the acute care system. We end with recommendations for how researchers, policymakers, payers, patients, and providers can use the model to identify and prioritize ways to improve acute care delivery. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
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Lind, Susanne; Sandberg, J; Brytting, T; Fürst, C J; Wallin, L
2018-01-21
Although hospitals have been described as inadequate place for end-of-life care, many deaths still occur in hospital settings. Although patient-reported outcome measures have shown positive effects for patients in need of palliative care, little is known about how to implement them. We aimed to explore the feasibility of a pilot version of an implementation strategy for the Integrated Palliative care Outcome Scale (IPOS) in acute care settings. A strategy, including information, training, and facilitation to support the use of IPOS, was developed and carried out at three acute care units. For an even broader understanding of the strategy, it was also tested at a palliative care unit. A process evaluation was conducted including collecting quantitative data and performing interviews with healthcare professionals. Result Factors related to the design and performance of the strategy and the context contributed to the results. The prevalence of completed IPOS in the patient's records varied from 6% to 44% in the acute care settings. At the palliative care unit, the prevalence in the inpatient unit was 53% and the specialized home care team 35%. The qualitative results showed opposing perspectives concerning the training provided: Related to everyday work at the acute care units and Nothing in it for us at the palliative care unit. In the acute care settings, A need for an improved culture regarding palliative care was identified. A context characterized by A constantly increasing workload, a feeling of Constantly on-going changes, and a feeling of Change fatigue were found at all units. Furthermore, the internal facilitators and the nurse managers' involvement in the implementation differed between the units. Significance of the results The feasibility of the strategy in our study is considered to be questionable and the components need to be further explored to enhance the impact of the strategy and thereby improve the use of IPOS.
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PAs and NPs in an emergency room-linked acute care clinic.
Currey, C J
1984-12-01
The use of hospital emergency rooms for nonurgent care during evenings hours often strains medical resources and may affect the quality of emergency care. One facility's effective use of an after-hours acute care clinic staffed by PAs and NPs to divert nonurgent problems away from its emergency room is outlined. PAs and NPs work during peak demand hours (evenings and weekends) under the supervision of an emergency room physician, and receive supplementary support from other emergency room personnel. Incoming patients are referred to the emergency room or acute care clinic, depending on the nature of their problems. Acute care clinic patients are then treated by the PA or NP and either released or referred to an emergency room physician, if their conditions warrant additional treatment. As a result, use of the acute care clinic has greatly reduced the amount of non-urgent medical treatment in the emergency room and has provided other advantages to both patients and staff as well. These advantages and the encouraging statistics following six months of the clinic's operation are discussed.
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Brooks, Gabriel A.; Li, Ling; Uno, Hajime; Hassett, Michael J.; Landon, Bruce E.; Schrag, Deborah
2014-01-01
The root causes of regional variation in medical spending are poorly understood and vary by clinical condition. To identify drivers of regional spending variation for Medicare patients with advanced cancer, we used linked Surveillance, Epidemiology, and End Results (SEER) program–Medicare data from 2004–10. We broke down Medicare spending into thirteen cancer-relevant service categories. We then calculated the contribution of each category to spending and regional spending variation. Acute hospital care was the largest component of spending and the chief driver of regional spending variation, accounting for 48 percent of spending and 67 percent of variation. In contrast, chemotherapy accounted for 16 percent of spending and 10 percent of variation. Hospice care comprised 5 percent of spending; however variation in hospice spending was fully offset by opposing variation in other categories. Our analysis suggests that the strategy with the greatest potential to improve the value of care for patients with advanced cancer is to reduce reliance on acute hospital care for this patient population. PMID:25288424
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All patient refined-diagnostic related group and case mix index in acute care palliative medicine.
Lagman, Ruth L; Walsh, Declan; Davis, Mellar P; Young, Brett
2007-03-01
The All Patient Refined-Diagnostic Related Group (APR-DRG) is a modification of the traditional DRG that adds four classes of illness severity and four classes of mortality risk. The APR-DRG is a more accurate assessment of the complexity of care. When individuals with advanced illness are admitted to an acute inpatient palliative medicine unit, there may be a perception that they receive less intense acute care. Most of these patients, however, are multisymptomatic, have several comorbidities, and are older. For all patients admitted to the unit, a guide was followed by staff physicians to document clinical information that included the site(s) of malignancy, site(s) of metastases, disease complications, disease-related symptoms, and comorbidities. We then prospectively compared DRGs, APR-DRGs, and case mix index (CMI) from January 1-June 30, 2003, and February 1-July 31,2004, before and after the use of the guide. The overall mean severity of illness (ASOI) increased by 25% (P < 0.05). The mean CMI increased by 12% (P < 0.05). The average length of stay over the same period increased slightly from 8.97 to 9.56 days. Systematic documentation of clinical findings using a specific tool for patients admitted to an acute inpatient palliative medicine unit based on APR-DRG classifications captured a higher severity of illness and may better reflect resource utilization.
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Use of chest sonography in acute-care radiology☆
De Luca, C.; Valentino, M.; Rimondi, M.R.; Branchini, M.; Baleni, M. Casadio; Barozzi, L.
2008-01-01
Diagnosis of acute lung disease is a daily challenge for radiologists working in acute-care areas. It is generally based on the results of chest radiography performed under technically unfavorable conditions. Computed tomography (CT) is undoubtedly more accurate in these cases, but it cannot always be performed on critically ill patients who need continuous care. The use of thoracic ultrasonography (US) has recently been proposed for the study of acute lung disease. It can be carried out rapidly at the bedside and does not require any particularly sophisticated equipment. This report analyzes our experience with chest sonography as a supplement to chest radiography in an Emergency Radiology Unit. We performed chest sonography – as an adjunct to chest radiography – on 168 patients with acute chest pathology. Static and dynamic US signs were analyzed in light of radiographic findings and, when possible, CT. The use of chest US improved the authors' ability to provide confident diagnoses of acute disease of the chest and lungs. PMID:23397048
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Fluid accumulation during acute kidney injury in the intensive care unit.
Berthelsen, R E; Perner, A; Jensen, A K; Jensen, J-U; Bestle, M H
2018-07-01
Fluid therapy is a ubiquitous intervention in patients admitted to the intensive care unit, but positive fluid balance may be associated with poor outcomes and particular in patients with acute kidney injury. Studies describing this have defined fluid overload either at specific time points or considered patients with a positive mean daily fluid balance as fluid overloaded. We wished to detail this further and performed joint model analyses of the association between daily fluid balance and outcome represented by mortality and renal recovery in patients admitted with acute kidney injury. We did a retrospective cohort study of patients admitted to the intensive care unit with acute kidney injury during a 2-year observation period. We used serum creatinine measurements to identify patients with acute kidney injury and collected sequential daily fluid balance during the first 5 days of admission to the intensive care unit. We used joint modelling techniques to correlate the development of fluid overload with survival and renal recovery adjusted for age, gender and disease severity. The cohort contained 863 patients with acute kidney injury of whom 460 (53%) and 254 (29%) developed 5% and 10% fluid overload, respectively. We found that both 5% and 10% fluid overload was correlated with reduced survival and renal recovery. Joint model analyses of fluid accumulation in patients admitted to the intensive care unit with acute kidney injury confirm that even a modest degree of fluid overload (5%) may be negatively associated with both survival and renal recovery. © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.
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Franklin, Matthew; Berdunov, Vladislav; Edmans, Judi; Conroy, Simon; Gladman, John; Tanajewski, Lukasz; Gkountouras, Georgios; Elliott, Rachel A
2014-09-01
acute medical units allow for those who need admission to be correctly identified, and for those who could be managed in ambulatory settings to be discharged. However, re-admission rates for older people following discharge from acute medical units are high and may be associated with substantial health and social care costs. identifying patient-level health and social care costs for older people discharged from acute medical units in England. a prospective cohort study of health and social care resource use. an acute medical unit in Nottingham, England. four hundred and fifty-six people aged over 70 who were discharged from an acute medical unit within 72 h of admission. hospitalisation and social care data were collected for 3 months post-recruitment. In Nottingham, further approvals were gained to obtain data from general practices, ambulance services, intermediate care and mental healthcare. Resource use was combined with national unit costs. costs from all sectors were available for 250 participants. The mean (95% CI, median, range) total cost was £1926 (1579-2383, 659, 0-23,612). Contribution was: secondary care (76.1%), primary care (10.9%), ambulance service (0.7%), intermediate care (0.2%), mental healthcare (2.1%) and social care (10.0%). The costliest 10% of participants accounted for 50% of the cost. this study highlights the costs accrued by older people discharged from acute medical units (AMUs): they are mainly (76%) in secondary care and half of all costs were incurred by a minority of participants (10%). © The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.
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2010-01-01
Background Management decisions regarding quality and quantity of nurse staffing have important consequences for hospital budgets. Furthermore, these management decisions must address the nursing care requirements of the particular patients within an organizational unit. In order to determine optimal nurse staffing needs, the extent of nursing workload must first be known. Nursing workload is largely a function of the composite of the patients' individual health status, particularly with respect to functioning status, individual need for nursing care, and severity of symptoms. The International Classification of Functioning, Disability and Health (ICF) and the derived subsets, the so-called ICF Core Sets, are a standardized approach to describe patients' functioning status. The objectives of this study were to (1) examine the association between patients' functioning, as encoded by categories of the Acute ICF Core Sets, and nursing workload in patients in the acute care situation, (2) compare the variance in nursing workload explained by the ICF Core Set categories and with the Barthel Index, and (3) validate the Acute ICF Core Sets by their ability to predict nursing workload. Methods Patients' functioning at admission was assessed using the respective Acute ICF Core Set and the Barthel Index, whereas nursing workload data was collected using an established instrument. Associations between dependent and independent variables were modelled using linear regression. Variable selection was carried out using penalized regression. Results In patients with neurological and cardiopulmonary conditions, selected ICF categories and the Barthel Index Score explained the same variance in nursing workload (44% in neurological conditions, 35% in cardiopulmonary conditions), whereas ICF was slightly superior to Barthel Index Score for musculoskeletal conditions (20% versus 16%). Conclusions A substantial fraction of the variance in nursing workload in patients with rehabilitation
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Medicare's post-acute care payment: a review of the issues and policy proposals.
Linehan, Kathryn
2012-12-07
Medicare spending on post-acute care provided by skilled nursing facility providers, home health providers, inpatient rehabilitation facility providers, and long-term care hospitals has grown rapidly in the past several years. The Medicare Payment Advisory Commission and others have noted several long-standing problems with the payment systems for post-acute care and have suggested refinements to Medicare's post-acute care payment systems that are intended to encourage the delivery of appropriate care in the right setting for a patient's condition. The Patient Protection and Affordable Care Act of 2010 contained several provisions that affect the Medicare program's post-acute care payment systems and also includes broader payment reforms, such as bundled payment models. This issue brief describes Medicare's payment systems for post-acute care providers, evidence of problems that have been identified with the payment systems, and policies that have been proposed or enacted to remedy those problems.
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Flat inferior vena cava: indicator of poor prognosis in trauma and acute care surgery patients.
Ferrada, Paula; Vanguri, Poornima; Anand, Rahul J; Whelan, James; Duane, Therese; Wolfe, Luke; Ivatury, Rao
2012-12-01
Flat inferior vena cava (IVC) on ultrasound examination has been shown to correlate with hypovolemic status. We hypothesize that a flat IVC on limited echocardiogram (LTTE) performed in the emergency room (ER) correlates with poor prognosis in acutely ill surgical patients. We conducted a retrospective review of all patients undergoing LTTE in the ER from September 2010 until June 2011. IVC diameter was estimated by subxiphoid window. Flat IVC was defined as diameter less than 2 cm. Fat IVC was defined as diameter greater than 2 cm. Need for intensive care unit admission, blood transfusion requirement, mortality, and need for emergent operation between patients with flat versus Fat IVC were compared. One hundred one hypotensive patients had LTTE performed in the ER. Average age was 38 years. Admission diagnosis was blunt trauma (n = 80), penetrating trauma (n = 13), acute care surgery pathology (n = 7), and burn (n = 1). Seventy-four patients had flat IVC on initial LTTE. Compared with those with fat IVC, flat patients were found have higher rates of intensive care unit admission (51.3 vs 14.8%; P = 0.001), blood transfusion requirement (12.2 vs 3.7%), and mortality (13.5 vs 3.7%). This population also underwent emergent surgery on hospital Day 1 more often (16.2 vs 0%; P = 0.033). Initial flat IVC on LTTE is an indicator of hypovolemia and a predictor of poor outcome.
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Cardiac acute care nurse practitioner and 30-day readmission.
David, Daniel; Britting, Lorraine; Dalton, Joanne
2015-01-01
The utilization outcomes of nurse practitioners (NPs) in the acute care setting have not been widely studied. The purpose of this study was to determine the impact on utilization outcomes of NPs on medical teams who take care of patients admitted to a cardiovascular intensive care unit. A retrospective 2-group comparative design was used to evaluate the outcomes of 185 patients with ST- or non ST-segment elevation myocardial infarction or heart failure who were admitted to a cardiovascular intensive care unit in an urban medical center. Patients received care from a medical team that included a cardiac acute care NP (n = 109) or medical team alone (n = 76). Patient history, cardiac assessment, medical interventions, discharge disposition, discharge time, and 3 utilization outcomes (ie, length of stay, 30-day readmission, and time of discharge) were compared between the 2 treatment groups. Logistic regression was used to identify predictors of 30-day readmission. Patients receiving care from a medical team that included an NP were rehospitalized approximately 50% less often compared with those receiving care from a medical team without an NP. Thirty-day hospital readmission (P = .011) and 30-day return rates to the emergency department (P = .021) were significantly lower in the intervention group. Significant predictors for rehospitalization included diagnosis of heart failure versus myocardial infarction (odds ratio [OR], 3.153, P = 0.005), treatment by a medical team without NP involvement (OR, 2.905, P = 0.008), and history of diabetes (OR, 2.310, P = 0.032). The addition of a cardiac acute care NP to medical teams caring for myocardial infarction and heart failure patients had a positive impact on 30-day emergency department return and hospital readmission rates.
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Goodridge, Donna; Henry, Chrysanthus; Watson, Erin; McDonald, Meghan; New, Lucia; Harrison, Elizabeth L; Scharf, Murray; Penz, Erika; Campbell, Steve; Rotter, Thomas
2018-02-26
While effective engagement of patients and families in treatment is increasingly viewed as a priority for many healthcare systems, much remains to be learned about the nature and outcomes of approaches that seek to accomplish this goal in the acute care hospital setting. Wide variability in the implementation of practices designed to promote patient and family engagement in hospitals has been noted. Approaches aimed at promoting patient and family engagement in treatment share the over-arching goal of changing behaviors of patients, families, and healthcare providers and possibly administrators. Behavior change techniques (BCTs) can be a key element of patient and family engagement approaches. This scoping review will contribute to the development of an evidence base detailing that the BCTs have potential to be effective in patient and family engagement interventions. The specific objectives of this review are to (a) identify and classify approaches used in acute care hospitals to engage patient and families in treatment according to the behavior change technique taxonomy; and (b) evaluate and synthesize the outcomes for these approaches for patients and families, healthcare providers, and health administrators/funders. This systematic scoping review will allow us to determine the extent, range, and nature of research activity related to initiatives designed to promote patient and family engagement in care. A comprehensive electronic literature search will be conducted in MEDLINE, EMBASE, and CINAHL. Studies will be included if they report on outcomes of a structured or systematic approach to the promotion of adult inpatient and family engagement in treatment in acute care settings. Studies will be selected in a two-stage screening process (title and abstract; full text) and quality will be assessed using the mixed methods assessment tool. Data extraction will include narrative descriptions of the intervention and classification of the behavior change techniques
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Building Care Bridges between Acute and Long-Term Care with Nursing Diagnosis.
ERIC Educational Resources Information Center
Taylor, Carol A.
The increasing age of the American population and the current emphasis on cost containment in health care make the 1980s an ideal time for building bridges to span the health care needs of elderly persons in acute care and long-term care. While hospitals often discharge patients to nursing homes as an intermediate step between hospitalization and…
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Why Do Patients in Acute Care Hospitals Fall? Can Falls Be Prevented?
Dykes, Patricia C.; Carroll, Diane L.; Hurley, Ann C.; Benoit, Angela; Middleton, Blackford
2011-01-01
Objective Obtain the views of nurses and assistants as to why patients in acute care hospitals fall. Background Despite a large quantitative evidence base for guiding fall risk assessment and not needing highly technical, scarce, or expensive equipment to prevent falls, falls are serious problems in hospitals. Methods Basic content analysis methods were used to interpret descriptive data from 4 focus groups with nurses (n = 23) and 4 with assistants (n = 19). A 2-person consensus approach was used for analysis. Results Positive and negative components of 6 concepts—patient report, information access, signage, environment, teamwork, and involving patient/family—formed 2 core categories: knowledge/communication and capability/actions that are facilitators or barriers, respectively, to preventing falls. Conclusion Two conditions are required to reduce patient falls. A patient care plan including current and accurate fall risk status with associated tailored and feasible interventions needs to be easily and immediately accessible to all stakeholders (entire healthcare team, patients, and family). Second, stakeholders must use that information plus their own knowledge and skills and patient and hospital resources to carry out the plan. PMID:19509605
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All-Cause and Acute Pancreatitis Health Care Costs in Patients With Severe Hypertriglyceridemia.
Rashid, Nazia; Sharma, Puza P; Scott, Ronald D; Lin, Kathy J; Toth, Peter P
2017-01-01
The aim of this study was to assess health care utilization and costs related to acute pancreatitis (AP) in patients with severe hypertriglyceridemia (sHTG) levels. Patients with sHTG levels 1000 mg/dL or higher were identified from January 1, 2007, to June 30, 2013. The first identified incident triglyceride level was labeled as index date. All-cause, AP-related health care visits, and mean total all-cause costs in patients with and without AP were compared during 12 months postindex. A generalized linear model regression was used to compare costs while controlling for patient characteristics and comorbidities. Five thousand five hundred fifty sHTG patients were identified, and 5.4% of these patients developed AP during postindex. Patients with AP had significantly (P < 0.05) more all-cause outpatient visits, hospitalizations, longer length of stays during the hospital visits, and emergency department visits versus patients without AP. Mean (SD) unadjusted all-cause health care costs in the 12 months postindex were $25,343 ($33,139) for patients with AP compared with $15,195 ($24,040) for patients with no AP. The regression showed annual all-cause costs were 49.9% higher (P < 0.01) for patients with AP versus without AP. Patients who developed AP were associated with higher costs; managing patients with sHTG at risk of developing AP may help reduce unnecessary costs.
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Bundorf, M Kate; Schulman, Kevin A; Stafford, Judith A; Gaskin, Darrell; Jollis, James G; Escarce, José J
2004-02-01
To examine the effects of market-level managed care activity on the treatment, cost, and outcomes of care for Medicare fee-for-service acute myocardial infarction (AMI) patients. Patients from the Cooperative Cardiovascular Project (CCP), a sample of Medicare beneficiaries discharged from nonfederal acute-care hospitals with a primary discharge diagnosis of AMI from January 1994 to February 1996. We estimated models of patient treatment, costs, and outcomes using ordinary least squares and logistic regression. The independent variables of primary interest were market-area managed care penetration and competition. The models included controls for patient, hospital, and other market area characteristics. We merged the CCP data with Medicare claims and other data sources. The study sample included CCP patients aged 65 and older who were admitted during 1994 and 1995 with a confirmed AMI to a nonrural hospital. Rates of revascularization and cardiac catheterization for Medicare fee-for-service patients with AMI are lower in high-HMO penetration markets than in low-penetration ones. Patients admitted in high-HMO-competition markets, in contrast, are more likely to receive cardiac catheterization for treatment of their AMI and had higher treatment costs than those admitted in low-competition markets. The level of managed care activity in the health care market affects the process of care for Medicare fee-for-service AMI patients. Spillovers from managed care activity to patients with other types of insurance are more likely when managed care organizations have greater market power.
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Latent Growth Modeling of nursing care dependency of acute neurological inpatients.
Piredda, M; Ghezzi, V; De Marinis, M G; Palese, A
2015-01-01
Longitudinal three-time point study, addressing how neurological adult patient care dependency varies from the admission time to the 3rd day of acute hospitalization. Nursing care dependency was measured with the Care Dependency Scale (CDS) and a Latent Growth Modeling approach was used to analyse the CDS trend in 124 neurosurgical and stroke inpatients. Care dependence followed a decreasing linear trend. Results can help nurse-managers planning an appropriate amount of nursing care for acute neurological patients during their initial stage of hospitalization. Further studies are needed aimed at investigating the determinants of nursing care dependence during the entire in-hospital stay.
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ERIC Educational Resources Information Center
Pfaff, Jann
2013-01-01
Defining fall risk factors and predicting fall risk status among patients in acute care has been a topic of research for decades. With increasing pressure on hospitals to provide quality care and prevent hospital-acquired conditions, the search for effective fall prevention interventions continues. Hundreds of risk factors for falls in acute care…
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Hiring appropriate providers for different populations: acute care nurse practitioners.
Haut, Cathy; Madden, Maureen
2015-06-01
Acute care nurse practitioners, prepared as providers for a variety of populations of patients, continue to make substantial contributions to health care. Evidence indicates shorter stays, higher satisfaction among patients, increased work efficiency, and higher quality outcomes when acute care nurse practitioners are part of unit- or service-based provider teams. The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education outlines detailed guidelines for matching nurse practitioners' education with certification and practice by using a population-focused algorithm. Despite national support for the model, nurse practitioners and employers continue to struggle with finding the right fit. Nurse practitioners often use their interest and previous nursing experience to apply for an available position, and hospitals may not understand preparation or regulations related to matching the appropriate provider to the work environment. Evidence and regulatory guidelines indicate appropriate providers for population-focused positions. This article presents history and recommendations for hiring acute care nurse practitioners as providers for different populations of patients. ©2015 American Association of Critical-Care Nurses.
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Sickness certification for patients with acute cough/LRTI in primary care in Poland and Norway
Godycki-Cwirko, Maciek; Nocun, Marek; Butler, Christopher C; Muras, Magdalena; Fleten, Nils; Melbye, Hasse
2011-01-01
Objective To compare the frequency and duration of sickness certificates issued by GPs to Polish and Norwegian working adults with acute cough/lower respiratory tract infection (LRTI). Design Cross-sectional observational study with clinicians from nine primary care centres in Poland and 11 primary care centres in Norway. GPs filled out a case report form for all patients, including information on antibiotic prescribing, sickness certification, and advice to stay off work. Setting Primary care research networks in Poland and Norway. Subjects Working adults with a new or worsening cough or clinical presentation suggestive of LRTI. Main outcome measures Issuing sickness certificates and advising patients to stay off work. Results GPs recorded similar symptoms and signs in patients in the two countries. Antibiotics were prescribed more often in Polish than in Norwegian patients (70.4% vs. 27.1%, p < 0.0001). About half of the patients received a formal sickness certificate (50.5% in Norway and 52.0% in Poland). The proportion of patients advised to stay off work was significantly higher in the Polish sample compared with the Norwegian sample (75.2% vs. 56.1%, p = 0.002). Norwegian GPs less often issued sick certificates for more than seven days (5.6% vs. 36.9%, p < 0.0001). Conclusion The overall proportion of sickness certification for acute cough/LRTI was similar in Norwegian and Polish patients. However, in the Polish sample, GPs more often advised patients to take time off work without issuing a sick note. When sickness certificates were issued, duration of longer than seven days was more common in Polish than in Norwegian patients. PMID:21189105
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Dalal, Anuj K; Schnipper, Jeffrey; Massaro, Anthony; Hanna, John; Mlaver, Eli; McNally, Kelly; Stade, Diana; Morrison, Constance; Bates, David W
2017-04-01
Communication in acute care settings is fragmented and occurs asynchronously via a variety of electronic modalities. Providers are often not on the same page with regard to the plan of care. We designed and developed a secure, patient-centered "microblog" messaging platform that identifies care team members by synchronizing with the electronic health record, and directs providers to a single forum where they can communicate about the plan of care. The system was used for 35% of patients admitted to a medical intensive care unit over a 6-month period. Major themes in messages included care coordination (49%), clinical summarization (29%), and care team collaboration (27%). Message transparency and persistence were seen as useful features by 83% and 62% of respondents, respectively. Availability of alternative messaging tools and variable use by non-unit providers were seen as main barriers to adoption by 83% and 62% of respondents, respectively. This approach has much potential to improve communication across settings once barriers are addressed. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.
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Pharaon, Shad K; Schoch, Shawn; Marchand, Lucas; Mirza, Amer
2018-01-01
Multiply injured patients with fractures are co-managed by acute care surgeons and orthopaedic surgeons. In most centers, orthopaedic surgeons definitively manage fractures, but preliminary management, including washouts, splinting, reductions, and external fixations, may be performed by selected acute care surgeons. The acute care surgeon should have a working knowledge of orthopaedic terminology to communicate with colleagues effectively. They should have an understanding of the composition of bone, periosteum, and cartilage, and their reaction when there is an injury. Fractures are usually fixed urgently, but some multiply injured patients are better served with a damage control strategy. Extremity compartment syndrome should be suspected in all critically injured patients with or without fractures and a low threshold for compartment pressure measurements or empiric fasciotomy maintained. Acute care surgeons performing rib fracture fixation and other chest wall injury reconstructions should follow the principles of open fracture reduction and stabilization. PMID:29766123
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Pharaon, Shad K; Schoch, Shawn; Marchand, Lucas; Mirza, Amer; Mayberry, John
2018-01-01
Multiply injured patients with fractures are co-managed by acute care surgeons and orthopaedic surgeons. In most centers, orthopaedic surgeons definitively manage fractures, but preliminary management, including washouts, splinting, reductions, and external fixations, may be performed by selected acute care surgeons. The acute care surgeon should have a working knowledge of orthopaedic terminology to communicate with colleagues effectively. They should have an understanding of the composition of bone, periosteum, and cartilage, and their reaction when there is an injury. Fractures are usually fixed urgently, but some multiply injured patients are better served with a damage control strategy. Extremity compartment syndrome should be suspected in all critically injured patients with or without fractures and a low threshold for compartment pressure measurements or empiric fasciotomy maintained. Acute care surgeons performing rib fracture fixation and other chest wall injury reconstructions should follow the principles of open fracture reduction and stabilization.
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The utility of outpatient commitment: acute medical care access and protecting health.
Segal, Steven P; Hayes, Stephania L; Rimes, Lachlan
2018-06-01
This study considers whether, in an easy access single-payer health care system, patients placed on outpatient commitment-community treatment orders (CTOs) in Victoria Australia-are more likely to access acute medical care addressing physical illness than voluntary patients with and without severe mental illness. For years 2000 to 2010, the study compared acute medical care access of 27,585 severely mentally ill psychiatrically hospitalized patients (11,424 with and 16,161 without CTO exposure) and 12,229 never psychiatrically hospitalized outpatients (individuals with less morbidity risk as they were not considered to have severe mental illness). Logistic regression was used to determine the influence of the CTO on the likelihood of receiving a diagnosis of physical illness requiring acute care. Validating their shared and elevated morbidity risk, 53% of each hospitalized cohort accessed acute care compared to 32% of outpatients during the decade. While not under mental health system supervision, however, the likelihood that a CTO patient would receive a physical illness diagnosis was 31% lower than for non-CTO patients, and no different from lower morbidity-risk outpatients without severe mental illness. While, under mental health system supervision, the likelihood that CTO patients would receive a physical illness diagnosis was 40% greater than non-CTO patients and 5.02 times more likely than outpatients were. Each CTO episode was associated with a 4.6% increase in the likelihood of a member of the CTO group receiving a diagnosis. Mental health system involvement and CTO supervision appeared to facilitate access to physical health care in acute care settings for patients with severe mental illness, a group that has, in the past, been subject to excess morbidity and mortality.
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Antibiotic use among older adults on an acute care general surgery service
Pollmann, André S.; Bailey, Jon G.; Davis, Philip J.B.; Johnson, Paul M.
2017-01-01
Background Antibiotics play an important role in the treatment of many surgical diseases that affect older adults, and the potential for inappropriate use of these drugs is high. Our objective was to describe antibiotic use among older adults admitted to an acute care surgery service at a tertiary care teaching hospital. Methods Detailed data regarding diagnosis, comorbidities, surgery and antibiotic use were retrospectively collected for patients 70 years and older admitted to an acute care surgery service. We evaluated antibiotic use (perioperative prophylaxis and treatment) for appropriateness based on published guidelines. Results During the study period 453 patients were admitted to the acute care surgery service, and 229 underwent surgery. The most common diagnoses were small bowel obstruction (27.2%) and acute cholecystitis (11.0%). In total 251 nonelective abdominal operations were performed, and perioperative antibiotic prophylaxis was appropriate in 49.5% of cases. The most common prophylaxis errors were incorrect timing (15.5%) and incorrect dose (12.4%). Overall 206 patients received treatment with antibiotics for their underlying disease process, and 44.2% received appropriate first-line drug therapy. The most common therapeutic errors were administration of second- or third-line antibiotics without indication (37.9%) and use of antibiotics when not indicated (12.1%). There was considerable variation in the duration of treatment for patients with the same diagnoses. Conclusion Inappropriate antibiotic use was common among older patients admitted to an acute care surgery service. Quality improvement initiatives are needed to ensure patients receive optimal care in this complex hospital environment. PMID:28930045
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The Experience of Witnessing Patients' Trauma and Suffering among Acute Care Nurses
ERIC Educational Resources Information Center
Walsh, Mary E.; Buchanan, Marla J.
2011-01-01
A large body of research provides evidence of workplace injuries to those in the nursing profession. Research on workplace stress and burnout among medical professionals is also well known; however, the profession of acute care nursing has not been examined with regards to work-related stress. This qualitative study focused on acute care nurses'…
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Middleton, Addie; Kuo, Yong-Fang; Graham, James E; Karmarkar, Amol; Lin, Yu-Li; Goodwin, James S; Haas, Allen; Ottenbacher, Kenneth J
2018-04-21
Examine readmission patterns over 90-day episodes of care in persons discharged from hospitals to post-acute settings. Retrospective cohort study. Acute care hospitals. Medicare fee-for-service enrollees (N = 686,877) discharged from hospitals to post-acute care in 2013-2014. The cohort included beneficiaries >65 years of age hospitalized for stroke, joint replacement, or hip fracture and who survived for 90 days following discharge. 90-day unplanned readmissions. The cohort included 127,680 individuals with stroke, 442,195 undergoing joint replacement, and 117,002 with hip fracture. Thirty-day readmission rates ranged from 3.1% for knee replacement patients discharged to home health agencies (HHAs) to 14.4% for hemorrhagic stroke patients discharged to skilled nursing facilities (SNFs). Ninety-day readmission rates ranged from 5.0% for knee replacement patients discharged to HHAs to 26.1% for hemorrhagic stroke patients discharged to SNFs. Differences in readmission rates decreased between stroke subconditions (hemorrhagic and ischemic) and increased between joint replacement subconditions (knee, elective hip, and nonelective hip) from 30 to 90 days across all initial post-acute discharge settings. We observed clear patterns in readmissions over 90-day episodes of care across post-acute discharge settings and subconditions. Our findings suggest that patients with hemorrhagic stroke may be more vulnerable than those with ischemic over the first 30 days after hospital discharge. For patients receiving nonelective joint replacements, readmission prevention efforts should start immediately after discharge and continue, or even increase, over the 90-day episode of care. Copyright © 2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.
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Zhou, Xiurong; Chen, Jiafeng; Wang, Chengdong; Wu, Lili
2017-01-01
Intracerebral hemorrhage is one of the most common types of cerebrovascular disease in humans and often causes paralysis, a vegetative state and even death. Patients with acute intracerebral hemorrhage are frequently monitored in intensive care units (ICUs). Spontaneous intracerebral hemorrhage is associated with a higher rate of mortality and morbidity than other intracephalic diseases. The expression levels of inflammatory factors have important roles in inflammatory responses indicative of changes in a patient's condition and are therefore important in the monitoring and treatment of affected patients at the ICU as well as the development of therapeutic strategies for acute cerebral hemorrhage. The present study investigated the anti-inflammatory effects of Simvastatin in patients with acute intracerebral hemorrhage at an ICU, and inflammatory factors and cellular changes were systematically analyzed. The plasma concentrations of inflammatory factors, including interleukin (IL)-4, IL-6, IL-8 and IL-10, were evaluated by ELISAs. The plasma concentrations of inflammatory cellular changes were detected by using flow cytometry. The results demonstrated that after Simvastatin treatment of patients with acute cerebral hemorrhage at the ICU, the plasma concentrations of IL-4, IL-6, IL-8 and IL-10 were downregulated compared with those in placebo-treated controls. In addition, Simvastatin treatment at the ICU decreased lymphocytes, granulocytes and mononuclear cells in patients with acute cerebral hemorrhage. The levels of inflammatory factors were associated with brain edema in patients with acute cerebral hemorrhage treated at the ICU. In addition, the amount of bleeding was reduced in parallel with the inflammatory cell plasma concentration of lymphocytes, granulocytes and mononuclear cells. Importantly, Simvastatin treatment produced beneficial outcomes by improving brain edema and reducing the amount of bleeding. In conclusion, the present study demonstrated the
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End-of-Life Care in an Acute Care Hospital: Linking Policy and Practice
ERIC Educational Resources Information Center
Sorensen, Ros; Iedema, Rick
2011-01-01
The care of people who die in hospitals is often suboptimal. Involving patients in decisions about their care is seen as one way to improve care outcomes. Federal and state government policymakers in Australia are promoting shared decision making in acute care hospitals as a means to improve the quality of end-of-life care. If policy is to be…
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Luu, Ngoc-Phuong; Pitts, Samantha; Petty, Brent; Sawyer, Melinda D; Dennison-Himmelfarb, Cheryl; Boonyasai, Romsai Tony; Maruthur, Nisa M
2016-04-01
Most research on transitions of care has focused on the transition from acute to outpatient care. Little is known about the transition from outpatient to acute care. We conducted a systematic review of the literature on the transition from outpatient to acute care, focusing on provider-to-provider communication and its impact on quality of care. We searched the MEDLINE, CINAHL, Scopus, EMBASE, and Cochrane databases for English-language articles describing direct communication between outpatient providers and acute care providers around patients presenting to the emergency department or admitted to the hospital. We conducted double, independent review of titles, abstracts, and full text articles. Conflicts were resolved by consensus. Included articles were abstracted using standardized forms. We maintained search results via Refworks (ProQuest, Bethesda, MD). Risk of bias was assessed using a modified version of the Downs' and Black's tool. Of 4009 citations, twenty articles evaluated direct provider-to-provider communication around the outpatient to acute care transition. Most studies were cross-sectional (65%), conducted in the US (55%), and studied communication between primary care and inpatient providers (62%). Of three studies reporting on the association between communication and 30-day readmissions, none found a significant association; of these studies, only one reported a measure of association (adjusted OR for communication vs. no communication, 1.08; 95% CI 0.92-1.26). The literature on provider-to-provider communication at the transition from outpatient to acute care is sparse and heterogeneous. Given the known importance of communication for other transitions of care, future studies are needed on provider-to-provider communication during this transition. Studies evaluating ideal methods for communication to reduce medical errors, utilization, and optimize patient satisfaction at this transition are especially needed.
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Walsh, Declan
2004-01-01
In this study, a hematology/oncology computerized discharge database was qualitatively and quantitatively reviewed using an empirical methodology. The goal was to identify potential patients for admission to a planned acute-care, palliative medicine inpatient unit. Patients were identified by the International Classifications of Disease (ICD-9) codes. A large heterogenous population, comprising up to 40 percent of annual discharges from the Hematology/Oncology service, was identified. If management decided to add an acute-care, palliative medicine unit to the hospital, these are the patients who would benefit. The study predicted a significant change in patient profile, acuity, complexity, and resource utilization in current palliative care services. This study technique predicted the actual clinical load of the acute-care unit when it opened and was very helpful in program development. Our model predicted that 695 patients would be admitted to the acute-care palliative medicine unit in the first year of operation; 655 patients were actually admitted during this time.
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Acute Respiratory Failure in Renal Transplant Recipients: A Single Intensive Care Unit Experience.
Ulas, Aydin; Kaplan, Serife; Zeyneloglu, Pinar; Torgay, Adnan; Pirat, Arash; Haberal, Mehmet
2015-11-01
Frequency of pulmonary complications after renal transplant has been reported to range from 3% to 17%. The objective of this study was to evaluate renal transplant recipients admitted to an intensive care unit to identify incidence and cause of acute respiratory failure in the postoperative period and compare clinical features and outcomes between those with and without acute respiratory failure. We retrospectively screened the data of 540 consecutive adult renal transplant recipients who received their grafts at a single transplant center and included those patients admitted to an intensive care unit during this period for this study. Acute respiratory failure was defined as severe dyspnea, respiratory distress, decreased oxygen saturation, hypoxemia or hypercapnia on room air, or requirement of noninvasive or invasive mechanical ventilation. Among the 540 adult renal transplant recipients, 55 (10.7%) were admitted to an intensive care unit, including 26 (47.3%) admitted for acute respiratory failure. Median time from transplant to intensive care unit admission was 10 months (range, 0-67 mo). The leading causes of acute respiratory failure were bacterial pneumonia (56%) and cardiogenic pulmonary edema (44%). Mean partial pressure of arterial oxygen to fractional inspired oxygen ratio was 174 ± 59, invasive mechanical ventilation was used in 13 patients (50%), and noninvasive mechanical ventilation was used in 8 patients (31%). The overall mortality was 16.4%. Acute respiratory failure was the reason for intensive care unit admission in almost half of our renal transplant recipients. Main causes of acute respiratory failure were bacterial pneumonia and cardiogenic pulmonary edema. Mortality of patients admitted for acute respiratory failure was similar to those without acute respiratory failure.
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Online medical care: the current state of "eVisits" in acute primary care delivery.
Hickson, Ryan; Talbert, Jeffery; Thornbury, William C; Perin, Nathan R; Goodin, Amie J
2015-02-01
Online technologies offer the promise of an efficient, improved healthcare system. Patients benefit from increased access to care, physicians are afforded greater flexibility in care delivery, and the health system itself benefits from lower costs to provide such care. One method of incorporating online care into clinical practice, called electronic office visits or "eVisits," allows physicians to provide a consultation with patients online. We performed an analysis of the current published literature on eVisits as well as present emerging research describing the use of mobile platforms as the delivery model. We focused on the role of eVisits in acute primary care practice. A literature review was conducted using electronic databases with a variety of search terms related to the use of eVisits in primary care. Several advantages to eVisit utilization in the primary care setting were identified, namely, improvements in efficiency, continuity of care, quality of care, and access to care. Barriers to eVisit implementation were also identified, including challenges with incorporation into workflow, reimbursement, physician technological literacy, patient health literacy, overuse, security, confidentiality, and integration with existing medical technologies. Only one study of patient satisfaction with eVisit acute primary care services was identified, and this suggests that previous analyses of eVisit utilization are lacking this key component of healthcare service delivery evaluations. The delivery of primary care via eVisits on mobile platforms is still in adolescence, with few methodologically rigorous analyses of outcomes of efficiency, patient health, and satisfaction.
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Antibiotic treatment of acute respiratory infections in acute care settings.
Gonzales, Ralph; Camargo, Carlos A; MacKenzie, Thomas; Kersey, Ayanna S; Maselli, Judith; Levin, Sara K; McCulloch, Charles E; Metlay, Joshua P
2006-03-01
To examine the patterns of antibiotic use for acute respiratory tract infections (ARIs) in acute care settings. Chart reviews were performed retrospectively on a random sample of adult ARI visits to seven Veterans Affairs (VA) and seven non-VA emergency departments (EDs) for the period of November 2003 to February 2004. Visits were limited to those discharged to home and those with primary diagnoses of antibiotic-responsive (pneumonia, acute exacerbation of chronic bronchitis, pharyngitis, sinusitis) and antibiotic-nonresponsive conditions (acute bronchitis, nonspecific upper respiratory tract infection [URI]). Results are expressed as adjusted odds ratios with 95% confidence intervals. Of 2,270 ARI visits, 62% were for antibiotic-nonresponsive diagnoses. Seventy-two percent of acute bronchitis and 38% of URI visits were treated with antibiotics (p < 0.001). Stratified analyses show that antibiotic prescription rates were similar among attending-only and housestaff-associated visits for antibiotic-responsive diagnoses (p = 0.11), and acute bronchitis (76% vs. 59%; p = 0.31). However, the antibiotic prescription rate for URIs was greater for attending-only visits compared with housestaff-associated visits (48% vs. 15%; p = 0.01). Antibiotic prescription rates for total ARIs varied between sites, ranging from 42% to 89%. Patient age, gender, race and ethnicity, smoking status, comorbidities, and clinical setting (VA vs. non-VA) were not independently associated with antibiotic prescribing. Acute care settings are important targets for reducing inappropriate antibiotic prescribing. The mechanisms accounting for lower antibiotic prescription rates observed with housestaff-associated visits merit further study.
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Cole, Evan S; Campbell, Claudia; Diana, Mark L; Webber, Larry; Culbertson, Richard
2015-01-01
The patient-centered medical home model of primary care has received considerable attention for its potential to improve outcomes and reduce health care costs. Yet little information exists about the model's ability to achieve these goals for Medicaid patients. We sought to evaluate the effect of patient-centered medical home certification of Louisiana primary care clinics on the quality and cost of care over time for a Medicaid population. We used a quasi-experimental pre-post design with a matched control group to assess the effect of medical home certification on outcomes. We found no impact on acute care use and modest support for reduced costs and primary care use among medical homes serving higher proportions of chronically ill patients. These findings provide preliminary results related to the ability of the patient-centered medical home model to improve outcomes for Medicaid beneficiaries. The findings support a case-mix-adjusted payment policy for medical homes going forward. Project HOPE—The People-to-People Health Foundation, Inc.
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Quality geriatric care as perceived by nurses in long-term and acute care settings.
Barba, Beth Ellen; Hu, Jie; Efird, Jimmy
2012-03-01
evidence-based practice guidelines that promote autonomy and independence of patients and staff could improve acute care nurses' perceptions of quality of geriatric care. © 2011 Blackwell Publishing Ltd.
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Benchmarking antibiotic use in Finnish acute care hospitals using patient case-mix adjustment.
Kanerva, Mari; Ollgren, Jukka; Lyytikäinen, Outi
2011-11-01
It is difficult to draw conclusions about the prudence of antibiotic use in different hospitals by directly comparing usage figures. We present a patient case-mix adjustment model of antibiotic use to rank hospitals while taking patient characteristics into account. Data on antibiotic use were collected during the national healthcare-associated infection (HAI) prevalence survey in 2005 in Finland in all 5 tertiary care, all 15 secondary care and 10 (25% of 40) other acute care hospitals. The use of antibiotics was measured using use-days/100 patient-days during a 7day period and the prevalence of patients receiving at least two antimicrobials during the study day. Case-mix-adjusted antibiotic use was calculated by using multivariate models and an indirect standardization method. Parameters in the model included age, sex, severity of underlying diseases, intensive care, haematology, preceding surgery, respirator, central venous and urinary catheters, community-associated infection, HAI and contact isolation due to methicillin-resistant Staphylococcus aureus. The ranking order changed one position in 12 (40%) hospitals and more than two positions in 13 (43%) hospitals when the case-mix-adjusted figures were compared with those observed. In 24 hospitals (80%), the antibiotic use density observed was lower than expected by the case-mix-adjusted use density. The patient case-mix adjustment of antibiotic use ranked the hospitals differently from the ranking according to observed use, and may be a useful tool for benchmarking hospital antibiotic use. However, the best set of easily and widely available parameters that would describe both patient material and hospital activities remains to be determined.
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Hospital-Level Care at Home for Acutely Ill Adults: a Pilot Randomized Controlled Trial.
Levine, David M; Ouchi, Kei; Blanchfield, Bonnie; Diamond, Keren; Licurse, Adam; Pu, Charles T; Schnipper, Jeffrey L
2018-05-01
Hospitals are standard of care for acute illness, but hospitals can be unsafe, uncomfortable, and expensive. Providing substitutive hospital-level care in a patient's home potentially reduces cost while maintaining or improving quality, safety, and patient experience, although evidence from randomized controlled trials in the US is lacking. Determine if home hospital care reduces cost while maintaining quality, safety, and patient experience. Randomized controlled trial. Adults admitted via the emergency department with any infection or exacerbation of heart failure, chronic obstructive pulmonary disease, or asthma. Home hospital care, including nurse and physician home visits, intravenous medications, continuous monitoring, video communication, and point-of-care testing. Primary outcome was direct cost of the acute care episode. Secondary outcomes included utilization, 30-day cost, physical activity, and patient experience. Nine patients were randomized to home, 11 to usual care. Median direct cost of the acute care episode for home patients was 52% (IQR, 28%; p = 0.05) lower than for control patients. During the care episode, home patients had fewer laboratory orders (median per admission: 6 vs. 19; p < 0.01) and less often received consultations (0% vs. 27%; p = 0.04). Home patients were more physically active (median minutes, 209 vs. 78; p < 0.01), with a trend toward more sleep. No adverse events occurred in home patients, one occurred in control patients. Median direct cost for the acute care plus 30-day post-discharge period for home patients was 67% (IQR, 77%; p < 0.01) lower, with trends toward less use of home-care services (22% vs. 55%; p = 0.08) and fewer readmissions (11% vs. 36%; p = 0.32). Patient experience was similar in both groups. The use of substitutive home-hospitalization compared to in-hospital usual care reduced cost and utilization and improved physical activity. No significant differences in quality, safety
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Amy, Chen; Zagorski, Brandon; Chan, Vincy; Parsons, Daria; Vander Laan, Rika; Colantonio, Angela
2012-05-01
Alternate-level-of-care (ALC) days represent hospital beds that are taken up by patients who would more appropriately be cared for in other settings. ALC days have been found to be costly and may result in worse functional outcomes, reduced motor skills and longer lengths of stay in rehabilitation. This study examines the factors that are associated with acute care ALC days among patients with acquired brain injury (ABI). We used the Discharge Abstract Database to identify patients with ABI using International Classification of Disease-10 codes. From fiscal years 2007/08 to 2009/10, 17.5% of patients with traumatic and 14% of patients with non-traumatic brain injury had at least one ALC day. Significant predictors include having a psychiatric co-morbidity, increasing age and length of stay in acute care. These findings can inform planning for care of people with ABI in a publicly funded healthcare system.
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Opening the Door: The Experience of Chronic Critical Illness in a Long-Term Acute Care Hospital.
Lamas, Daniela J; Owens, Robert L; Nace, R Nicholas; Massaro, Anthony F; Pertsch, Nathan J; Gass, Jonathon; Bernacki, Rachelle E; Block, Susan D
2017-04-01
Chronically critically ill patients have recurrent infections, organ dysfunction, and at least half die within 1 year. They are frequently cared for in long-term acute care hospitals, yet little is known about their experience in this setting. Our objective was to explore the understanding and expectations and goals of these patients and surrogates. We conducted semi-structured interviews with chronically critically ill long-term acute care hospital patients or surrogates. Conversations were recorded, transcribed, and analyzed. One long-term acute care hospital. Chronically critically ill patients, defined by tracheotomy for prolonged mechanical ventilation, or surrogates. Semi-structured conversation about quality of life, expectations, and planning for setbacks. A total of 50 subjects (30 patients and 20 surrogates) were enrolled. Thematic analyses demonstrated: 1) poor quality of life for patients; 2) surrogate stress and anxiety; 3) optimistic health expectations; 4) poor planning for medical setbacks; and 5) disruptive care transitions. Nearly 80% of patient and their surrogate decision makers identified going home as a goal; 38% were at home at 1 year. Our study describes the experience of chronically critically ill patients and surrogates in an long-term acute care hospital and the feasibility of patient-focused research in this setting. Our findings indicate overly optimistic expectations about return home and unmet palliative care needs, suggesting the need for integration of palliative care within the long-term acute care hospital. Further research is also needed to more fully understand the challenges of this growing population of ICU survivors.
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Hughes, M; MacKirdy, F N; Ross, J; Norrie, J; Grant, I S
2003-09-01
This prospective audit of incidence and outcome of the acute respiratory distress syndrome was conducted as part of the national audit of intensive care practice in Scotland. All patients with acute respiratory distress syndrome in 23 adult intensive care units were identified using the diagnostic criteria defined by the American-European Consensus Conference. Daily data collection was continued until death or intensive care unit discharge. Three hundred and sixty-nine patients were diagnosed with acute respiratory distress syndrome over the 8-month study period. The frequency of acute respiratory distress syndrome in the intensive care unit population was 8.1%; the incidence in the Scottish population was estimated at 16.0 cases.100,000(-1).year(-1). Intensive care unit mortality for acute respiratory distress syndrome was 53.1%, with a hospital mortality of 60.9%. In our national unselected population of critically ill patients, the overall outcome is comparable with published series (Acute Physiology and Chronic Health Evaluation II standardised mortality ratio = 0.99). However, mortality from acute respiratory distress syndrome in Scotland is substantially higher than in recent other series suggesting an improvement in outcome in this condition.
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St George Acute Care Team: the local variant of crisis resolution model of care.
Cupina, Denise D; Wand, Anne P F; Phelan, Emma; Atkin, Rona
2016-10-01
The objective of this study was to describe functioning and clinical activities of the St George Acute Care Team and how it compares to the typical crisis resolution model of care. Descriptive data including demographics, sources of referral, type of clinical intervention, length of stay, diagnoses and outcomes were collected from records of all patients who were discharged from the team during a 10 week period. There were 677 referrals. The team's functions consisted of post-discharge follow-up (31%), triage and intake (30%), case management support (23%) and acute community based assessment and treatment (16%). The average length of stay was 5 days. The majority of patients were diagnosed with a mood (23%) or a psychotic (25%) disorder. Points of contrast to other reported crisis resolution teams include shorter length of stay, relatively less focus on direct clinical assessment and more telephone follow-up and triage. St George Acute Care Team provides a variety of clinical activities. The focus has shifted away from the original model of crisis resolution care to meet local and governmental requirements. © The Royal Australian and New Zealand College of Psychiatrists 2016.
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Avallin, Therese; Muntlin Athlin, Åsa; Sorensen, Erik Elgaard; Kitson, Alison; Björck, Martin; Jangland, Eva
2018-06-12
To explore and describe the impact of the organizational culture on and the patient-practitioner patterns of actions that contribute to or detract from successful pain management for the patient with acute abdominal pain across the acute care pathway. Although pain management is a recognised human right, unmanaged pain continues to cause suffering and prolong hospital care. Unanswered questions about how to successfully manage pain relate to both organizational culture and individual practitioners' performance. Focused ethnography, applying the Developmental Research Sequence and the Fundamentals of Care framework. Participant observation and informal interviews (92 hours) were performed at one emergency department and two surgical wards at a University Hospital during April - November 2015. Data includes 261 interactions between patients, aged ≥18 years seeking care for acute abdominal pain at the emergency department and admitted to a surgical ward (N = 31; aged 20-90 years; 14 men, 17 women; 9 with communicative disabilities) and healthcare practitioners (N =198). The observations revealed an organizational culture with considerable impact on how well pain was managed. Well managed pain presupposed the patient and practitioners to connect in a holistic pain management including a trustful relationship, communication to share knowledge and individualized analgesics. Person-centred pain management requires an organization where patients and practitioners share their knowledge of pain and pain management as true partners. Leaders and practitioners should make small behavioural changes to enable the crucial positive experience of pain management. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
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Vento-Wilson, Margaret T; McGuire, Anthony; Ostergren, Jennifer A
2015-01-01
Severe communication deficits occur frequently in acute care. Augmentative and alternative communication (AAC) may improve patient-nurse communication, yet it remains underutilized. The objective of this study was to assess the impact of training student nurses (SNs) in acute and critical care on the use of AAC with regard to confidence levels and likelihood of implementation of AAC by SNs in acute care. Training in AAC techniques was provided to SNs. A pretraining and posttraining assessment was completed along with follow-up surveys conducted after the SNs had an opportunity to use AAC. A 6-fold increase in confidence (P < .01) was reported by the SNs after AAC training, as was an approximately 3-fold increase in likelihood of use (P < .01). The reliable yes/no was the most reported AAC technique (34.7% of the students). Providing SNs with AAC tools accompanied by brief training increases their confidence in the use of AAC and the likelihood that they will use them. Inclusion of AAC education in nursing curricula and nursing orientations could be an important step in risk reduction among patients with severe communication disorders. Further study is needed of the relationship between training student nurses in the use of AAC as a way to change practice and improve communication outcomes.
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Evaluating and Managing Acute Low Back Pain in the Primary Care Setting
Atlas, Steven J; Deyo, Richard A
2001-01-01
Acute low back pain is a common reason for patient calls or visits to a primary care clinician. Despite a large differential diagnosis, the precise etiology is rarely identified, although musculoligamentous processes are usually suspected. For most patients, back symptoms are nonspecific, meaning that there is no evidence for radicular symptoms or underlying systemic disease. Because episodes of acute, nonspecific low back pain are usually self-limited, many patients treat themselves without contacting their primary care clinician. When patients do call or schedule a visit, evaluation and management by primary care clinicians is appropriate. The history and physical examination usually provide clues to the rare but potentially serious causes of low back pain, as well as to identify patients at risk for prolonged recovery. Diagnostic testing, including plain x-rays, is often unnecessary during the initial evaluation. For patients with acute, nonspecific low back pain, the primary emphasis of treatment should be conservative care, time, reassurance, and education. Current recommendations focus on activity as tolerated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patients whose symptoms are not improving over 2 to 4 weeks. Specialty referral should be considered for patients with a progressive neurologic deficit, failure of conservative therapy, or an uncertain or serious diagnosis. The prognosis for most patients is good, although recurrence is common. Thus, educating patients about the natural history of acute low back pain and how to prevent future episodes can help ensure reasonable expectations. PMID:11251764
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Processes of care associated with acute stroke outcomes.
Bravata, Dawn M; Wells, Carolyn K; Lo, Albert C; Nadeau, Steven E; Melillo, Jean; Chodkowski, Diane; Struve, Frederick; Williams, Linda S; Peixoto, Aldo J; Gorman, Mark; Goel, Punit; Acompora, Gregory; McClain, Vincent; Ranjbar, Noshene; Tabereaux, Paul B; Boice, John L; Jacewicz, Michael; Concato, John
2010-05-10
Many processes of care have been proposed as metrics to evaluate stroke care. We sought to identify processes of stroke care that are associated with improved patient outcomes after adjustment for both patient characteristics and other process measures. This retrospective cohort study included patients 18 years or older with an ischemic stroke or transient ischemic attack (TIA) onset no more than 2 days before admission and a neurologic deficit on admission. Patients were excluded if they resided in a skilled nursing facility, were already admitted to the hospital at stroke onset, or were transferred from another acute-care facility. The combined outcome included in-hospital mortality, discharge to hospice, or discharge to a skilled nursing facility. Seven processes of stroke care were evaluated: fever management, hypoxia management, blood pressure management, neurologic evaluation, swallowing evaluation, deep vein thrombosis (DVT) prophylaxis, and early mobilization. Risk adjustment included age, comorbidity (medical history), concomitant medical illness present at admission, preadmission symptom course, prestroke functional status, code status, stroke severity, nonneurologic status, modified APACHE (Acute Physiology and Chronic Health Evaluation) III score, and admission brain imaging findings. Among 1487 patients, the outcome was observed in 239 (16%). Three processes of care were independently associated with an improvement in the outcome after adjustment: swallowing evaluation (adjusted odds ratio [OR], 0.64; 95% confidence interval [CI], 0.43-0.94); DVT prophylaxis (adjusted OR, 0.60; 95% CI, 0.37-0.96); and treating all episodes of hypoxia with supplemental oxygen (adjusted OR, 0.26; 95% CI, 0.09-0.73). Outcomes among patients with ischemic stroke or TIA can be improved by attention to swallowing function, DVT prophylaxis, and treatment of hypoxia.
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DOE Office of Scientific and Technical Information (OSTI.GOV)
Palac, R.T.; Gray, L.; Brown, P.H.
1988-09-01
This is the third article in a four-part continuing education series relating to patient care and management. After completing the article, the reader should be able to: 1) understand the application, potential, and problems of nuclear cardiology in the coronary care unit; 2) recognize the utilization of nuclear cardiology in acute coronary care management; and 3) appreciate the important role of nuclear cardiology in cardiac patient care.
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Regional variation in acute stroke care organisation.
Muñoz Venturelli, Paula; Robinson, Thompson; Lavados, Pablo M; Olavarría, Verónica V; Arima, Hisatomi; Billot, Laurent; Hackett, Maree L; Lim, Joyce Y; Middleton, Sandy; Pontes-Neto, Octavio; Peng, Bin; Cui, Liying; Song, Lily; Mead, Gillian; Watkins, Caroline; Lin, Ruey-Tay; Lee, Tsong-Hai; Pandian, Jeyaraj; de Silva, H Asita; Anderson, Craig S
2016-12-15
Few studies have assessed regional variation in the organisation of stroke services, particularly health care resourcing, presence of protocols and discharge planning. Our aim was to compare stroke care organisation within middle- (MIC) and high-income country (HIC) hospitals participating in the Head Position in Stroke Trial (HeadPoST). HeadPoST is an on-going international multicenter crossover cluster-randomized trial of 'sitting-up' versus 'lying-flat' head positioning in acute stroke. As part of the start-up phase, one stroke care organisation questionnaire was completed at each hospital. The World Bank gross national income per capita criteria were used for classification. 94 hospitals from 9 countries completed the questionnaire, 51 corresponding to MIC and 43 to HIC. Most participating hospitals had a dedicated stroke care unit/ward, with access to diagnostic services and expert stroke physicians, and offering intravenous thrombolysis. There was no difference for the presence of a dedicated multidisciplinary stroke team, although greater access to a broad spectrum of rehabilitation therapists in HIC compared to MIC hospitals was observed. Significantly more patients arrived within a 4-h window of symptoms onset in HIC hospitals (41 vs. 13%; P<0.001), and a significantly higher proportion of acute ischemic stroke patients received intravenous thrombolysis (10 vs. 5%; P=0.002) compared to MIC hospitals. Although all hospitals provided advanced care for people with stroke, differences were found in stroke care organisation and treatment. Future multilevel analyses aims to determine the influence of specific organisational factors on patient outcomes. Copyright © 2016 Elsevier B.V. All rights reserved.
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Planning for subacute care: predicting demand using acute activity data.
Green, Janette P; McNamee, Jennifer P; Kobel, Conrad; Seraji, Md Habibur R; Lawrence, Suanne J
2016-01-01
Objective The aim of the present study was to develop a robust model that uses the concept of 'rehabilitation-sensitive' Diagnosis Related Groups (DRGs) in predicting demand for rehabilitation and geriatric evaluation and management (GEM) care following acute in-patient episodes provided in Australian hospitals. Methods The model was developed using statistical analyses of national datasets, informed by a panel of expert clinicians and jurisdictional advice. Logistic regression analysis was undertaken using acute in-patient data, published national hospital statistics and data from the Australasian Rehabilitation Outcomes Centre. Results The predictive model comprises tables of probabilities that patients will require rehabilitation or GEM care after an acute episode, with columns defined by age group and rows defined by grouped Australian Refined (AR)-DRGs. Conclusions The existing concept of rehabilitation-sensitive DRGs was revised and extended. When applied to national data, the model provided a conservative estimate of 83% of the activity actually provided. An example demonstrates the application of the model for service planning. What is known about the topic? Health service planning is core business for jurisdictions and local areas. With populations ageing and an acknowledgement of the underservicing of subacute care, it is timely to find improved methods of estimating demand for this type of care. Traditionally, age-sex standardised utilisation rates for individual DRGs have been applied to Australian Bureau of Statistics (ABS) population projections to predict the future need for subacute services. Improved predictions became possible when some AR-DRGs were designated 'rehabilitation-sensitive'. This improved methodology has been used in several Australian jurisdictions. What does this paper add? This paper presents a new tool, or model, to predict demand for rehabilitation and GEM services based on in-patient acute activity. In this model, the
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Ellis, Kerri A; Connolly, Ann; Hosseinnezhad, Alireza; Lilly, Craig M
2015-11-01
To increase the frequency of communication of patient information between acute and primary care providers. A secondary objective was to determine whether higher rates of communication were associated with lower rates of hospital readmission 30 days after discharge. A validated instrument was used for telephone surveys before and after an intervention designed to increase the frequency of communication among acute care and primary care providers. The communication intervention was implemented in 3 adult intensive care units from 2 campuses of an academic medical center. The frequency of communication among acute care and primary care providers, the perceived usefulness of the intervention, and its association with 30-day readmission rates were assessed for 202 adult intensive care episodes before and 100 episodes after a communication intervention. The frequency of documented communication increased significantly (5/202 or 2% before to 72/100 or 72% after the intervention; P < .001) and the communication was considered useful by every participating primary care provider. Rates of rehospitalization at 30 days were lower for the intervention group than the preintervention group, but the difference was not statistically significant (41/202 or 23% vs 16/88 or 18% of discharged patients; P = .45; power 0.112 at P = .05). The frequency of communication episodes that provide value can be increased through standardized processes. The key aspects of this effective intervention were setting the expectation that communication should occur, documenting when communication has occurred, and reviewing that documentation during multiprofessional rounds. ©2015 American Association of Critical-Care Nurses.
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General surgery 2.0: the emergence of acute care surgery in Canada
Hameed, S. Morad; Brenneman, Frederick D.; Ball, Chad G.; Pagliarello, Joe; Razek, Tarek; Parry, Neil; Widder, Sandy; Minor, Sam; Buczkowski, Andrzej; MacPherson, Cailan; Johner, Amanda; Jenkin, Dan; Wood, Leanne; McLoughlin, Karen; Anderson, Ian; Davey, Doug; Zabolotny, Brent; Saadia, Roger; Bracken, John; Nathens, Avery; Ahmed, Najma; Panton, Ormond; Warnock, Garth L.
2010-01-01
Over the past 5 years, there has been a groundswell of support in Canada for the development of organized, focused and multidisciplinary approaches to caring for acutely ill general surgical patients. Newly forged acute care surgery (ACS) services are beginning to provide prompt, evidence-based and goal-directed care to acutely ill general surgical patients who often present with a diverse range of complex pathologies and little or no pre- or postoperative planning. Through a team-based structure with attention to processes of care and information sharing, ACS services are well positioned to improve outcomes, while finding and developing efficiencies and reducing costs of surgical and emergency health care delivery. The ACS model also offers enhanced opportunities for surgical education for students, residents and practicing surgeons, and it will provide avenues to strengthen clinical and academic bonds between the community and academic surgical centres. In the near future, cooperation of ACS services from community and academic hospitals across the country will lead to the formation of systems of acute surgical care whose development will be informed by rigorous data collection and research and evidence-based quality-improvement initiatives. In an era of increasing subspecialization, ACS is a strong unifying force in general surgery and a platform for collective advocacy for an important patient population. PMID:20334738
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Bonnefoy-Cudraz, Eric; Bueno, Hector; Casella, Gianni; De Maria, Elia; Fitzsimons, Donna; Halvorsen, Sigrun; Hassager, Christian; Iakobishvili, Zaza; Magdy, Ahmed; Marandi, Toomas; Mimoso, Jorge; Parkhomenko, Alexander; Price, Susana; Rokyta, Richard; Roubille, Francois; Serpytis, Pranas; Shimony, Avi; Stepinska, Janina; Tint, Diana; Trendafilova, Elina; Tubaro, Marco; Vrints, Christiaan; Walker, David; Zahger, Doron; Zima, Endre; Zukermann, Robert; Lettino, Maddalena
2018-02-01
Acute cardiovascular care has progressed considerably since the last position paper was published 10 years ago. It is now a well-defined, complex field with demanding multidisciplinary teamworking. The Acute Cardiovascular Care Association has provided this update of the 2005 position paper on acute cardiovascular care organisation, using a multinational working group. The patient population has changed, and intensive cardiovascular care units now manage a large range of conditions from those simply requiring specialised monitoring, to critical cardiovascular diseases with associated multi-organ failure. To describe better intensive cardiovascular care units case mix, acuity of care has been divided into three levels, and then defining intensive cardiovascular care unit functional organisation. For each level of intensive cardiovascular care unit, this document presents the aims of the units, the recommended management structure, the optimal number of staff, the need for specially trained cardiologists and cardiovascular nurses, the desired equipment and architecture, and the interaction with other departments in the hospital and other intensive cardiovascular care units in the region/area. This update emphasises cardiologist training, referring to the recently updated Acute Cardiovascular Care Association core curriculum on acute cardiovascular care. The training of nurses in acute cardiovascular care is additionally addressed. Intensive cardiovascular care unit expertise is not limited to within the unit's geographical boundaries, extending to different specialties and subspecialties of cardiology and other specialties in order to optimally manage the wide scope of acute cardiovascular conditions in frequently highly complex patients. This position paper therefore addresses the need for the inclusion of acute cardiac care and intensive cardiovascular care units within a hospital network, linking university medical centres, large community hospitals, and smaller
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The US emergency care system: meeting everyday acute care needs while being ready for disasters.
Lurie, Nicole; Margolis, Gregg S; Rising, Kristin L
2013-12-01
The emergency care system is an essential part of the US health care system. In addition to providing acute resuscitation and life- and limb-saving care, the emergency care system provides considerable support to physicians outside the emergency department and serves as an important safety-net provider. In times of disaster, the emergency care system must be able to surge rapidly to accommodate a massive influx of patients, sometimes with little or no notice. Extreme daily demands on the system can promote innovations and adaptations that are invaluable in responding to disasters. However, excessive and inappropriate utilization is wasteful and can diminish "surge capacity" when it is most needed. Certain features of the US health care system have imposed strains on the emergency care system. We explore policy issues related to moving toward an emergency care system that can more effectively meet both individuals' needs for acute care and the broader needs of the community in times of disaster. Strategies for the redesign of the emergency care system must include the active engagement of both patients and the community and a close look at how to align incentives to reward quality and efficiency throughout the health care system.
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The Relative Importance of Post-Acute Care and Readmissions for Post-Discharge Spending.
Huckfeldt, Peter J; Mehrotra, Ateev; Hussey, Peter S
2016-10-01
To understand what patterns of health care use are associated with higher post-hospitalization spending. Medicare hospital, skilled nursing, inpatient rehabilitation, and home health agency claims, and Medicare enrollment data from 2007 and 2008. For 10 common inpatient conditions, we calculated variation across hospitals in price-standardized and case mix-adjusted Medicare spending in the 30 days following hospital discharge. We estimated the fraction of spending differences between low- and high-spending hospitals attributable to readmissions versus post-acute care, and within post-acute care between inpatient rehabilitation facility (IRF) versus skilled nursing facility (SNF) use. For each service, we distinguished between differences in probability of use and spending conditional on use. We identified index hospital claims and examined hospital and post-acute care occurring within a 30-day period following hospital discharge. For each Medicare Severity Diagnosis-Related Group (MS-DRG) at each hospital, we calculated average price-standardized Medicare payments for readmissions, SNFs, IRFs, and post-acute care overall (also including home health agencies and long-term care hospitals). There was extensive variation across hospitals in Medicare spending in the 30 days following hospital discharge. For example, the interquartile range across hospitals ranged from $1,245 for chronic obstructive pulmonary disease to over $4,000 for myocardial infarction MS-DRGs. The proportion of differences attributable to readmissions versus post-acute care differed across conditions. For myocardial infarction, 74 to 93 percent of the variation was due to readmissions. For hip and femur procedures and joint replacement, 72 to 92 percent of the variation was due to differences in post-acute care spending. There was also variation in the relative importance of the type of post-acute spending. For hip and femur procedures, joint replacement, and stroke, whether patients received IRF
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Landman, Adam B; Spatz, Erica S; Cherlin, Emily J; Krumholz, Harlan M; Bradley, Elizabeth H; Curry, Leslie A
2013-02-01
Evidence suggests that active collaboration between hospitals and emergency medical services (EMS) is significantly associated with lower acute myocardial infarction mortality rates; however, the nature of such collaborations is not well understood. We seek to characterize views of key hospital staff about collaboration with EMS in the care of patients hospitalized with acute myocardial infarction. We performed an exploratory analysis of qualitative data previously collected from site visits and detailed interviews with 11 US hospitals that ranked in the top or bottom 5% of performance on 30-day risk-standardized acute myocardial infarction mortality rates, using Centers for Medicare & Medicaid Services data from 2005 to 2007. We selected all codes from the previous analysis in which EMS was most likely to have been discussed. A multidisciplinary team analyzed the data with the constant comparative method to generate recurrent themes. Both higher- and lower-performing hospitals reported that EMS is critical to the provision of timely care for patients with acute myocardial infarction. However, close collaborative relationships with EMS were more apparent in the higher-performing hospitals, which demonstrated specific investment in and attention to EMS through respect for EMS as valued professionals and colleagues, strong communication and coordination with EMS and active engagement of EMS in hospital acute myocardial infarction quality improvement efforts. Hospital staff from higher-performing hospitals described broad, multifaceted strategies to support collaboration with EMS in providing acute myocardial infarction care. The association of these strategies with hospital performance should be tested quantitatively in a larger representative study. Copyright © 2012. Published by Mosby, Inc.
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Schiele, Francois; Gale, Chris P; Bonnefoy, Eric; Capuano, Frederic; Claeys, Marc J; Danchin, Nicolas; Fox, Keith Aa; Huber, Kurt; Iakobishvili, Zaza; Lettino, Maddalena; Quinn, Tom; Rubini Gimenez, Maria; Bøtker, Hans E; Swahn, Eva; Timmis, Adam; Tubaro, Marco; Vrints, Christiaan; Walker, David; Zahger, Doron; Zeymer, Uwe; Bueno, Hector
2017-02-01
Evaluation of quality of care is an integral part of modern healthcare, and has become an indispensable tool for health authorities, the public, the press and patients. However, measuring quality of care is difficult, because it is a multifactorial and multidimensional concept that cannot be estimated solely on the basis of patients' clinical outcomes. Thus, measuring the process of care through quality indicators (QIs) has become a widely used practice in this context. Other professional societies have published QIs for the evaluation of quality of care in the context of acute myocardial infarction (AMI), but no such indicators exist in Europe. In this context, the European Society of Cardiology (ESC) Acute Cardiovascular Care Association (ACCA) has reflected on the measurement of quality of care in the context of AMI (ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI)) and created a set of QIs, with a view to developing programmes to improve quality of care for the management of AMI across Europe. We present here the list of QIs defined by the ACCA, with explanations of the methodology used, scientific justification and reasons for the choice for each measure.
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The perspective of allied health staff on the role of nurses in sub-acute care.
Digby, Robin; Bolster, Danielle; Perta, Andrew; Bucknall, Tracey K
2018-06-12
To explore allied health staff perceptions on the role of nurses in sub-acute care wards. A consequence of earlier discharge from acute hospitals is higher acuity of patients in sub-acute care. The impact on nurses' roles and required skill mix remains unknown. Similarly, nurses' integration into the rehabilitation team is ambiguous. Descriptive qualitative inquiry. Semi-structured interviews conducted with 14 allied health staff from one sub-acute care facility in Melbourne, Australia. Interviews were audio-recorded and transcribed verbatim. Analysis using the framework approach. Three main themes were evident: 1) The changing context of care: patient acuity, rapid patient discharge and out-dated buildings influenced care, 2) Generalist as opposed to specialist rehabilitation nurses: a divide between traditional nursing roles of clinical and personal care and a specialist rehabilitation role, and 3) Interdisciplinary relations and communication demonstrated lack of respect for nurses and integrating holistic care into everyday routines. Allied health staff had limited understanding of nurses' role in sub-acute care, and expectations varied. Power relationships appeared to hamper teamwork. Failure to include nurses in team discussions and decision-making could hinder patient outcomes. Progressing patients to levels of independence involves both integrating rehabilitation into activities of daily living with nurses and therapy-based sessions. Promotion of the incorporation of nursing input into patient rehabilitation is needed with both nurses and allied health staff. Lack of understanding of the nurses' role contributes to lack of respect for the nursing contribution to rehabilitation. Nurses have a key role in rehabilitation sometimes impeded by poor teamwork with allied health staff. Processes in sub-acute care wards need examination to facilitate more effective team practices inclusive of nurses. Progressing patients' independence in rehabilitation units
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Bartanusz, Viktor; Corneille, Michael G; Sordo, Salvador; Gildea, Marianne; Michalek, Joel E; Nair, Prakash V; Stewart, Ronald M; Jezova, Daniela
2014-12-01
Acute trauma patients represent a specific subgroup of the critically ill population due to sudden and dramatic changes in homeostasis and consequently extreme demands on the activity of the hypothalamic-pituitary-adrenocortical (HPA) axis. Salivary cortisol is an accepted surrogate for serum free cortisol in the assessment of HPA axis function. The purpose of this study was (1) to establish the feasibility of salivary cortisol measurement in acute trauma patients in the neurosurgical-surgical intensive care unit (NSICU), and (2) to determine the diurnal pattern of salivary cortisol in the acute phase after injury. Saliva from 50 acute trauma patients was prospectively collected twice a day at 6AM and 4PM during the first week after injury in the NSICU. Mean PM cortisol concentrations were significantly higher in subjects versus controls (p<0.001). Subjects failed to develop the expected PM versus AM decrease in cortisol concentration seen in controls (p=0.005). Salivary cortisol did not vary significantly with baseline Glasgow Coma Scale (GCS), Injury Severity Score, sex, injury type, ethnicity, or age. When comparing mean AM and PM salivary cortisol by GCS severity category (GCS ⩽8 and GCS >8) the AM salivary cortisol was significantly higher in patients with GCS ⩽8 (p=0.002). The results show a loss of diurnal cortisol variation in acute trauma patient in the NSICU during the first week of hospitalization. Patients with severe brain injury had higher morning cortisol levels than those with mild/moderate brain injury. Copyright © 2014 Elsevier Ltd. All rights reserved.
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Taw, Benedict B T; Lam, Alan C S; Ho, Faith L Y; Hung, K N; Lui, W M; Leung, Gilberto K K
2012-07-01
Severe head injury is known to be a major cause of early mortalities and morbidities. Patients' long-term outcome after acute care, however, has not been widely studied. We aim to review the outcome of severely head-injured patients after discharge from acute care at a designated trauma center in Hong Kong. This is a retrospective study of prospectively collected data of patients admitted with severe head injuries between 2004 and 2008. Patients' functional status post-discharge was assessed using the Extended Glasgow Outcome Score (GOSE). Of a total of 1565 trauma patients, 116 had severe head injuries and 41 of them survived acute hospital care. Upon the last follow-up, 23 (56.1%) of the acute-care survivors had improvements in their GOSE, six (11.8%) experienced deteriorations, and 12 (23.5%) did not exhibit any change. The greatest improvement was observed in patients with GOSE of 5 and 6 upon discharge, but two of the 16 patients with GOSE 2 or 3 also had a good recovery. On logistic regression analysis, old age and prolonged acute hospital stay were found to be independent predictors of poor functional outcome after a mean follow-up duration of 42 months. Multidisciplinary neurorehabilitation service is an important component of comprehensive trauma care. Despite significant early mortalities, a proportion of severely head-injured patients who survive acute care may achieve good long-term functional recovery. Copyright © 2012, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved.
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Facilitating earlier transfer of care from acute stroke services into the community.
Robinson, Jennifer
This article outlines an initiative to reduce length of stay for stroke patients within an acute hospital and to facilitate earlier transfer of care. Existing care provision was remodelled and expanded to deliver stroke care to patients within a community bed-based intermediate care facility or intermediate care at home. This new model of care has improved the delivery of rehabilitation through alternative and innovative ways of addressing service delivery that meet the needs of the patients.
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Pirhonen, Laura; Olofsson, Elisabeth Hansson; Fors, Andreas; Ekman, Inger; Bolin, Kristian
2017-02-01
To study the effects of person-centred care provided to patients with acute coronary syndrome, using four different health-related outcome measures. Also, to examine the performance of these outcomes when measuring person-centred care. The data used in this study consists of primary data from a multicentre randomized parallel group, controlled intervention study for patients with acute coronary syndrome at Sahlgrenska University Hospital in Gothenburg, Sweden. The intervention and control group consisted of 94 and 105 patients, respectively. The effect of the intervention on health-related outcomes was estimated, controlling for socio-economic and disease-related variables. Patients in the intervention group reported significantly higher general self-efficacy than those in the control group six months after intervention start-up. Moreover, the intervention group returned to work in a greater extent than controls; their physical activity level had increased more and they had a higher EQ-5D score, meaning higher health-related quality of life. These latter effects are not significant but are all pointing towards the beneficial effects of person-centred care. All the effects were estimated while controlling for important socio-economic and disease-related variables. The effectiveness of person-centred care varies between different outcomes considered. A statistically significant beneficial effect was found for one of the four outcome measures (self-efficacy). The other measures all captured beneficial, but not significant, effects. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
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Snow, Richard; Granata, Jaymes; Ruhil, Anirudh V S; Vogel, Karen; McShane, Michael; Wasielewski, Ray
2014-10-01
Health-care costs following acute hospital care have been identified as a major contributor to regional variation in Medicare spending. This study investigated the associations of preoperative physical therapy and post-acute care resource use and its effect on the total cost of care during primary hip or knee arthroplasty. Historical claims data were analyzed using the Centers for Medicare & Medicaid Services Limited Data Set files for Diagnosis Related Group 470. Analysis included descriptive statistics of patient demographic characteristics, comorbidities, procedures, and post-acute care utilization patterns, which included skilled nursing facility, home health agency, or inpatient rehabilitation facility, during the ninety-day period after a surgical hospitalization. To evaluate the associations, we used bivariate and multivariate techniques focused on post-acute care use and total episode-of-care costs. The Limited Data Set provided 4733 index hip or knee replacement cases for analysis within the thirty-nine-county Medicare hospital referral cluster. Post-acute care utilization was a significant variable in the total cost of care for the ninety-day episode. Overall, 77.0% of patients used post-acute care services after surgery. Post-acute care utilization decreased if preoperative physical therapy was used, with only 54.2% of the preoperative physical therapy cohort using post-acute care services. However, 79.7% of the non-preoperative physical therapy cohort used post-acute care services. After adjusting for demographic characteristics and comorbidities, the use of preoperative physical therapy was associated with a significant 29% reduction in post-acute care use, including an $871 reduction of episode payment driven largely by a reduction in payments for skilled nursing facility ($1093), home health agency ($527), and inpatient rehabilitation ($172). The use of preoperative physical therapy was associated with a 29% decrease in the use of any post-acute care
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Trends in acute psychiatric inpatient care in Massachusetts.
Hudson, Christopher G
2004-11-01
This report presents the preliminary results of a longitudinal study of acute psychiatric hospitalization in the Commonwealth of Massachusetts for fiscal years 1994 to 2000. The study was a secondary analysis of data obtained through the Commonwealth's mandated case-mix reporting system, covering 42 acute psychiatric facilities and 119,284 patients. Results include a 58.4 percent increase in the patient population, accompanied by declines in both length of stay and readmission rates; increases in the number of diagnoses of depression and in the number of patient deaths; and shifts to an older population increasingly supported by Medicaid and Medicare, especially managed care programs.
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King, Allana; Long, Lesley; Lisy, Karolina
2015-11-01
The organization of the work of nurses, according to recognized models of care, can have a significant impact on the wellbeing and performance of nurses and nursing teams. This review focuses on two models of nursing care delivery, namely, team and total patient care, and their effect on nurses' wellbeing. To examine the effectiveness of team nursing compared to total patient care on staff wellbeing when organizing nursing work in acute care wards. Participants were nurses working on wards in acute care hospitals.The intervention was the use of a team nursing model when organizing nursing work. The comparator was the use of a total patient care model.This review considered quantitative study designs for inclusion in the review.The outcome of interest was staff wellbeing which was measured by staff outcomes in relation to job satisfaction, turnover, absenteeism, stress levels and burnout. The search strategy aimed to find both published and unpublished studies from 1995 to April 21, 2014. Quantitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute. Data was extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute. The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and its specific objectives. Due to the heterogeneity of the included quantitative studies, meta-analysis was not possible. Results have been presented in a narrative form. The database search returned 10,067 records. Forty-three full text titles were assessed, and of these 40 were excluded, resulting in three studies being included in the review. Two of the studies were quasi experimental designs and the other was considered an uncontrolled before and after experimental study
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Improving acute care through use of medical device data.
Kennelly, R J
1998-02-01
The Medical Information Bus (MIB) is a data communications standard for bedside patient connected medical devices. It is formally titled IEEE 1073 Standard for Medical Device Communications. MIB defines a complete seven layer communications stack for devices in acute care settings. All of the design trade-offs in writing the standard were taken to optimize performance in acute care settings. The key clinician based constraints on network performance are: (1) the network must be able to withstand multiple daily reconfigurations due to patient movement and condition changes; (2) the network must be 'plug-and-play' to allow clinicians to set up the network by simply plugging in a connector, taking no other actions; (3) the network must allow for unambiguous associations of devices with specific patients. A network of this type will be used by clinicians, thus giving complete, accurate, real time data from patient connected devices. This capability leads to many possible improvements in patient care and hospital cost reduction. The possible uses for comprehensive automatic data capture are only limited by imagination and creativity of clinicians adapting to the new hospital business paradigm.
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Reasoning about truth-telling in end-of-life care of patients with acute stroke.
Rejnö, Åsa; Silfverberg, Gunilla; Ternestedt, Britt-Marie
2017-02-01
Ethical problems are a universal phenomenon but rarely researched concerning patients dying from acute stroke. These patients often have a reduced consciousness from stroke onset and thereby lack ability to convey their needs and could be described as 'incompetent' decision makers regarding their own care. The aim of the study was to deepen the understanding of stroke team members' reasoning about truth-telling in end-of-life care due to acute stroke. Qualitative study based on individual interviews utilizing combined deductive and inductive content analysis. Participants and research context: A total of 15 stroke team members working in stroke units of two associated county hospitals in western Sweden participated. Ethical considerations: The study was approved by the Regional Ethics Review Board, Gothenburg, Sweden. The main findings were the team members' dynamic movement between the categories 'Truth above all' and 'Hide truth to protect'. Honesty was highly valued and considered as a reason for always telling the truth, with the argument of truth as common morality. However, the carers also argued for hiding the truth for different reasons such as not adding extra burden in the sorrow, awaiting a timely moment and not being a messenger of bad news. Withholding truth could both be seen as a way of protecting themselves from difficult conversations and to protect others. The results indicate that there are various barriers for truthfulness. Interpreted from a virtue of ethics perspective, withholding of truth might also be seen as an expression of sound judgement to put the patient's best interest first. The carers may need support in the form of supervision to be given space to reflect on their experience and thereby promote ethically justified care. Here, the multi-professional team can be of great value and contribute through inter-professional sharing of knowledge.
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Rehabilitation Practitioners' Prioritized Care Processes in Hip Fracture Post-Acute Care
Kim, Lauren H.; Leland, Natalie E.
2017-01-01
Aims Occupational and physical therapy in post-acute care (PAC) has reached the point where quality indicators for hip fracture are needed. This study characterizes the practitioners' prioritized hip fracture rehabilitation practices, which can guide future quality improvement initiatives. Methods Ninety-two practitioners participating in a parent mixed methods study were asked to rank a series of evidence-based best practices across five clinical domains (assessment, intervention, discharge planning, caregiver training and patient education). Results Prioritized practices reflected patient-practitioner collaboration, facilitating an effective discharge, and preventing adverse events. The highest endorsed care processes include: developing meaningful goals with patient input (84%) in assessment, using assistive devices in intervention (75%) and patient education (65%), engaging the patient and caregiver (50%) in discharge planning, and fall prevention (60%) in caregiver education. Conclusions Practitioners identified key care priorities. This study lays the foundation for future work evaluating the extent to which these practices are delivered in PAC. PMID:28989216
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Walley, Alexander Y; Paasche-Orlow, Michael; Lee, Eugene C; Forsythe, Shaula; Chetty, Veerappa K; Mitchell, Suzanne; Jack, Brian W
2012-03-01
Hospital discharge may be an opportunity to intervene among patients with substance use disorders to reduce subsequent hospital utilization. This study determined whether having a substance use disorder diagnosis was associated with subsequent acute care hospital utilization. We conducted an observational cohort study among 738 patients on a general medical service at an urban, academic, safety-net hospital. The main outcomes were rate and risk of acute care hospital utilization (emergency department visit or hospitalization) within 30 days of discharge. The main independent variable was presence of a substance use disorder primary or secondary discharge diagnosis code at the index hospitalization. At discharge, 17% of subjects had a substance use disorder diagnosis. These patients had higher rates of recurrent acute care hospital utilization than patients without substance use disorder diagnoses (0.63 vs 0.32 events per subject at 30 days, P < 0.01) and increased risk of any recurrent acute care hospital utilization (33% vs 22% at 30 days, P < 0.05). In adjusted Poisson regression models, the incident rate ratio at 30 days was 1.49 (95% confidence interval, 1.12-1.98) for patients with substance use disorder diagnoses compared with those without. In subgroup analyses, higher utilization was attributable to those with drug diagnoses or a combination of drug and alcohol diagnoses, but not to those with exclusively alcohol diagnoses. Medical patients with substance use disorder diagnoses, specifically those with drug use-related diagnoses, have higher rates of recurrent acute care hospital utilization than those without substance use disorder diagnoses.
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The costs and service implications of substituting intermediate care for acute hospital care.
Mayhew, Leslie; Lawrence, David
2006-05-01
Intermediate care is part of a package of initiatives introduced by the UK Government mainly to relieve pressure on acute hospital beds and reduce delayed discharge (bed blocking). Intermediate care involves caring for patients in a range of settings, such as in the home or community or in nursing and residential homes. This paper considers the scope of intermediate care and its role in relation to acute hospital services. In particular, it develops a framework that can be used to inform decisions about the most cost-effective care pathways for given clinical situations, and also for wider planning purposes. It does this by providing a model for evaluating the costs of intermediate care services provided by different agencies and techniques for calibrating the model locally. It finds that consistent application of the techniques over a period of time, coupled with sound planning and accounting, should result in savings to the health economy.
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Small, Neil; Green, John; Spink, Joanna; Forster, Anne; Young, John
2009-01-01
This article contrasts community hospital and general hospital philosophies of care and examines how they relate to patients' and caregivers' experiences. Semi-structured interviews with 42 staff were used to produce care setting vignettes in six community hospitals and four general hospitals in the midlands and north of England. The vignettes were used with 26 patients and 10 caregivers in semi-structured interviews. Community hospital and general hospital staff identified shared understandings of requirements for post-acute rehabilitation care for older people. Distinctive features were: general hospital--medical efficiency, helping patients get better, high standard of care, need for stimulation; community hospital--home-like setting, quiet, calm ambience, good views, orientated to elderly people, encouragement of social interaction, involvement of relatives in care. In the main there was symmetry between staff aspirations and patients' experience. However some concepts used and assumptions made by staff were not recognised by patients. These were characteristically reframed in patients' answers as if they were discussing subjective dimensions of care. There was patient and caregiver preference for the home-like environment of community hospitals. In care of older people, where the focus is rehabilitation, patient preferences are particularly pertinent and should be considered alongside clinical outcomes and cost-effectiveness.
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Chao, Tzu-Hao; Hsieh, Tien-Jen; Wang, Vinchi
2014-12-01
There were many reports about the "do not resuscitate" (DNR) order while practicing in the critical care units and conducting hospice affairs but limited in the neurological issues. This study investigated the possible flaws in the execution of the DNR order among patients who received acute neurological care in Taiwan. Over a 3-year period, we retrospectively reviewed the medical records of 77 deceased patients with neurological conditions for DNR orders. Registry and analysis works included demography, hospital courses, DNR data, and clinical usefulness of the lab and image examinations. Sixty-seven DNR orders were requested by the patients' families, and more than half were signed by the patients' children or grandchildren. The main DNR items were chest compression, cardiac defibrillation, and pacemaker use, although several DNR patients received resuscitation. The mean duration from the coding date to death was 7.6 days. Two-thirds of the patients with DNR requests remained in the intensive care unit, with a mean stay of 6.9 days. Several patients underwent regular roentgenography and blood tests on the day of their death, despite their DNR orders. Hospital courses and DNR items may be valuable information on dealing with the patients with DNR orders. The results of this study also suggest the public education about the DNR orders implemented for neurological illnesses.
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The outcomes of the elderly in acute care general surgery.
St-Louis, E; Sudarshan, M; Al-Habboubi, M; El-Husseini Hassan, M; Deckelbaum, D L; Razek, T S; Feldman, L S; Khwaja, K
2016-02-01
Elderly patients form a growing subset of the acute care surgery (ACS) population. Older age may be associated with poorer outcomes for some elective procedures, but there are few studies focusing on outcomes for the elderly ACS population. Our objective is to characterize differences in mortality and morbidity for acute care surgery patients >80 years old. A retrospective review of all ACS admissions at a large teaching hospital over 1 year was conducted. Patients were classified into non-elderly (<80 years old) and elderly (≥80 years old). In addition to demographic differences, outcomes including care efficiency, mortality, postoperative complications, and length of stay were studied. Data analysis was completed with the Student's t test for continuous variables and Fisher's exact test for categorical variables using STATA 12 (College Station, TX, USA). We identified 467 non-elderly and 60 elderly patients with a mean age-adjusted Charlson score of 3.2 and 7.2, respectively (p < 0.001) and a mortality risk of 1.9 and 11.7 %, respectively (p < 0.001). The elderly were at risk of longer duration (>4 days) hospital stay (p = 0.05), increased postoperative complications (p = 0.002), admission to the ICU (p = 0.002), and were more likely to receive a non-operative procedure (p = 0.003). No difference was found (p = NS) for patient flow factors such as time to consult general surgery, time to see consult by general surgery, and time to operative management and disposition. Compared to younger patients admitted to an acute care surgery service, patients over 80 years old have a higher risk of complications, are more likely to require ICU admission, and stay longer in the hospital.
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[Cases of acute poisoning admitted to a medical intensive care unit].
Viertel, A; Weidmann, E; Brodt, H R
2001-10-19
Because of the paucity of information on the epidemiology of acute poisoning requiring intensive medical care, all such patients treated on the medical intensive care unit of the university hospital in Frankfurt am Main, Germany, between January 1993 and December 1999, were retrospectively evaluated. Of the total of 6211 patients, 147 (80 women, 67 men, mean age 41 years, 2,3 %) were treated for acute intoxication in the intensive care unit. Reasons for admission to the intensive care unit were the need for ventilator treatment or intensive monitoring of vital functions. 52 % of the patients (n = 76) had attempted suicide, most of them using anti-depressive drugs (n = 19), paracetamol (n = 16), or benzodiazepines (n = 9). Two patients (2,6 %) died. 48 % of the patients (n = 71) were admitted because of accidental poisoning. Leading toxic agents in this group were heroin (n = 19), alcohol (n = 18) and digitalis (n = 12). 11 patients had taken herbicides, animal poisons or chemicals used at work or for house cleaning. In this cohort, three i. v. drug abusers (4,2 %) had died. Depending on the agents used, a variety of treatments (charcoal, antidots, extracorporal therapy) were undertaken. Due to excellent care in the prehospital phase and in the emergency room the number of patients requiring treatment on the intensive care unit was rather low. The mortality was in the range of other reports.
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Patients' and Care Partners' Perspectives on Dignity and Respect During Acute Care Hospitalization.
Gazarian, Priscilla K; Morrison, Constance R C; Lehmann, Lisa Soleymani; Tamir, Orly; Bates, David W; Rozenblum, Ronen
2017-02-22
Delivering patient-centered care (PCC) is essential to our healthcare system. Patient dignity and respect are foundational elements of PCC. Understanding patients' and their care partner's perspectives on the meaning of dignity and respect within a clinical care environment is critical to achieving our goal of PCC. The aim of the study was to understand how patients and their care partners define, describe, and experience dignity and respect during hospitalization. We conducted a qualitative study with 22 patients and care partners hospitalized in high-acuity patient care areas in 1 academic medical center. Data collected from semistructured interviews were analyzed using grounded theory open coding in Atlas Ti software. Our data provide a definition of dignity and respect during hospitalization from the patient and care partner perspective and a conceptual model of the factors needed to enhance patients' and care partners' experience of dignity and respect in the hospital setting. Dignity was felt to be intrinsic to personhood including the recognition of that person's value by others. Respect was characterized as the behavioral or social norms that acknowledge dignity. Determinants of dignity and respect were categorized at the organizational (macro) level and within the microsystem between clinicians, patients, and their care partners. The definition of dignity and respect and the conceptual model presented here represent an important supplement to our understanding of dignity and respect during hospitalization. Healthcare organizations should focus on the key factors found in this study to create a culture that treats patients with dignity and respect.
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Variability in antibiotic use across Ontario acute care hospitals.
Tan, Charlie; Vermeulen, Marian; Wang, Xuesong; Zvonar, Rosemary; Garber, Gary; Daneman, Nick
2017-02-01
Antibiotic stewardship is a required organizational practice for Canadian acute care hospitals, yet data are scarce regarding the quantity and composition of antibiotic use across facilities. We sought to examine the variability, and risk-adjusted variability, in antibiotic use across acute care hospitals in Ontario, Canada's most populous province. Antibiotic purchasing data from IMS Health, previously demonstrated to correlate strongly with internal antibiotic dispensing data, were acquired for 129 Ontario hospitals from January to December 2014 and linked to patient day (PD) denominator data from administrative datasets. Hospital variation in DDDs/1000 PDs was determined for overall antibiotic use, class-specific use and six practices of clinical or ecological significance. Multivariable risk adjustment for hospital and patient characteristics was used to compare observed versus expected utilization. There was 7.4-fold variability in the quantity of antibiotic use across the 129 acute care hospitals, from 253 to 1873 DDDs/1000 PDs. Variation was evident within hospital subtypes, exceeded that explained by hospital and patient characteristics, and included wide variability in proportion of broad-spectrum antibiotics (IQR 36%-48%), proportion of fluoroquinolones among respiratory antibiotics (IQR 40%-62%), proportion of ciprofloxacin among urinary anti-infectives (IQR 44%-60%), proportion of antibiotics with highest risk for Clostridium difficile (IQR 29%-40%), proportion of 'reserved-use' antibiotics (IQR 0.8%-3.5%) and proportion of anti-pseudomonal antibiotics among antibiotics with Gram-negative coverage (IQR 26%-40%). There is extensive variability in antibiotic use, and risk-adjusted use, across acute care hospitals. This could motivate, focus and benchmark antibiotic stewardship efforts. © The Author 2016. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please email
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Smeds-Alenius, Lisa; Tishelman, Carol; Lindqvist, Rikard; Runesdotter, Sara; McHugh, Matthew D
2016-09-01
Quality and safety in health care has been increasingly in focus during the past 10-15 years. Stakeholders actively discuss ways to measure safety and quality of care to improve the health care system as a whole. Defining and measuring quality and safety, however, is complicated. One underutilized resource worthy of further exploration is the use of registered nurses (RNs) as informants of overall quality of care and patient safety. However, research is still scarce or lacking regarding RN assessments of patient safety and quality of care and their relationship to objective patient outcomes. To investigate relationships between RN assessed quality of care and patient safety and 30-day inpatient mortality post-surgery in acute-care hospitals. This is a national cross-sectional study. A survey (n=>10,000 RNs); hospital organizational data (n=67); hospital discharge registry data (n>200,000 surgical patients). RN data derives from a national sample of RNs working directly with inpatient care in surgical/medical wards in acute-care hospitals in Sweden in 2010. Patient data are from the same hospitals in 2009-2010. Adjusted multivariate logistic regression models were used to estimate relationships between RN assessments and 30-day inpatient mortality. Patients cared for in hospitals where a high proportion of RNs reported excellent quality of care (the highest third of hospitals) had 23% lower odds of 30-day inpatient mortality compared to patients cared for in hospitals in the lowest third (OR 0.77, CI 0.65-0.91). Similarly, patients in hospitals where a high proportion of RNs reported excellent patient safety (highest third) had is 26% lower odds of death (OR 0.74, CI 0.60-0.91). RN assessed excellent patient safety and quality of care are related to significant reductions in odds of 30-day inpatient mortality, suggesting that positive RN reports of quality and safety can be valid indicators of these key variables. Copyright © 2016 The Author(s). Published by
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Creating learning momentum through overt teaching interactions during real acute care episodes.
Piquette, Dominique; Moulton, Carol-Anne; LeBlanc, Vicki R
2015-10-01
Clinical supervisors fulfill a dual responsibility towards patient care and learning during clinical activities. Assuming such roles in today's clinical environments may be challenging. Acute care environments present unique learning opportunities for medical trainees, as well as specific challenges. The goal of this paper was to better understand the specific contexts in which overt teaching interactions occurred in acute care environments. We conducted a naturalistic observational study based on constructivist grounded theory methodology. Using participant observation, we collected data on the teaching interactions occurring between clinical supervisors and medical trainees during 74 acute care episodes in the critical care unit of two academic centers, in Toronto, Canada. Three themes contributed to a better understanding of the conditions in which overt teaching interactions among trainees and clinical supervisors occurred during acute care episodes: seizing emergent learning opportunities, coming up against challenging conditions, and creating learning momentum. Our findings illustrate how overt learning opportunities emerged from certain clinical situations and how clinical supervisors and trainees could purposefully modify unfavorable learning conditions. None of the acute care episodes encountered in the critical care environment represented ideal conditions for learning. Yet, clinical supervisors and trainees succeeded in engaging in overt teaching interactions during many episodes. The educational value of these overt teaching interactions should be further explored, as well as the impact of interventions aimed at increasing their use in acute care environments.
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Feasibility and Efficacy of Nurse-Driven Acute Stroke Care.
Mainali, Shraddha; Stutzman, Sonja; Sengupta, Samarpita; Dirickson, Amanda; Riise, Laura; Jones, Donald; Yang, Julian; Olson, DaiWai M
2017-05-01
Acute stroke care requires rapid assessment and intervention. Replacing traditional sequential algorithms in stroke care with parallel processing using telestroke consultation could be useful in the management of acute stroke patients. The purpose of this study was to assess the feasibility of a nurse-driven acute stroke protocol using a parallel processing model. This is a prospective, nonrandomized, feasibility study of a quality improvement initiative. Stroke team members had a 1-month training phase, and then the protocol was implemented for 6 months and data were collected on a "run-sheet." The primary outcome of this study was to determine if a nurse-driven acute stroke protocol is feasible and assists in decreasing door to needle (intravenous tissue plasminogen activator [IV-tPA]) times. Of the 153 stroke patients seen during the protocol implementation phase, 57 were designated as "level 1" (symptom onset <4.5 hours) strokes requiring acute stroke management. Among these strokes, 78% were nurse-driven, and 75% of the telestroke encounters were also nurse-driven. The average door to computerized tomography time was significantly reduced in nurse-driven codes (38.9 minutes versus 24.4 minutes; P < .04). The use of a nurse-driven protocol is feasible and effective. When used in conjunction with a telestroke specialist, it may be of value in improving patient outcomes by decreasing the time for door to decision for IV-tPA. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.
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Delivering quality care: what can emergency gynaecology learn from acute obstetrics?
Bika, O H; Edozien, L C
2014-08-01
Emergency obstetric care in the UK has been systematically developed over the years to high quality standards. More recently, advances have been made in the organisation and delivery of care for women presenting with acute gynaecological problems, but a lot remains to be done, and emergency gynaecology has a lot to learn from the evolution of its sister special interest area: acute obstetric care. This paper highlights areas such as consultant presence, risk management, patient flow pathways, out-of-hours care, clinical guidelines and protocols, education and training and facilities, where lessons from obstetrics are transferrable to emergency gynaecology.
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Johnston, Bridget; Pringle, Jan; Gaffney, Marion; Narayanasamy, Melanie; McGuire, Margaret; Buchanan, Deans
2015-01-01
Providing person-centred, dignity-conserving care for hospitalised patients is central to many healthcare policies and essential to the provision of effective palliative care. The Patient Dignity Question (PDQ) "What do I need to know about you as a person to take the best care of you that I can?" was designed from empirical research on patients' perceptions of their dignity at end of life to help healthcare professionals (HCPs) understand the patient as a person. This mixed method pilot study was designed to inform a larger multisite study in the future. It tests the hypothesis that the PDQ intervention could be used to enhance a more person-centred climate for people with palliative care needs in the acute hospital setting, and provide evidence regarding its acceptability. Outcome measures pre and post intervention Person-centred Climate Questionnaire--patient version (PCQ-P), and the Consultation and Relational Empathy (CARE) measure; PDQ feedback questionnaires were used for all participants post intervention, in addition to qualitative interviews. 30 patients, 17 HCPs, and 4 family members participated. Results showed a positive correlation between higher PCQ-P scores and higher CARE scores, indicating that the PDQ can make improvements to a person-centred environment and levels of empathy perceived by patients. Individual results from the PCQ-P and the CARE indicated overall improvements in the majority of fields. The PDQ supported disclosure of information previously unknown to HCPs, has implications for improving person-centred care. Positive results from PDQ feedback questionnaires were received from all participants. Qualitative findings indicated patients' appreciation of staff (Attributes and attitudes), that patients wanted staff to have awareness of them (Know me as a person), take the time to talk, and work flexibly, to allow for patient individuality (Time and place). The PDQ has potential to improve patients' perceptions of care, and HCP attitudes
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Konetzka, R Tamara; Stuart, Elizabeth A; Werner, Rachel M
2018-02-07
In this paper we examine empirically the effect of integration on Medicare payment and rehospitalization. We use 2005-2013 data on Medicare beneficiaries receiving post-acute care (PAC) in the U.S. to examine integration between hospitals and the two most common post-acute care settings: skilled nursing facilities (SNFs) and home health agencies (HHA), using two measures of integration-formal vertical integration and informal integration representing preferential relationships between providers without formal relationships. Our identification strategy is twofold. First, we use longitudinal models with a fixed effect for each hospital-PAC pair in a market to test how changes in integration impact patient outcomes. Second, we use an instrumental variable approach to account for patient selection into integrated providers. We find that vertical integration between hospitals and SNFs increases Medicare payments and reduces rehospitalization rates. However, vertical integration between hospitals and HHAs has little effect, nor does informal integration between hospitals and either PAC setting. Copyright © 2018 The Author(s). Published by Elsevier B.V. All rights reserved.
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Chang, Esther; Hancock, Karen; Hickman, Louise; Glasson, Janet; Davidson, Patricia
2007-09-01
There is a lack of research investigating models of nursing care for older hospitalised patients that address the nursing needs of this group. The objective of this study is to evaluate the efficacy of models of care for acutely older patients tailored to two contexts: an aged care specific ward and a medical ward. This is a repeated measures design. Efficacy of the models was evaluated in terms of: patient and nurses' satisfaction with care provided; increased activities of daily living; reduced unplanned hospital readmissions; and medication knowledge. An aged care specific ward and a medical ward in two Sydney teaching hospitals. There were two groups of patients aged 65 years or older who were admitted to hospital for an acute illness: those admitted prior to model implementation (n=232) and those admitted during model implementation (n=116). Patients with moderate or severe dementia were excluded. The two groups of nurses were the pre-model group (n=90) who were working on the medical and aged care wards for the study prior to model implementation, and the post-model group (n=22), who were the nurses working on the wards during model implementation. Action research was used to develop the models of care in two wards: one for an aged care specific ward and another for a general medical ward where older patients were admitted. The models developed were based on empirical data gathered in an earlier phase of this study. The models were successful in both wards in terms of increasing satisfaction levels in patients and nurses (p<0.001), increasing functional independence as measured by activities of daily living (p<0.01), and increasing medication knowledge (p<0.001). Findings indicate that models of care developed by nurses using an evidence-based action research strategy can enhance both satisfaction and health outcomes in older patients.
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Association of Cost Sharing With Mental Health Care Use, Involuntary Commitment, and Acute Care.
Ravesteijn, Bastian; Schachar, Eli B; Beekman, Aartjan T F; Janssen, Richard T J M; Jeurissen, Patrick P T
2017-09-01
A higher out-of-pocket price for mental health care may lead not only to cost savings but also to negative downstream consequences. To examine the association of higher patient cost sharing with mental health care use and downstream effects, such as involuntary commitment and acute mental health care use. This difference-in-differences study compared changes in mental health care use by adults, who experienced an increase in cost sharing, with changes in youths, who did not experience the increase and thus formed a control group. The study examined all 2 780 558 treatment records opened from January 1, 2010, through December 31, 2012, by 110 organizations that provide specialist mental health care in the Netherlands. Data analysis was performed from January 18, 2016, to May 9, 2017. On January 1, 2012, the Dutch national government increased the out-of-pocket price of mental health services for adults by up to €200 (US$226) per year for outpatient treatment and €150 (US$169) per month for inpatient treatment. The number of treatment records opened each day in regular specialist mental health care, involuntary commitment, and acute mental health care, and annual specialist mental health care spending. This study included 1 448 541 treatment records opened from 2010 to 2012 (mean [SD] age, 41.4 [16.7] years; 712 999 men and 735 542 women). The number of regular mental health care records opened for adults decreased abruptly and persistently by 13.4% (95% CI, -16.0% to -10.8%; P < .001) per day when cost sharing was increased in 2012. The decrease was substantial and significant for severe and mild disorders and larger in low-income than in high-income neighborhoods. Simultaneously, in 2012, daily record openings increased for involuntary commitment by 96.8% (95% CI, 87.7%-105.9%; P < .001) and for acute mental health care by 25.1% (95% CI, 20.8%-29.4%; P < .001). In contrast to our findings for adults, the use of regular care among youths
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Mobile integrated health to reduce post-discharge acute care visits: A pilot study.
Siddle, Jennica; Pang, Peter S; Weaver, Christopher; Weinstein, Elizabeth; O'Donnell, Daniel; Arkins, Thomas P; Miramonti, Charles
2018-05-01
Mobile Integrated Health (MIH) leverages specially trained paramedics outside of emergency response to bridge gaps in local health care delivery. To evaluate the efficacy of a MIH led transitional care strategy to reduce acute care utilization. This was a retrospective cohort analysis of a quality improvement pilot of patients from an urban, single county EMS, MIH transitional care initiative. We utilized a paramedic/social worker (or social care coordinator) dyad to provide in home assessments, medication review, care coordination, and improve access to care. The primary outcome compared acute care utilization (ED visits, observation stays, inpatient visits) 90days before MIH intervention to 90days after. Of the 203 patients seen by MIH teams, inpatient utilization decreased significantly from 140 hospitalizations pre-MIH to 26 post-MIH (83% reduction, p=0.00). ED and observation stays, however, increased numerically, but neither was significant. (ED 18 to 19 stays, p=0.98; observation stays 95 to 106, p=0.30) Primary care visits increased 15% (p=0.11). In this pilot before/after study, MIH significantly reduces acute care hospitalizations. Copyright © 2017 Elsevier Inc. All rights reserved.
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[Prehospital care of patients with acute ST elevation myocardial infarction].
Arntz, Hans-Richard
2005-12-01
Symptomatic prehospital therapy of patients suffering from an ST elevation myocardial infarction basically does not differ from in-hospital care regarding pain relief, beta-blockers, antiplatelets, and thrombin antagonists as well as therapy of elevated blood pressure and acute heart failure. Precondition of a targeted and adequate treatment, however, is the twelve-lead ECG whose reliability does not differ from the ECG in the hospital. Biomarkers have no role in the prehospital setting. Out-of-hospital thrombolysis, which has been proven to be superior to later in-hospital initiation, can be used as a safe strategy for reperfusion. Only the prehospital phase offers a chance to treat the majority of patients within the first 2 h after symptom onset, a time window where thrombolysis results in equal or even better outcomes with respect to mortality, if compared to percutaneous intervention. Therefore, prehospital thrombolysis should be routinely applied in areas with a weak infrastructure and few and less experienced facilities for intervention but should also be considered a principal way for earliest start of reperfusion therapy. There is increasing evidence supporting the "rescue PCI" concept in patients in whom thrombolysis has failed. By contrast, the role of "facilitated PCI" still has to be defined.
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Anderson, Deverick J.; Cochran, Ronda L.; Hicks, Lauri A.; Srinivasan, Arjun; Dodds Ashley, Elizabeth S.
2017-01-01
Antimicrobial stewardship programs (ASPs) positively impact patient care, but metrics to assess ASP impact are poorly defined. We used a modified Delphi approach to select relevant metrics for assessing patient-level interventions in acute-care settings for the purposes of internal program decision making. An expert panel rated 90 candidate metrics on a 9-point Likert scale for association with 4 criteria: improved antimicrobial prescribing, improved patient care, utility in targeting stewardship efforts, and feasibility in hospitals with electronic health records. Experts further refined, added, or removed metrics during structured teleconferences and re-rated the retained metrics. Six metrics were rated >6 in all criteria: 2 measures of Clostridium difficile incidence, incidence of drug-resistant pathogens, days of therapy over admissions, days of therapy over patient days, and redundant therapy events. Fourteen metrics rated >6 in all criteria except feasibility were identified as targets for future development. PMID:27927866
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A comparison of two patient classification instruments in an acute care hospital.
Seago, Jean Ann
2002-05-01
Patient classification systems are alternately praised and vilified by staff nurses, nurse managers, and nurse executives. Most nurses agree that substantial resources are used to create or find, implement, manage, and maintain the systems, and that the predictive ability of the instruments is intermittent. The purpose of this study is to compare the predictive validity of two types of patient classification instruments commonly used in acute care hospitals in California. Acute care hospitals in California are required by both the Joint Commission on Accreditation of Healthcare Organizations and California Title 22 to have a reliable and valid patient classification system (PCS). The two general types of systems commonly used are the summative task type PCS and the critical incident or criterion type PCS. There is little to assist nurse executives in deciding which type of PCS to choose. There is modest research demonstrating the validity and reliability of different PCSs but no published data comparing the predictive validity of the different types of systems. The unit of analysis is one patient shift called the study shift. The study shift is defined as the first day shift after the patient has been in the hospital for a full 24 hours. Data were collected using medical record review only. Both types, criterion and summative, of PCS data collection instruments were completed for all patients at both collection points. Each patient had a before and after score for each type of instrument. Three hundred forty-nine medical records for inpatients meeting the inclusion criteria were examined. The average patient age was 76 years, the average length of stay was 6.6 days with an average of 6.7 secondary diagnoses recorded. Fifty-five percent of the sample was female and the most common primary diagnosis was CHF, followed by COPD, CVA, and pneumonia. There was a difference in mean summative predictor score and the mean summative actual score of 1.57 points with the
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Interest in spiritually integrated psychotherapy among acute psychiatric patients.
Rosmarin, David H; Forester, Brent P; Shassian, Daniel M; Webb, Christian A; Björgvinsson, Thröstur
2015-12-01
Spiritually integrated psychotherapy (SIP) is increasingly common, though systematic assessment of interest in such treatments, and predictors of such interest, has not yet been conducted among acute psychiatric patients. We conducted a survey with 253 acute psychiatric patients (95-99% response rate) at a private psychiatric hospital in Eastern Massachusetts to assess for interest in SIP, religious affiliation, and general spiritual or religious involvement alongside clinical and demographic factors. More than half (58.2%) of patients reported "fairly" or greater interest in SIP, and 17.4% reported "very much" interest. Demographic and clinical factors were not significant predictors except that current depression predicted greater interest. Religious affiliation and general spiritual or religious involvement were associated with more interest; however, many affiliated patients reported low or no interest (42%), and conversely many unaffiliated patients reported "fairly" or greater interest (37%). Many acute psychiatric patients, particularly individuals with major depression, report interest in integrating spirituality into their mental health care. Assessment of interest in SIP should be considered in the context of clinical care. (c) 2015 APA, all rights reserved).
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Clarke, Martina A; Moore, Joi L; Steege, Linsey M; Koopman, Richelle J; Belden, Jeffery L; Canfield, Shannon M; Kim, Min S
2018-09-01
The purpose of this study was to determine the information needs of primary care patients as they review clinic visit notes to inform information that should be contained in an after-visit summary (AVS). We collected data from 15 patients with an acute illness and 14 patients with a chronic disease using semi-structured interviews. The acute patients reviewed seven major sections, and chronic patients reviewed eight major sections of a simulated, but realistic visit note to identify relevant information needs for their AVS. Patients in the acute illness group identified the Plan, Assessment and History of Present Illness the most as important note sections, while patients in the chronic care group identified Significant Lab Data, Plan, and Assessment the most as important note sections. This study was able to identify primary care patients' information needs after clinic visit. Primary care patients have information needs pertaining to diagnosis and treatment, which may be the reason why both patient groups identified Plan and Assessment as important note sections. Future research should also develop and assess an AVS based on the information gathered in this study and evaluate its usefulness among primary care patients. The results of this study can be used to inform the development of an after-visit summary that assists patients to fully understand their treatment plan, which may improve treatment adherence.
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Smith, Tracy A; Disler, Rebecca T; Jenkins, Christine R; Ingham, Jane M; Davidson, Patricia M
2017-06-01
Patients requiring non-invasive ventilation for acute-on-chronic respiratory failure due to chronic obstructive pulmonary disease or heart failure exacerbations may have a poor prognosis underscoring the importance of advance care planning. We aimed to describe attitudes to, and experiences of, discussing the future among patients recently treated with non-invasive ventilation. Qualitative research using thematic analysis. Tertiary teaching hospital. Patients with acute hypercapnic respiratory failure requiring non-invasive ventilation. Individuals recently treated with non-invasive ventilation describe feeling the future is beyond their control and instead controlled by their illness. Participants often recognised their poor prognosis but avoided discussing some difficult topics. The majority preferred not to undergo cardiopulmonary resuscitation but most had not discussed this with healthcare professionals. When participants voiced concerns about their future health to family members, they were met with polarised responses. Some encountered willingness for further discussion, while others met deflection, deterring further conversation. An overarching narrative of 'Looking through my illness to an uncertain but concerning future' unites these themes. This study suggests opportunities and barriers for advance care planning in individuals with chronic disease. Patients' understanding of their prognosis and their attitudes to cardiopulmonary resuscitation suggests an opportunity for advance care planning. Structuring discussions around patients' preferences for care during future exacerbations may foster a sense of control over the future despite illness. The diversity of familial responses to patients' concerns about their future health has implications for advance care planning. These findings have the potential to improve care for patients with respiratory failure and suggest an important ongoing research agenda.
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[Types of Care for Adult Patients Diagnosed With Acute and Maintenance Phase Schizophrenia].
Bohórquez Peñaranda, Adriana; Gómez Restrepo, Carlos; Oviedo Lugo, Gabriel Fernando; de la Hoz Bradford, Ana María; Castro Díaz, Sergio Mario; García Valencia, Jenny; Jaramillo González, Luis Eduardo; Ávila-Guerra, Mauricio
2014-01-01
To assist the clinician in making decisions about the types of care available for adults with schizophrenia. To determine which are the modalities of treatment associated with better outcomes in adults with schizophrenia. A clinical practice guideline was elaborated under the parameters of the Methodological Guide of the Ministerio de Salud y Protección Social to identify, synthesize and evaluate the evidence and make recommendations about the treatment and follow-up of adult patients with schizophrenia. The evidence of NICE guide 82 was adopted and updated. The evidence was presented to the Guideline Developing Group and recommendations, employing the GRADE system, were produced. Patients who were in Assertive community treatment had a lower risk of new hospitalizations. For the intensive case management, the results favored this intervention in the outcomes: medium term readmissions, social functioning and satisfaction with services. The crisis resolution teams was associated with better outcomes on outcomes of readmissions, social functioning and service satisfaction in comparison with standard care. The use of different modalities of care leads to the need of a comprehensive approach to patients to reduce the overall disability associated with the disease. Evidence shows overall benefit for most outcomes studied without encountering hazards for health of patients. This evaluation is recommended to use the professional ways of providing health services that are community-based and have a multidisciplinary group. It is not recommended the modality "day hospital" during the acute phase of schizophrenia in adults. Copyright © 2014 Asociación Colombiana de Psiquiatría. Publicado por Elsevier España. All rights reserved.
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Treggiari, Miriam M; Martin, Diane P; Yanez, N David; Caldwell, Ellen; Hudson, Leonard D; Rubenfeld, Gordon D
2007-10-01
Prior studies supported an association between intensive care unit (ICU) organizational model or staffing patterns and outcome in critically ill patients. To examine the association of closed versus open models with patient mortality across adult ICUs in King County (WA). Cohort study of patients with acute lung injury (ALI). ICU structure, organization, and patient care practices were assessed using self-administered mail questionnaires completed by the medical director and nurse manager. We defined closed ICUs as units that required patient transfer to or mandatory patient comanagement by an intensivist and open ICUs as those relying on other organizational models. Outcomes were obtained from the King County Lung Injury Project, a population-based cohort of patients with ALI. The main endpoint was hospital mortality. Of 24 eligible ICUs, 13 ICUs were designated closed and 11 open. Complete survey data were available for 23 (96%) ICUs. Higher physician and nurse availability was reported in closed versus open ICUs. A total of 684 of 1,075 (63%) of patients with ALI were cared for in closed ICUs. After adjusting for potential confounders, patients with ALI cared for in closed ICUs had reduced hospital mortality (adjusted odds ratio, 0.68; 95% confidence interval, 0.53, 0.89; P = 0.004). Consultation by a pulmonologist in open ICUs was not associated with improved mortality (adjusted odds ratio, 0.94; 95% confidence interval, 0.74, 1.20; P = 0.62). These findings were robust for varying assumptions about the study population definition. Patients with ALI cared for in a closed-model ICU have reduced mortality. These data support recommendations to implement structured intensive care in the United States.
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Closa, Conxita; Mas, Miquel À; Santaeugènia, Sebastià J; Inzitari, Marco; Ribera, Aida; Gallofré, Miquel
2017-09-01
To compare outcomes and costs for patients with orthogeriatric conditions in a home-based integrated care program versus conventional hospital-based care. Quasi-experimental longitudinal study. An acute care hospital, an intermediate care hospital, and the community of an urban area in the North of Barcelona, in Southern Europe. In a 2-year period, we recruited 367 older patients attended at an orthopedic/traumatology unit in an acute hospital for fractures and/or arthroplasty. Patients were referred to a hospital-at-home integrated care unit or to standard hospital-based postacute orthogeriatric unit, based on their social support and availability of the resource. We compared home-based care versus hospital-based care for Relative Functional Gain (gain/loss of function measured by the Barthel Index), mean direct costs, and potential savings in terms of reduction of stay in the acute care hospital. No differences were found in Relative Functional Gain, median (Q25-Q75) = 0.92 (0.64-1.09) in the home-based group versus 0.93 (0.59-1) in the hospital-based group, P =.333. Total health service direct cost [mean (standard deviation)] was significantly lower for patients receiving home-based care: €7120 (3381) versus €12,149 (6322), P < .001. Length of acute hospital stay was significantly shorter in patients discharged to home-based care [10.1 (7)] than in patients discharged to the postacute orthogeriatric hospital-based unit [15.3 (12) days, P < .001]. The hospital-at-home integrated care program was suitable for managing older patients with orthopedic conditions who have good social support for home care. It provided clinical care comparable to the hospital-based model, and it seems to enable earlier acute hospital discharge and lower direct costs. Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.
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Changes in Post-acute Care in the Medicare Shared Savings Program
McWilliams, J. Michael; Gilstrap, Lauren G.; Stevenson, David G.; Chernew, Michael E.; Huskamp, Haiden A.; Grabowski, David C.
2017-01-01
Importance Post-acute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit post-acute spending has implications for the importance and design of other payment models that include post-acute care. Objective To assess changes in post-acute spending and utilization associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred. Design and Setting Using fee-for-service Medicare claims from 2009–2014, we conducted difference-in-difference comparisons of beneficiaries served by ACOs with beneficiaries served by local non-ACO providers (control group) before vs. after entry into the MSSP. We estimated differential changes separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014. Participants Random 20% sample of beneficiaries with 25,544,650 patient-years, 8,395,426 hospital admissions, and 1,595,352 SNF stays from 2009–2014. Exposure Patient attribution to an ACO in the MSSP. Main Outcomes and Measures Post-acute spending, discharge to a facility, length of SNF stays, readmissions, use of highly-rated SNFs, and mortality, adjusted for patient characteristics. Results For the 2012 cohort of ACOs, MSSP participation was associated with an overall reduction in post-acute spending (differential change in 2014 for ACOs vs. control group: −$106/beneficiary or −9.0%; P=0.003) that was driven by differential reductions in inpatient utilization, discharges to facilities rather than home (−0.6 percentage points or −2.7%; P=0.03), and length of SNF stays (−0.60 days/stay or −2.2%; P=0.002). Reductions in SNF use and length of stay were due largely to within-hospital or within-SNF changes in care specifically for ACO patients. MSSP participation was associated with smaller significant reductions in SNF spending in 2014 for the 2013 ACO cohort but not in the 2013 or 2014 cohort’s first year of participation
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Mallidou, Anastasia A; Cummings, Greta G; Estabrooks, Carole A; Giovannetti, Phyllis B
2011-01-01
Hospital organizational culture is widely held to matter to the delivery of services, their effectiveness, and system performance in general. However, little empirical evidence exists to support that culture affects provider and patient outcomes; even less evidence exists to support how this occurs. To explore causal relationships and mechanisms between nursing specialty subcultures and selected patient outcomes (i.e., quality of care, adverse patient events). Martin's differentiation perspective of culture (nested subcultures within organizations) was used as a theoretical framework to develop and test a model. Hospital nurse subcultures were identified as being reflected in formal practices (i.e., satisfactory salary, continuing education, quality assurance program, preceptorship), informal practices (i.e., autonomy, control over practice, nurse-physician relationships), and content themes (i.e., emotional exhaustion). A series of structural equation models were assessed using LISREL on a large nurse survey database representing four specialties (i.e., medical, surgical, intensive care, emergency) in acute care hospitals in Alberta, Canada. Nursing specialty subcultures differentially influenced patient outcomes. Specifically, quality of care (a) was affected by nurses' control over practice, (b) was better in intensive care than in medical specialty, and (c) was related to lower adverse patient events; nurses in intensive care and emergency specialties reported fewer adverse events than did their counterparts in medical specialties. Understanding the meaning of subcultures in clinical settings would influence nurses and administrators efforts to implement clinical change and affect outcomes. More research is needed on nested subcultures within healthcare organizations for better understanding differentiated subspecialty effects on complexity of care and outcomes in hospitals. Copyright © 2010 Elsevier Ltd. All rights reserved.
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Referral Regions for Time-Sensitive Acute Care Conditions in the United States.
Wallace, David J; Mohan, Deepika; Angus, Derek C; Driessen, Julia R; Seymour, Christopher M; Yealy, Donald M; Roberts, Mark M; Kurland, Kristen S; Kahn, Jeremy M
2018-03-24
Regional, coordinated care for time-sensitive and high-risk medical conditions is a priority in the United States. A necessary precursor to coordinated regional care is regions that are actionable from clinical and policy standpoints. The Dartmouth Atlas of Health Care, the major health care referral construct in the United States, uses regions that cross state and county boundaries, limiting fiscal or political ownership by key governmental stakeholders in positions to create incentive and regulate regional care coordination. Our objective is to develop and evaluate referral regions that define care patterns for patients with acute myocardial infraction, acute stroke, or trauma, yet also preserve essential political boundaries. We developed a novel set of acute care referral regions using Medicare data in the United States from 2011. For acute myocardial infraction, acute stroke, or trauma, we iteratively aggregated counties according to patient home location and treating hospital address, using a spatial algorithm. We evaluated referral political boundary preservation and spatial accuracy for each set of referral regions. The new set of referral regions, the Pittsburgh Atlas, had 326 distinct regions. These referral regions did not cross any county or state borders, whereas 43.1% and 98.1% of all Dartmouth Atlas hospital referral regions crossed county and state borders. The Pittsburgh Atlas was comparable to the Dartmouth Atlas in measures of spatial accuracy and identified larger at-risk populations for all 3 conditions. A novel and straightforward spatial algorithm generated referral regions that were politically actionable and accountable for time-sensitive medical emergencies. Copyright © 2018 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
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Zochling, J; Grill, E; Alten, R; Ernst, J; Stucki, G; Braun, J
2007-01-01
To identify the most relevant problems to be addressed in the multi-disciplinary care of patients with acute arthritis using focus groups of health professionals followed by a Delphi process. Focus group and Delphi methodology were applied. The focus groups were conducted at three specialist rheumatology hospital clinics in Germany, each group comprising rheumatologists, nurses, physiotherapists, occupational therapists, psychologists and social workers. The participants were asked to decide which categories of the International Classification of Functioning, Disability and Health (ICF) are relevant to the care of patients with acute inflammatory arthritis. The results from the focus groups were then followed by an anonymous Delphi process. Twenty-six health professionals participated in the 3 focus groups. 167 of the second-level ICF categories (63% of all second-level categories) were considered as relevant by the rheumatology health professionals. Items from all four components, Body Functions, Body Structures, Activities and Participation and Environmental Factors were represented. Agreement between focus groups and between different health professional groups was substantial for all components with the exception of Environmental Factors (Cohen's kappa 0.23). The involvement of experts from different health professions is a valuable tool to identify typical patient characteristics, expressed as distinct ICF categories, to aid in patient care in the acute rheumatology setting. Acute patient care cannot and should not be separated from ongoing long-term management.
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Kvangarsnes, Marit; Torheim, Henny; Hole, Torstein; Öhlund, Lennart S
2013-02-01
To report a study conducted to explore intensive care unit nurses' perceptions of patient participation in the acute phase of chronic obstructive pulmonary disease exacerbation. An acute exacerbation is a life-threatening situation, which patients often consider to be extremely frightening. Healthcare personnel exercise considerable power in this situation, which challenges general professional notions of patient participation. Critical discourse analysis. In the autumn of 2009, three focus group interviews with experienced intensive care nurses were conducted at two hospitals in western Norway. Two groups had six participants each, and one group had five (N = 17). The transcribed interviews were analysed by means of critical discourse analysis. The intensive care nurses said that an exacerbation is often an extreme situation in which healthcare personnel are exercising a high degree of control and power over patients. Patient participation during exacerbation often takes the form of non-involvement. The participating nurses attached great importance to taking a sensitive approach when meeting patients. The nurses experienced challenging ethical dilemmas. This study shows that patient participation should not be understood in universal terms, but rather in relation to a specific setting and the interactions that occur in this setting. Healthcare personnel must develop skill, understanding, and competence to meet these challenging ethical dilemmas. A collaborative inter-professional approach between physicians and nurses is needed to meet the patients' demand for involvement. © 2012 Blackwell Publishing Ltd.
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Noninvasive ventilation for patients with acute lung injury or acute respiratory distress syndrome.
Nava, Stefano; Schreiber, Ania; Domenighetti, Guido
2011-10-01
Few studies have been performed on noninvasive ventilation (NIV) to treat hypoxic acute respiratory failure in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). The outcomes of these patients, for whom endotracheal intubation is not mandatory, depend on the degree of hypoxia, the presence of comorbidities and complications, and their illness severity. The use of NIV as an alternative to invasive ventilation in severely hypoxemic patients with ARDS (ie, P(aO(2))/F(IO(2)) < 200) is not generally advisable and should be limited to hemodynamically stable patients who can be closely monitored in an intensive care unit by highly skilled staff. Early NIV application may be extremely helpful in immunocompromised patients with pulmonary infiltrates, in whom intubation dramatically increases the risk of infection, pneumonia, and death. The use of NIV in patients with severe acute respiratory syndrome and other airborne diseases has generated debate, despite encouraging clinical results, mainly because of safety issues. Overall, the high rate of NIV failure suggests a cautious approach to NIV use in patients with ALI/ARDS, including early initiation, intensive monitoring, and prompt intubation if signs of NIV failure emerge.
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Alonso de Leciñana-Cases, María; Gil-Núñez, Antonio; Díez-Tejedor, Exuperio
2009-01-01
Stroke is a neurological emergency. The early administration of specific treatment improves the prognosis of the patients. Emergency care systems with early warning for the hospital regarding patients who are candidates for this treatment (stroke code) increases the number of patients treated. Currently, reperfusion via thrombolysis for ischemic stroke and attention in stroke units are the bases of treatment. Healthcare professionals and health provision authorities need to work together to organize systems that ensure continuous quality care for the patients during the whole process of their disease. To implement this, there needs to be an appropriate analysis of the requirements and resources with the objective of their adjustment for efficient use. It is necessary to provide adequate information and continuous training for all professionals who are involved in stroke care, including primary care physicians, extrahospital emergency teams and all physicians involved in the care of stroke patients within the hospital. The neurologist has the function of coordinating the protocols of intrahospital care. These organizational plans should also take into account the process beyond the acute phase, to ensure the appropriate application of measures of secondary prevention, rehabilitation, and chronic care of the patients that remain in a dependent state. We describe here the stroke care program in the Community of Madrid (Spain). (c) 2009 S. Karger AG, Basel.
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Schlyter, Mona; Östman, Margareta; Engström, Gunnar; André-Petersson, Lena; Tydén, Patrik; Leosdottir, Margrét
2017-04-01
Whether personality factors and depressive traits affect patients' utilization of health care following an acute myocardial infarction is relatively unknown. The aim of this study was to examine whether hospital-based health care utilization after a myocardial infarction was correlated with patients' personality factors and depressive symptoms. We studied 366 myocardial infarction patients admitted to Malmö University Hospital between 2002 and 2005 who subsequently participated in a cardiac rehabilitation programme. The patients were followed for two years after their index event. We investigated whether personality factors and depressive traits were correlated with the participants' health care utilization, defined as a) out-patient Cardiology visits and phone calls to a physician, nurse or a social worker, and b) acute visits or admissions to the Emergency or Cardiology Departments, using negative binominal regression analysis. In unadjusted comparisons neuroticism predicted more out-patient contacts. This significance remained after adjusting for age, sex, smoking, alcohol consumption and size of the myocardial infarction (measured as max level on troponin-I and left ventricular ejection fraction). There were no significant correlations between other personality factors or depression and out-patient contacts. None of the personality factors or depression predicted acute admissions. Apart from neuroticism, personality factors did not explain utilization of health care in terms of Cardiology out-patient contacts or acute admissions in myocardial infarction patients participating in a cardiac rehabilitation programme. Neither did depressive symptoms predict more health care utilization. This might indicate a robust cardiac rehabilitation programme offered to the study subjects, minimizing the need for additional health care contacts.
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Abdoulhadi, Dalia; Chevalet, Pascal; Moret, Leila; Fix, Marie-Hélène; Gégu, Marine; Jaulin, Philippe; Berrut, Gilles; de Decker, Laure
2015-03-01
The patient population staying in nursing homes is increasingly vulnerable and dependent and should benefit from a direct access to an acute care geriatric unit. Nevertheless, the easy access by a simple phone call from the general practitioner to the geriatrician, as well as the lack of orientation of these patients by emergency units, might lead to inappropriate admissions. This work studied the appropriateness of direct admissions of 40 patients living in nursing home in an acute care geriatric unit. Based on the AEPf assessment grid, 82.5% of these admissions were considered as appropriate (52.5%) or justified (30% based on an expert panel decision), and 17.5% were inappropriate. In conclusion, the process of direct admission does not seem to increase the rate of inappropriate admissions. Some actions could decrease this rate: implementation of geriatric mobile teams or psychogeriatric mobile teams intervening in nursing home, a better and more adapted use of ambulatory structures, a better information to the general practitioners. In order to reduce the intervention of the panel of experts, an adaptation of the AEPf assessment grid to these geriatric patients has been proposed. The "AEPg" assessment grid should benefit from a validation study.
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Baatiema, Leonard; de-Graft Aikins, Ama; Sav, Adem; Mnatzaganian, George; Chan, Carina K Y; Somerset, Shawn
2017-01-01
Objective Despite major advances in research on acute stroke care interventions, relatively few stroke patients benefit from evidence-based care due to multiple barriers. Yet current evidence of such barriers is predominantly from high-income countries. This study seeks to understand stroke care professionals’ views on the barriers which hinder the provision of optimal acute stroke care in Ghanaian hospital settings. Design A qualitative approach using semistructured interviews. Both thematic and grounded theory approaches were used to analyse and interpret the data through a synthesis of preidentified and emergent themes. Setting A multisite study, conducted in six major referral acute hospital settings (three teaching and three non-teaching regional hospitals) in Ghana. Participants A total of 40 participants comprising neurologists, emergency physician specialists, non-specialist medical doctors, nurses, physiotherapists, clinical psychologists and a dietitian. Results Four key barriers and 12 subthemes of barriers were identified. These include barriers at the patient (financial constraints, delays, sociocultural or religious practices, discharge against medical advice, denial of stroke), health system (inadequate medical facilities, lack of stroke care protocol, limited staff numbers, inadequate staff development opportunities), health professionals (poor collaboration, limited knowledge of stroke care interventions) and broader national health policy (lack of political will) levels. Perceived barriers varied across health professional disciplines and hospitals. Conclusion Barriers from low/middle-income countries differ substantially from those in high-income countries. For evidence-based acute stroke care in low/middle-income countries such as Ghana, health policy-makers and hospital managers need to consider the contrasts and uniqueness in these barriers in designing quality improvement interventions to optimise patient outcomes. PMID:28450468
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Multidisciplinary acute care research organization (MACRO): if you build it, they will come.
Early, Barbara J; Huang, David T; Callaway, Clifton W; Zenati, Mazen; Angus, Derek C; Gunn, Scott R; Yealy, Donald M; Unikel, Daniel; Billiar, Timothy R; Peitzman, Andrew B; Sperry, Jason L
2013-07-01
Clinical research will increasingly play a core role in the evolution and growth of acute care surgery program development across the country. What constitutes an efficient and effective clinical research infrastructure in the current fiscal and academic environment remains obscure. We sought to characterize the effects of implementation of a multidisciplinary acute care research organization (MACRO) at a busy tertiary referral university setting. In 2008, to minimize redundancy and cost as well as to maximize existing resources promoting acute care research, MACRO was created, unifying clinical research infrastructure among the Departments of Critical Care Medicine, Emergency Medicine, and Surgery. During the periods 2008 to 2012, we performed a retrospective analysis and determined volume of clinical studies, patient enrollment for both observational and interventional trials, and staff growth since MACRO's origination and characterized changes over time. From 2008 to 2011, the volume of patients enrolled in clinical studies, which MACRO facilitates has significantly increased more than 300%. The percentage of interventional/observational trials has remained stable during the same period (50-60%). Staff has increased from 6 coordinators to 10, with an additional 15 research associates allowing 24/7 service. With this significant growth, MACRO has become financially self-sufficient, and additional outside departments now seek MACRO's services. Appropriate organization of acute care clinical research infrastructure minimizes redundancy and can promote sustainable, efficient growth in the current academic environment. Further studies are required to determine if similar models can be successful at other acute care surgery programs.
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Tatlisumak, Turgut
2015-06-01
Timely recanalization leads to improved patient outcomes in acute ischemic stroke. Recent trial results demonstrated a strong benefit for endovascular therapies over standard medical care in patients with acute ischemic stroke and a major intracranial artery occlusion≤6 hours or even beyond from symptom onset and independent of patients' age. Previous studies have shown the benefit of intravenous thrombolysis that had gradually, albeit slowly, reshaped acute stroke care worldwide. Now, given the superior benefits of endovascular intervention, the whole structure of acute stroke care needs to be reorganized to meet patient needs and to deliver evidence-based treatments effectively. However, a blueprint for success with novel stroke treatments should be composed of numerous elements and requires efforts from various parties. Regarding the endovascular therapies, the strengths of Europe include highly organized democratic society structures, high rate of urbanization, well-developed revenue-based healthcare systems, and high income levels, whereas the obstacles include the east-west disparity in wealth, the ongoing economic crisis hindering spread of fairly costly new treatments, and the quickly aging population putting more demands on health care in general. Regional and national plans for covering whole population with 24/7 adequate acute stroke care are necessary in close cooperation of professionals and decision-makers. Europe-wide new training programs for expert physicians in stroke care should be initiated shortly. European Stroke Organisation has a unique role in providing expertise, consultation, guidelines, and versatile training in meeting new demands in stroke care. This article discusses the current situation, prospects, and challenges in Europe offering personal views on potential solutions. © 2015 American Heart Association, Inc.
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Modular acute system for general surgery: hand over the operation, not the patient.
Poole, Garth H; Glyn, Tamara; Srinivasa, Sanket; Hill, Andrew G
2012-03-01
Various models have been proposed to effectively provide acute surgical care in Australasia. Recently, General Surgeons Australia (GSA) has published a 12-point plan with guiding principles on this matter. This study describes a model of providing acute general surgical care in a high-volume institution, evaluates clinical outcomes and critically appraises the system against the GSA 12-point plan. The acute care system is qualitatively described with quantitative measures of workload. The outcomes of acute laparoscopic cholecystectomy were used as a proxy of system performance. The system was critically appraised against the GSA 12-point plan. Teams are on call once per week with each surgeon on call once per fortnight. The three key elements of acute management - collecting patients, post-acute ward round and operating - are treated as modules. The patient remains under the care of the admitting consultant but is often operated on by another team. From June 2009 to 2010, there were 7429 acute general surgical admissions (mean: 20.4 patients per day) with 2999 acute operations (mean: 8.4 operations per day). The other activities of the department were not compromised. In that time, 388 acute laparoscopic cholecystectomies were performed with a conversion rate of 1.3% and no major bile duct injury. The system is compatible with the GSA 12-point plan. This study describes an efficient and safe system for providing acute general surgical care in a high-volume setting with satisfactory clinical outcomes. It is compatible with the GSA 12-point plan. © 2012 The Authors. ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons.
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Acute care clinical pharmacy practice: unit- versus service-based models.
Haas, Curtis E; Eckel, Stephen; Arif, Sally; Beringer, Paul M; Blake, Elizabeth W; Lardieri, Allison B; Lobo, Bob L; Mercer, Jessica M; Moye, Pamela; Orlando, Patricia L; Wargo, Kurt
2012-02-01
This commentary from the 2010 Task Force on Acute Care Practice Model of the American College of Clinical Pharmacy was developed to compare and contrast the "unit-based" and "service-based" orientation of the clinical pharmacist within an acute care pharmacy practice model and to offer an informed opinion concerning which should be preferred. The clinical pharmacy practice model must facilitate patient-centered care and therefore must position the pharmacist to be an active member of the interprofessional team focused on providing high-quality pharmaceutical care to the patient. Although both models may have advantages and disadvantages, the most important distinction pertains to the patient care role of the clinical pharmacist. The unit-based pharmacist is often in a position of reacting to an established order or decision and frequently is focused on task-oriented clinical services. By definition, the service-based clinical pharmacist functions as a member of the interprofessional team. As a team member, the pharmacist proactively contributes to the decision-making process and the development of patient-centered care plans. The service-based orientation of the pharmacist is consistent with both the practice vision embraced by ACCP and its definition of clinical pharmacy. The task force strongly recommends that institutions pursue a service-based pharmacy practice model to optimally deploy their clinical pharmacists. Those who elect to adopt this recommendation will face challenges in overcoming several resource, technologic, regulatory, and accreditation barriers. However, such challenges must be confronted if clinical pharmacists are to contribute fully to achieving optimal patient outcomes. © 2012 Pharmacotherapy Publications, Inc.
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Association of Cost Sharing With Mental Health Care Use, Involuntary Commitment, and Acute Care
Schachar, Eli B.; Beekman, Aartjan T. F.; Janssen, Richard T. J. M.; Jeurissen, Patrick P. T.
2017-01-01
Importance A higher out-of-pocket price for mental health care may lead not only to cost savings but also to negative downstream consequences. Objective To examine the association of higher patient cost sharing with mental health care use and downstream effects, such as involuntary commitment and acute mental health care use. Design, Setting, and Participants This difference-in-differences study compared changes in mental health care use by adults, who experienced an increase in cost sharing, with changes in youths, who did not experience the increase and thus formed a control group. The study examined all 2 780 558 treatment records opened from January 1, 2010, through December 31, 2012, by 110 organizations that provide specialist mental health care in the Netherlands. Data analysis was performed from January 18, 2016, to May 9, 2017. Exposures On January 1, 2012, the Dutch national government increased the out-of-pocket price of mental health services for adults by up to €200 (US$226) per year for outpatient treatment and €150 (US$169) per month for inpatient treatment. Main Outcomes and Measures The number of treatment records opened each day in regular specialist mental health care, involuntary commitment, and acute mental health care, and annual specialist mental health care spending. Results This study included 1 448 541 treatment records opened from 2010 to 2012 (mean [SD] age, 41.4 [16.7] years; 712 999 men and 735 542 women). The number of regular mental health care records opened for adults decreased abruptly and persistently by 13.4% (95% CI, −16.0% to −10.8%; P < .001) per day when cost sharing was increased in 2012. The decrease was substantial and significant for severe and mild disorders and larger in low-income than in high-income neighborhoods. Simultaneously, in 2012, daily record openings increased for involuntary commitment by 96.8% (95% CI, 87.7%-105.9%; P < .001) and for acute mental health care by 25.1% (95% CI, 20
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A qualitative study of patient experiences of decentralized acute healthcare services.
Linqvist Leonardsen, Ann-Chatrin; Del Busso, Lilliana; Abrahamsen Grøndahl, Vigdis; Ghanima, Waleed; Barach, Paul; Jelsness-Jørgensen, Lars-Petter
2016-09-01
Municipality acute wards (MAWs) have recently been launched in Norway as an alternative to hospitalizations, and are aimed at providing treatment for patients who otherwise would have been hospitalized. The objective of this study was to explore how patients normally admitted to hospitals perceived the quality and safety of treatment in MAWs. The study had a qualitative design. Thematic analysis was used to analyze the data. The study was conducted in a county in south-eastern Norway and included five different MAWs. Semi-structured interviews were conducted with 27 participants who had required acute health care and who had been discharged from the five MAWs. Three subthemes were identified that related to the overarching theme of hospital-like standards ("almost a hospital, but…"), namely (a) treatment and competence, (b) location and physical environment, and (c) adequate time for care. Participants reported the treatment to be comparable to hospital care, but they also experienced limitations. Participants spoke positively about MAW personnel and the advantages of having a single patient room, a calm environment, and proximity to home. Participants felt safe when treated at MAWs, even though they realized that the diagnostic services were not similar to that in hospitals. Geographical proximity, treatment facilities and time for care positively distinguished MAWs from hospitals, while the lack of diagnostic resources was stressed as a limitation. Key points Municipality acute wards (MAWs) have been implemented across Norway. Research on patient perspectives on the decentralization of acute healthcare in MAWs is lacking. • Patients perceive decentralized acute healthcare and treatment as being comparable to the quality they would have expected in hospitals. • Geographical proximity, a home-like atmosphere and time for care were aspects stressed as positive features of the decentralized services. • Lack of diagnostic
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Pitfalls of implementing acute care surgery.
Kaplan, Lewis J; Frankel, Heidi; Davis, Kimberly A; Barie, Philip S
2007-05-01
Incorporating emergency general surgery into the current practice of the trauma and critical care surgeon carries sweeping implications for future practice and training. Herein, we examine the known benefits of the practice of emergency general surgery, contrast it with the emerging paradigm of acute care surgery, and examine pitfalls already encountered in integration of emergency general surgery into a traditional trauma/critical care surgery service. A MEDLINE literature search was supplemented with local experience and national presentations at major meetings to provide data for this review. Considerations including faculty complement, service structure, resident staffing, physician extenders, the decreased role of community hospitals in providing trauma and emergency general surgery care, and the effects on an elective operative schedule are inadequately explored at present. There are no firm recommendations as to how to incorporate emergency general surgery into a trauma/critical care practice that will satisfy both academic and community practice paradigms. The near future seems likely to embrace the expanded training and clinical care program termed acute care surgery. A host of essential elements have yet to be examined to undertake a critical analysis of the applicability, advisability, and appropriate structure of both emergency general surgery and acute care surgery in the United States. Proceeding along this pathway may be fraught with training, education, and implementation pitfalls that are ideally addressed before deploying acute care surgery as a national standard.
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Providing quality nutrition care in acute care hospitals: perspectives of nutrition care personnel.
Keller, H H; Vesnaver, E; Davidson, B; Allard, J; Laporte, M; Bernier, P; Payette, H; Jeejeebhoy, K; Duerksen, D; Gramlich, L
2014-04-01
Malnutrition is common in acute care hospitals worldwide and nutritional status can deteriorate during hospitalisation. The aim of the present qualitative study was to identify enablers and challenges and, specifically, the activities, processes and resources, from the perspective of nutrition care personnel, required to provide quality nutrition care. Eight hospitals participating in the Nutrition Care in Canadian Hospitals study provided focus group data (n = 8 focus groups; 91 participants; dietitians, dietetic interns, diet technicians and menu clerks), which were analysed thematically. Five themes emerged from the data: (i) developing a nutrition culture, where nutrition practice is considered important to recovery of patients and teams work together to achieve nutrition goals; (ii) using effective tools, such as screening, evidence-based protocols, quality, timely and accurate patient information, and appropriate and quality food; (iii) creating effective systems to support delivery of care, such as communications, food production and delivery; (iv) being responsive to care needs, via flexible food systems, appropriate menus and meal supplements, up to date clinical care and including patient and family in the care processes; and (v) uniting the right person with the right task, by delineating roles, training staff, providing sufficient time to undertake these important tasks and holding staff accountable for their care. The findings of the present study are consistent with other work and provide guidance towards improving the nutrition culture in hospitals. Further empirical work on how to support successful implementation of nutrition care processes is needed. © 2013 The British Dietetic Association Ltd.
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Communication in acute ambulatory care.
Dean, Marleah; Oetzel, John; Sklar, David P
2014-12-01
Effective communication has been linked to better health outcomes, higher patient satisfaction, and treatment adherence. Communication in ambulatory care contexts is even more crucial, as providers typically do not know patients' medical histories or have established relationships, conversations are time constrained, interruptions are frequent, and the seriousness of patients' medical conditions may create additional tension during interactions. Yet, health communication often unduly emphasizes information exchange-the transmission and receipt of messages leading to a mutual understanding of a patient's condition, needs, and treatments. This approach does not take into account the importance of rapport building and contextual issues, and may ultimately limit the amount of information exchanged.The authors share the perspective of communication scientists to enrich the current approach to medical communication in ambulatory health care contexts, broadening the under standing of medical communication beyond information exchange to a more holistic, multilayered viewpoint, which includes rapport and contextual issues. The authors propose a socio-ecological model for understanding communication in acute ambulatory care. This model recognizes the relationship of individuals to their environment and emphasizes the importance of individual and contextual factors that influence patient-provider interactions. Its key elements include message exchange and individual, organizational, societal, and cultural factors. Using this model, and following the authors' recommendations, providers and medical educators can treat communication as a holistic process shaped by multiple layers. This is a step toward being able to negotiate conflicting demands, resolve tensions, and create encounters that lead to positive health outcomes.
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[Dysphagia management of acute and long-term critically ill intensive care patients].
Zielske, J; Bohne, S; Axer, H; Brunkhorst, F M; Guntinas-Lichius, O
2014-10-01
Dysphagia is a severe complication in critically ill patients and affects more than half the patients in an intensive care unit. Dysphagia also has a strong impact on morbidity and mortality. Risk factors for the development of dysphagia are neurological diseases, age >55-70 years, intubation >7 days and sepsis. With increasing numbers of long-term survivors chronic dysphagia is becoming an increasing problem. There is not much knowledge on the influence of specific diseases, including the direct impact of sepsis on the development of dysphagia. Fiberoptic evaluation of swallowing is a standardized tool for bedside evaluation, helping to plan swallowing training during the acute phase and to decrease the rate of chronic dysphagia. For evaluation of chronic dysphagia even more extensive diagnostic tools as well as several options of stepwise rehabilitation using restitution, compensation and adaption strategies for swallowing exist. Currently it seems that these options are not being sufficiently utilized. In general, there is a need for controlled clinical trials analyzing specific swallowing rehabilitation concepts for former critically ill patients and long-term survivors.
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Cluster Analysis of Acute Care Use Yields Insights for Tailored Pediatric Asthma Interventions.
Abir, Mahshid; Truchil, Aaron; Wiest, Dawn; Nelson, Daniel B; Goldstick, Jason E; Koegel, Paul; Lozon, Marie M; Choi, Hwajung; Brenner, Jeffrey
2017-09-01
We undertake this study to understand patterns of pediatric asthma-related acute care use to inform interventions aimed at reducing potentially avoidable hospitalizations. Hospital claims data from 3 Camden city facilities for 2010 to 2014 were used to perform cluster analysis classifying patients aged 0 to 17 years according to their asthma-related hospital use. Clusters were based on 2 variables: asthma-related ED visits and hospitalizations. Demographics and a number of sociobehavioral and use characteristics were compared across clusters. Children who met the criteria (3,170) were included in the analysis. An examination of a scree plot showing the decline in within-cluster heterogeneity as the number of clusters increased confirmed that clusters of pediatric asthma patients according to hospital use exist in the data. Five clusters of patients with distinct asthma-related acute care use patterns were observed. Cluster 1 (62% of patients) showed the lowest rates of acute care use. These patients were least likely to have a mental health-related diagnosis, were less likely to have visited multiple facilities, and had no hospitalizations for asthma. Cluster 2 (19% of patients) had a low number of asthma ED visits and onetime hospitalization. Cluster 3 (11% of patients) had a high number of ED visits and low hospitalization rates, and the highest rates of multiple facility use. Cluster 4 (7% of patients) had moderate ED use for both asthma and other illnesses, and high rates of asthma hospitalizations; nearly one quarter received care at all facilities, and 1 in 10 had a mental health diagnosis. Cluster 5 (1% of patients) had extreme rates of acute care use. Differences observed between groups across multiple sociobehavioral factors suggest these clusters may represent children who differ along multiple dimensions, in addition to patterns of service use, with implications for tailored interventions. Copyright © 2017 American College of Emergency Physicians
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Acute stroke care at rural hospitals in Idaho: challenges in expediting stroke care.
Gebhardt, James G; Norris, Thomas E
2006-01-01
Thrombolytics are currently the most effective treatment for stroke. However, the National Institute for Neurological Disorders and Stroke criteria for initiation of thrombolytic therapy, most notably the 3-hour time limit from symptom onset, have proven challenging for many rural hospitals to achieve. To provide a snapshot of stroke care at rural hospitals in Idaho and to investigate the experiences of these hospitals in expediting stroke care. Using a standard questionnaire, a telephone survey of hospital staff at 21 rural hospitals in Idaho was performed. The survey focused on acute stroke care practices and strategies to expedite stroke care. The median number of stroke patients treated per year was 23.3. Patient delays were reported by 77.8% of hospitals, transport delays by 66.7%, in-hospital delays by 61.1%, equipment delays by 22.2%, and ancillary services delays by 61.1%. Approximately 67% of hospitals had implemented a clinical pathway for stroke and 80.0% had provided staff with stroke-specific training. No hospitals surveyed had a designated stroke team, and only 33.3% reported engaging in quality improvement efforts to expedite stroke care. Thrombolytics (tPA) were available and indicated for stroke at 55.6% of the hospitals surveyed. Rural hospitals in Idaho face many difficult challenges as they endeavor to meet the 3-hour deadline for thrombolytic therapy, including limited resources and experience in acute stroke care, and many different types of prehospital and in-hospital delays.
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Use of outsourced nurses in long-term acute care hospitals: outcomes and leadership preferences.
Alvarez, M Raymond; Kerr, Bernard J; Burtner, Joan; Ledlow, Gerald; Fulton, Larry V
2011-02-01
When staffing effectiveness is not maintained over time, the likelihood of negative outcomes increases. This challenge is particularly problematic in long-term acute care hospitals (LTACHs) where use of outsourced temporary nurses is common when providing safe, sufficient care to medically complex patients who require longer hospital stays than normally would occur. To assess this issue, the authors discuss the outcomes of their survey of LTACH chief nursing officers that demonstrated LTACH quality indicators and overall patient satisfaction were within nationally accepted benchmarks even with higher levels of outsourced nurses used in this post-acute care setting.
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Torheim, Henny; Kvangarsnes, Marit
2014-01-01
The aim was to gain insight into how patients with advanced chronic obstructive pulmonary disease (COPD) experience care in the acute phase. The study has a qualitative design with a phenomenological approach. The empirics consist of qualitative in-depth interviews with ten patients admitted to the intensive care units in two Norwegian hospitals. The interviews were carried out from November 2009 to June 2011. The data have been analysed through meaning condensation, in accordance with Amadeo Giorgi's four-step method. Kari Martinsen's phenomenological philosophy of nursing has inspired the study. An essential structure of the patients' experiences of care in the intensive care unit by acute COPD-exacerbation may be described as: Feelings of being trapped in a life-threatening situation in which the care system assumes control over their lives. This experience is conditioned not only by the medical treatment, but also by the entire interaction with the caregivers. The essence of the phenomenon is presented through three themes which describe the patient's lived experience: preserving the breath of life, vulnerable interactions and opportunities for better health. Acute COPD-exacerbation is a traumatic experience and the patients become particularly vulnerable when they depend on others for breathing support. The phenomenological analysis shows that the patients experience good care during breath of life preservation when the care is performed in a way that gives patients more insight into their illness and gives new opportunities for the future. PMID:24313779
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[Six-months outcomes after admission in acute geriatric care unit secondary to a fall].
Dickes-Sotty, Hélène; Chevalet, Pascal; Fix, Marie-Hélène; Riaudel, Typhaine; Serre-Sahel, Caroline; Ould-Aoudia, Vincent; Berrut, Gilles; De Decker, Laure
2012-12-01
Fall in elderly subject is a main event by its medical and social consequences, but few studies were dedicated to the prognosis from hospitalization in geriatric acute care unit. Describe the outcome of elderly subjects hospitalized after a fall in geriatric acute care unit. Longitudinal study of 6 months follow-up, 100 patients of 75 and more years old hospitalized after a fall in acute care geriatric unit. On a total of 128 patients hospitalized for fall, 100 agreed to participate in the study, 3 died during the hospitalization, so 97 subjects were able to be followed. During 6 months after the hospitalization, 14 patients died (14.9%), 51 (58%) have fallen again (58%) and 11 (22%) of them suffer from severe injuries. Thirty seven (39.7%) were rehospitalized and 10 of them related to fall. Among the patients coming from their home, 25 had been institutionalized. The main risk factor which have been identified to be associated with a new fall during the follow-up was a known dementia at the entry. The medical and social prognosis of an elderly subject hospitalized in an acute care unit is severe. The main comorbidity which influences the medical and social outcome is a known dementia, in addition to a history of previous fall.
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Darnell, Doyanne; O'Connor, Stephen; Wagner, Amy; Russo, Joan; Wang, Jin; Ingraham, Leah; Sandgren, Kirsten; Zatzick, Douglas
2017-03-01
Injured patients presenting to acute care medical settings have high rates of posttraumatic stress disorder (PTSD) and comorbidities, such as depression and substance use disorders. Integrating behavioral interventions that target symptoms of PTSD and comorbidities into the acute care setting can overcome common barriers to obtaining mental health care. This study examined the feasibility and acceptability of embedding elements of cognitive-behavioral therapy (CBT) in the delivery of routine postinjury care management. The investigation also explored the potential effectiveness of completion of CBT element homework that targeted PTSD symptom reduction. This study was a secondary analysis of data from a U.S. clinical trial of the effectiveness of a stepped collaborative care intervention versus usual care for injured inpatients. The investigation examined patients' willingness at baseline (prerandomization) to engage in CBT and pre- and postrandomization mental health service utilization among 115 patients enrolled in the clinical trial. Among intervention patients (N=56), the investigation examined acceptability of the intervention and used multiple linear regression to examine the association between homework completion as reported by the care manager and six-month PTSD symptom reduction as assessed by the PTSD Checklist-Civilian DSM-IV Version. Patients in the intervention condition reported obtaining significantly more psychotherapy or counseling than patients in the control group during the six-month follow-up, as well as a high degree of intervention acceptability. Completion of CBT element homework assignments was associated with improvement in PTSD symptoms. Integrating behavioral interventions into routine acute care service delivery may improve the reach of evidence-based mental health care targeting PTSD.
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Fromer, Len
2011-01-01
Current primary care patterns for chronic obstructive pulmonary disease (COPD) focus on reactive care for acute exacerbations, often neglecting ongoing COPD management to the detriment of patient experience and outcomes. Proactive diagnosis and ongoing multifactorial COPD management, comprising smoking cessation, influenza and pneumonia vaccinations, pulmonary rehabilitation, and symptomatic and maintenance pharmacotherapy according to severity, can significantly improve a patient's health-related quality of life, reduce exacerbations and their consequences, and alleviate the functional, utilization, and financial burden of COPD. Redesign of primary care according to principles of the chronic care model, which is implemented in the patient-centered medical home, can shift COPD management from acute rescue to proactive maintenance. The chronic care model and patient-centered medical home combine delivery system redesign, clinical information systems, decision support, and self-management support within a practice, linked with health care organization and community resources beyond the practice. COPD care programs implementing two or more chronic care model components effectively reduce emergency room and inpatient utilization. This review guides primary care practices in improving COPD care workflows, highlighting the contributions of multidisciplinary collaborative team care, care coordination, and patient engagement. Each primary care practice can devise a COPD care workflow addressing risk awareness, spirometric diagnosis, guideline-based treatment and rehabilitation, and self-management support, to improve patient outcomes in COPD.
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Psychosocial distress in acute cancer patients assessed with an expert rating scale.
Senf, Bianca; Brandt, Holger; Dignass, Axel; Kleinschmidt, Rolf; Kaiser, Jochen
2010-08-01
The identification of psychosocial stress in cancer patients has remained a challenging task especially in an acute care environment. The aims of the present study were to apply a short expert rating scale for the assessment of distress during the acute treatment phase and to identify potential sociodemographic and disease-related predictors. Four hundred seventy-eight ward cancer patients were assessed with the short form of the psycho-oncological basis documentation and its breast-cancer-specific version. In addition, they completed a self-rating questionnaire on stress in cancer patients. We recorded sociodemographic and disease-related variables and assessed their predictive value for psychosocial distress. According to the expert rating scale, 56.3% of patients were rated distressed. While only 31.3% of patients were classified as distressed according to a patient self-rating, both approaches showed a good degree of concurrence with a consistent classification of 69% of patients. Younger age, current psychotropic medication, and past psychological treatment were associated with higher distress levels. Patients with metastases and those with a poorer functional status were more distressed. Interestingly, having an operation was associated with a better psychological well-being. This study demonstrated that a substantial proportion of cancer patients in acute care are psychosocially distressed. A short expert rating scale proved to be a feasible tool for the assessment of distress in an acute care setting.
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Teichman, Sam L; Maisel, Alan S; Storrow, Alan B
2015-03-01
Acute heart failure is a common condition associated with considerable morbidity, mortality, and cost. However, evidence-based data on treating heart failure in the acute setting are limited, and current individual treatment options have variable efficacy. The healthcare team must often individualize patient care in ways that may extend beyond available clinical guidelines. In this review, we address the question, "How do you do the best you can clinically with incomplete evidence and imperfect drugs?" Expert opinion is provided to supplement guideline-based recommendations and help address the typical challenges that are involved in the management of patients with acute heart failure. Specifically, we discuss 4 key areas that are important in the continuum of patient care: differential diagnosis and risk stratification; choice and implementation of initial therapy; assessment of the adequacy of therapy during hospitalization or observation; and considerations for discharge/transition of care. A case study is presented to highlight the decision-making process throughout each of these areas. Evidence is accumulating that should help guide patients and healthcare providers on a path to better quality of care.
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Attitudes of Acutely Ill Patients Towards Euthanasia in Hong Kong
Lam, R.C.S; Chien, Wai-Tong
2007-01-01
The global euthanasia debate by health care professionals has raised important ethical issues concerning the professional duties and responsibilities of nurses caring for terminal patients. The purpose of this study was to examine the attitudes of acutely ill patients towards the practice of euthanasia in Hong Kong. A modified form of the 23-item Questionnaire for General Household Survey scale was used. This cross-sectional survey study was conducted with a stratified sample of in-patients recruited from a wide variety of departments in a regional, acute general hospital. Seventy-seven out of 129 patients responded (59.7%) and a high proportion of patients agreed with the use of euthanasia in the following circumstances: ‘where they were a third party’, if ‘someone they loved’ was affected, or if ‘they themselves were the patient’. Of the 77 patients, 54 agreed with active euthanasia (70.1%) and 65 with passive (84.4%). The results also indicated that a few socio-demographic characteristics (such as age, gender and household income) statistically significantly correlated with patients’ attitudes towards euthanasia. These findings highlight that Chinese patients with acute illness generally accept the use of euthanasia. Further research on the attitudes and perceptions of patients towards the use of euthanasia is recommended, particularly in diverse groups of Chinese and Asian patients with acute or terminal illness. PMID:19319212
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Wang, Yiyang; Tang, Jun; Zhou, Feiya; Yang, Lei; Wu, Jianbin
2017-01-01
Abstract Background: The aim of the current meta-analysis was to assess the treatment effect of comprehensive geriatric care in reducing acute perioperative delirium in older patients with hip fractures, compared with the effect of a routine orthopedic treatment protocol. Methods: We conducted a search of multiple databases to identify randomized controlled trials (RCTs) and quasi-RCTs comparing comprehensive geriatric care and routine orthopedic treatment regarding the following outcomes: incidence of delirium, assessment of cognitive status, and duration of delirium. Odds ratios (ORs) and mean differences (MDs) were pooled using either a fixed-effects or a random-effects model, depending on the heterogeneity of the trials included in the analysis. Results: Six RCTs and 1 quasi-RCT provided data from 1840 patients. These data revealed that comprehensive geriatric care may reduce the incidence of perioperative delirium (OR = 0.71; 95% confidence interval [CI], 0.57–0.89; P = .003) and that it was associated with higher cognitive status during hospitalization or at 1 month postoperatively (MD = 1.03; 95% CI, 0.93–1.13; P ≤ .00001). There was no significant difference in duration of perioperative delirium between the 2 treatment groups (MD = −2.48; 95% CI, −7.36 to 2.40; P = .32). Conclusion: Based on the quality of evidence provided, comprehensive geriatric care may reduce the incidence of perioperative delirium. To obtain evidence regarding the merits of comprehensive geriatric care in reducing severity of delirium and shortening the duration of delirium, there is a need for multicenter RCTs with high methodological quality. PMID:28658156
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Epidemiological profile of acute respiratory distress syndrome patients: A tertiary care experience.
Magazine, Rahul; Rao, Shobitha; Chogtu, Bharti; Venkateswaran, Ramkumar; Shahul, Hameed Aboobackar; Goneppanavar, Umesh
2017-01-01
Acute respiratory distress syndrome (ARDS) is seen in critically ill patients. Its etiological spectrum in India is expected to be different from that seen in western countries due to the high prevalence of tropical infections. To study the epidemiological profile of ARDS patients. A tertiary care hospital in Karnataka, India. Retrospective analysis of 150 out of the 169 ARDS patients diagnosed during 2010-2012. Data collected included the clinical features and severity scoring parameters. The mean age of the study population was 42.92 ± 13.91 years. The causes of ARDS included pneumonia ( n = 35, 23.3%), scrub typhus ( n = 33, 22%), leptospirosis ( n = 11, 7.3%), malaria ( n = 6, 4%), influenza (H1N1) ( n = 10, 6.7%), pulmonary tuberculosis ( n = 2, 1.3%), dengue ( n = 1, 0.7%), abdominal sepsis ( n = 16, 10.7%), skin infection ( n = 3, 2%), unknown cause of sepsis ( n = 18, 12%), and nonseptic causes ( n = 15, 10%). A total of 77 (51.3%) patients survived, 66 (44%) expired, and 7 (4.7%) were discharged against medical advice (AMA). Preexisting comorbidities (46) were present in 13 survivors, 19 nonsurvivors, and four discharged AMA. History of surgery prior to the onset of ARDS was present in one survivor, 13 nonsurvivors, and one discharge AMA. Mean Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, and Sequential Organ Failure Assessment scores in survivors were 9.06 ± 4.3, 49.22 ± 14, and 6.43 ± 2.5 and in nonsurvivors 21.11 ± 7, 86.45 ± 23.5, and 10.6 ± 10, respectively. The most common cause of ARDS in our study was pneumonia, but a large percentage of cases were due to the tropical infections. Preexisting comorbidity, surgery prior to the onset of ARDS, higher severity scores, and organ failure scores were more frequently observed among nonsurvivors than survivors.
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Readmission to Acute Care Hospital during Inpatient Rehabilitation for Traumatic Brain Injury
Hammond, Flora M.; Horn, Susan D.; Smout, Randall J.; Beaulieu, Cynthia L.; Barrett, Ryan S.; Ryser, David K.; Sommerfeld, Teri
2015-01-01
Objective To investigate frequency, reasons, and factors associated with readmission to acute care (RTAC) during inpatient rehabilitation for traumatic brain injury (TBI). Design Prospective observational cohort. Setting Inpatient rehabilitation. Participants 2,130 consecutive admissions for TBI rehabilitation. Interventions Not applicable. Main Outcome Measure(s) RTAC incidence, RTAC causes, rehabilitation length of stay (RLOS), and rehabilitation discharge location. Results 183 participants (9%) experienced RTAC for a total 210 episodes. 161 patients experienced 1 RTAC episode, 17 had 2, and 5 had 3. Mean days from rehabilitation admission to first RTAC was 22 days (SD 22). Mean duration in acute care during RTAC was 7 days (SD 8). 84 participants (46%) had >1 RTAC episode for medical reasons, 102 (56%) had >1 RTAC for surgical reasons, and RTAC reason was unknown for 6 (3%) participants. Most common surgical RTAC reasons were: neurosurgical (65%), pulmonary (9%), infection (5%), and orthopedic (5%); most common medical reasons were infection (26%), neurologic (23%), and cardiac (12%). Older age, history of coronary artery disease, history of congestive heart failure, acute care diagnosis of depression, craniotomy or craniectomy during acute care, and presence of dysphagia at rehabilitation admission predicted patients with RTAC. RTAC was less likely for patients with higher admission Functional Independence Measure Motor scores and education less than high school diploma. RTAC occurrence during rehabilitation was significantly associated with longer RLOS and smaller likelihood of discharge home. Conclusion(s) Approximately 9% of patients with TBI experience RTAC during inpatient rehabilitation for various medical and surgical reasons. This information may help inform interventions aimed at reducing interruptions in rehabilitation due to RTAC. RTACs were associated with longer RLOS and discharge to an institutional setting. PMID:26212405
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De Luca, Leonardo; Leonardi, Sergio; Cavallini, Claudio; Lucci, Donata; Musumeci, Giuseppe; Caporale, Roberto; Abrignani, Maurizio G; Lupi, Alessandro; Rakar, Serena; Gulizia, Michele M; Bovenzi, Francesco M; De Servi, Stefano
2015-10-01
Several new antithrombotic therapies have emerged for the treatment of acute coronary syndrome (ACS). We sought to assess contemporary patterns of antithrombotic therapies use in patients with ACS. EYESHOT (EmploYEd antithrombotic therapies in patients with acute coronary Syndromes HOspitalized in iTalian cardiac care units) was a nationwide, prospective registry aimed to evaluate antithrombotic strategies employed in patients admitted to intensive cardiac care units (CCUs) for an ACS in Italy. Over a three-week period, 203 CCUs enrolled 2585 consecutive patients: 41.2% with ST-elevation myocardial infarction (STEMI) and 58.8% with non-ST elevation ACS (NSTE-ACS). During hospitalisation, low-molecular-weight heparins, aspirin, and clopidogrel were the most commonly used antithrombotic therapies. Among patients treated with percutaneous coronary intervention (PCI, n=1755), any crossover of heparin therapy occurred in 30.8% of cases, while switching from one P2Y12 inhibitor to another occurred in 3.6% of cases in the CathLab and in 14.2% before discharge. Of the 790 patients who did not receive revascularisation, switching of a P2Y12 inhibitor occurred in 5.7% of cases. At discharge, a new P2Y12 inhibitor (ticagrelor or prasugrel) in association with aspirin was prescribed in 59.5% of STEMI and 33.9% of NSTE-ACS patients: the most powerful predictor for prescription was PCI (odds ratio (OR) 6.18; 95% confidence interval (CI) 4.76-8.01; p<0.0001), whereas age ≥ 75 years was strongly associated with clopidogrel use (OR 0.28; 95% CI 0.22-0.36; p<0.0001). The EYESHOT registry shows the current pattern of antithrombotic treatments for ACS patients admitted to Italian CCUs and provides insights which may help to improve the clinical care of such patients. © The European Society of Cardiology 2014.
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Lattanzio, Fabrizia; Pedone, Claudio; Garasto, Sabrina; Laino, Irma; Bustacchini, Silvia; Pranno, Luigi; Mazzei, Bruno; Passarino, Giuseppe; Incalzi, Raffaele Antonelli
2012-01-01
Abstract We investigated the prognostic role of the Short Physical Performance Battery (SPPB) in elderly patients discharged from the acute care hospital. Our series consisted of 506 patients aged 70 years or more enrolled in a multicenter collaborative observational study. We considered three main outcomes: 1-year survival after discharge, functional decline, and hospitalization during follow-up. Independent predictors/correlates of the outcomes were investigated by Cox regression or logistic regression analysis when appropriate. The diagnostic accuracy of SPPB in relation to study outcomes was investigated by receiver operating characteristic (ROC) curve. SPPB score was associated with reduced mortality (hazard ratio [HR]=0.86, 95% confidence interval [CI] 0.78–0.95). When the analysis was adjusted for functional status at discharge, such an association was still near significant only for SPPB values >8 (HR=0.51; 95% CI 0.30–1.05). An SPPB score<5 could identify patients who died during follow-up with fair sensitivity (0.66), specificity (0.62), and area under the ROC curve (0.66). SPPB also qualified as independent correlate of functional decline (odds ratio [OR]=0.82; 95% CI 0.70–0.96), but not of rehospitalization or combined end-point death or rehospitalization. An SPPB score <5 could identify patients experiencing functional decline during follow-up with lower sensitivity (0.60), but higher specificity (0.69), and area under the ROC curve (0.69) with respect to mortality. In conclusion, SPPB can be considered a valid instrument to identify patients at major risk of functional decline and death after discharge from acute care hospital. However, it could more efficiently target patients at risk of functional decline than those at risk of death. PMID:22004280
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Acute hospital dementia care: results from a national audit.
Timmons, Suzanne; O'Shea, Emma; O'Neill, Desmond; Gallagher, Paul; de Siún, Anna; McArdle, Denise; Gibbons, Patricia; Kennelly, Sean
2016-05-31
Admission to an acute hospital can be distressing and disorientating for a person with dementia, and is associated with decline in cognitive and functional ability. The objective of this audit was to assess the quality of dementia care in acute hospitals in the Republic of Ireland. Across all 35 acute public hospitals, data was collected on care from admission through discharge using a retrospective chart review (n = 660), hospital organisation interview with senior management (n = 35), and ward level organisation interview with ward managers (n = 76). Inclusion criteria included a diagnosis of dementia, and a length of stay greater than 5 days. Most patients received physical assessments, including mobility (89 %), continence (84 %) and pressure sore risk (87 %); however assessment of pain (75 %), and particularly functioning (36 %) was poor. Assessment for cognition (43 %) and delirium (30 %) was inadequate. Most wards have access at least 5 days per week to Liaison Psychiatry (93 %), Geriatric Medicine (84 %), Occupational Therapy (79 %), Speech & Language (81 %), Physiotherapy (99 %), and Palliative Care (89 %) Access to Psychology (9 %), Social Work (53 %), and Continence services (34 %) is limited. Dementia awareness training is provided on induction in only 2 hospitals, and almost half of hospitals did not offer dementia training to doctors (45 %) or nurses (48 %) in the previous 12 months. Staff cover could not be provided on 62 % of wards for attending dementia training. Most wards (84 %) had no dementia champion to guide best practice in care. Discharge planning was not initiated within 24 h of admission in 72 % of cases, less than 40 % had a single plan for discharge recorded, and 33 % of carers received no needs assessment prior to discharge. Length of stay was significantly greater for new discharges to residential care (p < .001). Dementia care relating to assessment, access to certain specialist services
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Chang, Andrew K; Bijur, Polly E; Davitt, Michelle; Gallagher, E John
2013-09-01
Opioid titration is an effective strategy for treating pain; however, titration is generally impractical in the busy emergency department (ED) setting. Our objective was to test a rapid, two-step, hydromorphone titration protocol against usual care in older patients presenting to the ED with acute severe pain. This was a prospective, randomized clinical trial of patients 65 years of age and older presenting to an adult, urban, academic ED with acute severe pain. The study was registered at http://www.clinicaltrials.gov (NCT01429285). Patients randomized to the hydromorphone titration protocol initially received 0.5 mg intravenous hydromorphone. Patients randomized to usual care received any dose of any intravenous opioid. At 15 min, patients in both groups were asked, 'Do you want more pain medication?' Patients in the hydromorphone titration group who answered 'yes' received a second dose of 0.5 mg intravenous hydromorphone. Patients in the usual care group who answered 'yes' had their ED attending physician notified, who then could administer any (or no) additional medication. The primary efficacy outcome was satisfactory analgesia defined a priori as the patient declining additional analgesia at least once when asked at 15 or 60 min after administration of the initial opioid. Dose was calculated in morphine equivalent units (MEU: 1 mg hydromorphone = 7 mg morphine). The need for naloxone to reverse adverse opioid effects was the primary safety outcome. 83.0 % of 153 patients in the hydromorphone titration group achieved satisfactory analgesia compared with 82.5 % of 166 patients in the usual care group (p = 0.91). Patients in the hydromorphone titration group received lower mean initial doses of opioids at baseline than patients in the usual care group (3.5 MEU vs. 4.7 MEU, respectively; p ≤ 0.001) and lower total opioids through 60 min (5.3 MEU vs. 6.0 MEU; p = 0.03). No patient needed naloxone. Low-dose titration of intravenous hydromorphone in increments of
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A qualitative study of patient experiences of decentralized acute healthcare services
Linqvist Leonardsen, Ann-Chatrin; Del Busso, Lilliana; Abrahamsen Grøndahl, Vigdis; Ghanima, Waleed; Barach, Paul; Jelsness-Jørgensen, Lars-Petter
2016-01-01
Objective Municipality acute wards (MAWs) have recently been launched in Norway as an alternative to hospitalizations, and are aimed at providing treatment for patients who otherwise would have been hospitalized. The objective of this study was to explore how patients normally admitted to hospitals perceived the quality and safety of treatment in MAWs. Design The study had a qualitative design. Thematic analysis was used to analyze the data. Setting The study was conducted in a county in south-eastern Norway and included five different MAWs. Patients Semi-structured interviews were conducted with 27 participants who had required acute health care and who had been discharged from the five MAWs. Results Three subthemes were identified that related to the overarching theme of hospital-like standards (“almost a hospital, but…”), namely (a) treatment and competence, (b) location and physical environment, and (c) adequate time for care. Participants reported the treatment to be comparable to hospital care, but they also experienced limitations. Participants spoke positively about MAW personnel and the advantages of having a single patient room, a calm environment, and proximity to home. Conclusions Participants felt safe when treated at MAWs, even though they realized that the diagnostic services were not similar to that in hospitals. Geographical proximity, treatment facilities and time for care positively distinguished MAWs from hospitals, while the lack of diagnostic resources was stressed as a limitation. Key Points Municipality acute wards (MAWs) have been implemented across Norway. Research on patient perspectives on the decentralization of acute healthcare in MAWs is lacking. • Patients perceive decentralized acute healthcare and treatment as being comparable to the quality they would have expected in hospitals. • Geographical proximity, a home-like atmosphere and time for care were aspects stressed as positive features of the decentralized
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Visual aid tool to improve decision making in acute stroke care.
Saposnik, Gustavo; Goyal, Mayank; Majoie, Charles; Dippel, Diederik; Roos, Yvo; Demchuk, Andrew; Menon, Bijoy; Mitchell, Peter; Campbell, Bruce; Dávalos, Antoni; Jovin, Tudor; Hill, Michael D
2016-10-01
Background Acute stroke care represents a challenge for decision makers. Recent randomized trials showed the benefits of endovascular therapy. Our goal was to provide a visual aid tool to guide clinicians in the decision process of endovascular intervention in patients with acute ischemic stroke. Methods We created visual plots (Cates' plots; www.nntonline.net ) representing benefits of standard of care vs. endovascular thrombectomy from the pooled analysis of five RCTs using stent retrievers. These plots represent the following clinically relevant outcomes (1) functionally independent state (modified Rankin scale (mRS) 0 to 2 at 90 days) (2) excellent recovery (mRS 0-1) at 90 days, (3) NIHSS 0-2 (4) early neurological recovery, and (5) revascularization at 24 h. Subgroups visually represented include time to treatment and baseline stroke severity strata. Results Overall, 1287 patients (634 assigned to endovascular thrombectomy, 653 assigned to control were included to create the visual plots. Cates' visual plots revealed that for every 100 patients with acute ischemic stroke and large vessel occlusion, 27 would achieve independence at 90 days (mRS 0-2) in the control group compared to 49 (95% CI 43-56) in the intervention group. Similarly, 21 patients would achieve early neurological recovery at 24 h compared to 54 (95% CI 45-63) out of 100 for the intervention group. Conclusion Cates' plots may assist clinicians and patients to visualize and compare potential outcomes after an acute ischemic stroke. Our results suggest that for every 100 treated individuals with an acute ischemic stroke and a large vessel occlusion, endovascular thrombectomy would provide 22 additional patients reaching independency at three months and 33 more patients achieving ENR compared to controls.
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CLINICAL AND THERAPEUTIC CORRELATIONS IN PATIENTS WITH SLIGHT ACUTE PANCREATITIS
MUNHOZ-FILHO, Clewis Henri; BATIGÁLIA, Fernando; FUNES, Hamilton Luiz Xavier
2015-01-01
Background Acute pancreatitis is an inflammatory disease of the pancreas due to enzymatic autodigestion which can cause necrosis or multiple organ failure; its pathophysiology is not fully known yet. Aim To evaluate the correlation between clinical and therapeutic data in patients with mild acute pancreatitis. Methods A retrospective study in 55 medical records of patients admitted with acute mild pancreatitis was realized to analyze the association between age, leukocytosis, serum glutamic-oxaloacetic transaminase and lactate dehydrogenase, glucose, antibiotics, time admission and Ranson´s scores. Results There was a positive association between less intensive care (strict hydration, analgesia and monitoring of vital signs), early antibiotic therapy (monotherapy), early return to diet after 48 hours and laboratory control of the serum amylase and lipase (high in the first week and decreasing after 10 days, without any prognostic value). Conclusions Changes in the management of patients with mild acute pancreatitis, such as enteral nutrition, rational use of lower spectrum antibiotics and intensive care, have contributed significantly to the reduction of hospitalization time and mortality. PMID:25861064
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Nontrauma emergency surgery: optimal case mix for general surgery and acute care surgery training.
Cherry-Bukowiec, Jill R; Miller, Barbra S; Doherty, Gerard M; Brunsvold, Melissa E; Hemmila, Mark R; Park, Pauline K; Raghavendran, Krishnan; Sihler, Kristen C; Wahl, Wendy L; Wang, Stewart C; Napolitano, Lena M
2011-11-01
To examine the case mix and patient characteristics and outcomes of the nontrauma emergency (NTE) service in an academic Division of Acute Care Surgery. An NTE service (attending, chief resident, postgraduate year-3 and postgraduate year-2 residents, and two physician assistants) was created in July 2005 for all urgent and emergent inpatient and emergency department general surgery patient consults and admissions. An NTE database was created with prospective data collection of all NTE admissions initiated from November 1, 2007. Prospective data were collected by a dedicated trauma registrar and Acute Physiology and Chronic Health Evaluation-intensive care unit (ICU) coordinator daily. NTE case mix and ICU characteristics were reviewed for the 2-year time period January 1, 2008, through December 31, 2009. During the same time period, trauma operative cases and procedures were examined and compared with the NTE case mix. Thousand seven hundred eight patients were admitted to the NTE service during this time period (789 in 2008 and 910 in 2009). Surgical intervention was required in 70% of patients admitted to the NTE service. Exploratory laparotomy or laparoscopy was performed in 449 NTE patients, comprising 37% of all surgical procedures. In comparison, only 118 trauma patients (5.9% of admissions) required a major laparotomy or thoracotomy during the same time period. Acuity of illness of NTE patients was high, with a significant portion (13%) of NTE patients requiring ICU admission. NTE patients had higher admission Acute Physiology and Chronic Health Evaluation III scores [61.2 vs. 58.8 (2008); 58.2 vs. 55.8 (2009)], increased mortality [(9.71% vs. 4.89% (2008); 6.78% vs. 5.16% (2009)], and increased readmission rates (15.5% vs. 7.4%) compared with the total surgical ICU (SICU) admissions. In an era of declining operative caseload in trauma, the NTE service provides ample opportunity for complex general surgery decision making and operative procedures for
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Gait speed is limited but improves over the course of acute care physical therapy.
Braden, Heather J; Hilgenberg, Sean; Bohannon, Richard W; Ko, Man-Soo; Hasson, Scott
2012-01-01
Gait is a common focus of physical therapists' management of patients in acute care settings. Walking speed, the distance a patient covers per unit time, has been advocated as a "sixth vital sign." However, the feasibility of measuring walking speed and the degree to which walking speed is limited or improves over the course of therapy in the acute care setting are unclear. The purpose of this study of patients undergoing physical therapy during acute care hospitalization, therefore, was to determine whether walking speed can be measured in acute care and whether walking speed is limited and changes over the course of therapy. This was an observational cross-sectional study. Participants were 46 hospital inpatients, mean age 75.0 years (SD = 7.8), referred to physical therapy and able to walk at least 20 ft. Information regarding diagnosis, comorbidities, physical assistance, device use, body height, and weight was obtained. Speed was determined during initial and final physical therapy visits while patients walked at their self-selected speed over a marked course in a hospital corridor. Therapists reported that walking speed was clinically feasible, requiring inexpensive, available resources, 4 minutes' additional time, and simple calculations for documentation. Initial walking speed was a mean of 0.33 m/s (SD = 0.21; 95% confidence interval [CI]: 0.27-0.39), whereas final speed was 0.37 m/s (SD = 0.20; 95% CI: 0.31-0.43). The Wilcoxon test showed the increase in walking speed (0.04 m/s) to be significant (P = .005) over a mean therapy period of 2.0 days (SD = 1.4) and total hospitalization period of 5.5 days (SD = 3.6). The effect size and standardized response mean were 0.19 and 0.36, respectively. Minimal detectable change was 0.18 m/s. Walking speed is a feasible measure for patients admitted to an acute care hospital. It shows that patients walk slowly relative to community requirements but that their speed improves even over a short course of therapy.
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Capp, Roberta; Misky, Gregory J; Lindrooth, Richard C; Honigman, Benjamin; Logan, Heather; Hardy, Rose; Nguyen, Dong Q; Wiler, Jennifer L
2017-10-01
Many high utilizers of the emergency department (ED) have public insurance, especially through Medicaid. We evaluated how participation in Bridges to Care (B2C)-an ED-initiated, multidisciplinary, community-based program-affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 percent) and significantly more primary care visits (an increase of 114.0 percent), compared to patients in the control group. In a subanalysis of patients with mental health comorbidities, we found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 percent) and hospitalizations (30.0 percent), and significantly more primary care visits (an increase of 123.2 percent), again compared to patients in the control group. The B2C program reduced acute care use and increased the number of primary care visits among high ED utilizers, including those with mental health comorbidities. Project HOPE—The People-to-People Health Foundation, Inc.
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Ekstedt, Mirjam; Stenberg, Una; Olsson, Mariann; Ruland, Cornelia M
2014-11-01
Being a family member of a patient who is being treated in an acute care setting for cancer often involves a number of challenges. Our study describes Norwegian cancer care health professionals' perceptions of family members who served as family caregivers (FCs) and their need for support during the in-hospital cancer treatment of their ill family member. Focus group discussions were conducted with a multidisciplinary team of 24 experienced social workers, physicians, and nurses who were closely involved in the patients' in-hospital cancer treatment and care. Drawing on qualitative hermeneutic analysis, four main themes describe health professionals' perceptions of FCs during the patient's in-hospital cancer care: an asset and additional burden, infinitely strong and struggling with helplessness, being an outsider in the center of care, and being in different temporalities. We conclude that it is a challenge for health care professionals to support the family and create room for FC's needs in acute cancer care. System changes are needed in health care, so that the patient/FC dyad is viewed as a unit of care in a dual process of caregiving, which would enable FCs to be given space and inclusion in care, with their own needs simultaneously considered alongside those of the patient. © The Author(s) 2014.
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A mobility program for an inpatient acute care medical unit.
Wood, Winnie; Tschannen, Dana; Trotsky, Alyssa; Grunawalt, Julie; Adams, Danyell; Chang, Robert; Kendziora, Sandra; Diccion-MacDonald, Stephanie
2014-10-01
For many patients, hospitalization brings prolonged periods of bed rest, which are associated with such adverse health outcomes as increased length of stay, increased risk of falls, functional decline, and extended-care facility placement. Most studies of progressive or early mobility protocols designed to minimize these adverse effects have been geared toward specific patient populations and conducted by multidisciplinary teams in either ICUs or surgical units. Very few mobility programs have been developed for and implemented on acute care medical units. This evidence-based quality improvement project describes how a mobility program, devised for and put to use on a general medical unit in a large Midwestern academic health care system, improved patient outcomes.
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Martinez, José Manuel; Pereira, Dulcineia; Chacim, Sérgio; Mesquita, Edgar; Sousa, Inês; Martins, Ângelo; Azevedo, Teresa; Mariz, José Mário
2014-09-01
This study intends to provide new insights into the incidence and care of mucositis by the epidemiological characterization of patients with hematological malignancy treated at our institution. It also aims to understand the effectiveness of several treatments used. This is a longitudinal observational single-center study-convenience sample-which includes malignant hematologic inpatients submitted to high-dose CT from February to August 2012. We registered epidemiological data, diagnosis, oral mucositis daily questionnaire (OMDQ), World Health Organization (WHO) oral toxicity scale, and supportive medications used for mucositis. We evaluated 30 patients who had 73 episodes of hospitalization, having recorded the development of mucositis in 21.9 % (n = 16) episodes (22 patients with acute leukemia (AL) and 8 patients with non-Hodgkin lymphoma (NHL)). Grades 3-4 mucositis was reported in 4.1 % of the total episodes. The results of OMDQ showed some limitations in the quality of life, of patients with mucositis, related with the ability to eat and drink due to mouth pain (p < 0.001). In patients with NHL and AL, neutropenia entails an increased risk of mucositis (p < 0.001). Patients who did not initiate early prophylaxis with conservative measures developed mucositis earlier (p < 0.05). The incidence of mucositis is high, being reported mainly in AL patients, with limitations in quality of life. Grade 4 neutropenia increases mucositis risk. Early prophylaxis with basic oral care may delay mucositis. Further studies are crucial to characterize mucositis epidemiology, physiopathology, and its management.
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Hu, Xiaoyi; Wang, Haozhong; Zhang, Lei; Hao, Qiukui; Dong, Birong
2016-01-01
Abstract Background The aim of this study is to assess the prevalence of sarcopenia and investigate the associations between sarcopenia and long‐term mortality and readmission in a population of elderly inpatients in acute care wards. Methods We conducted a prospective observational study in the acute care wards of a teaching hospital in western China. The muscle mass was estimated according to a previously validated anthropometric equation. Handgrip strength was measured with a handheld dynamometer, and physical performance was measured via a 4 m walking test. Sarcopenia was defined according to the recommended diagnostic algorithm of the Asia Working Group for Sarcopenia. The survival status and readmission information were obtained via telephone interviews at 12, 24, and 36 months during the 3 year follow‐up period following the baseline investigation. Results Two hundred and eighty‐eight participants (mean age: 81.1 ± 6.6 years) were included. Forty‐nine participants (17.0%) were identified as having sarcopenia. This condition was similar in men and women (16.9% vs. 17.5%, respectively, P = 0.915). During the 3 year follow‐up period, 49 men (22.7%) and 9 women (16.4%) died (P = 0.307). The mortality of sarcopenic participants was significantly increased compared with non‐sarcopenic participants (40.8% vs. 17.1%, respectively, P < 0.001). After adjusting for age, sex and other confounders, sarcopenia was an independent predictor of 3 year mortality (adjusted hazard ratio: 2.49; 95% confidential interval: 1.25–4.95) and readmission (adjusted hazard ratio: 1.81; 95% confidential interval: 1.17–2.80). Conclusions Sarcopenia, which is evaluated by a combination of anthropometric measures, gait speed, and handgrip strength, is valuable to predict hospital readmission and long‐term mortality in elderly patients in acute care wards. PMID:27896949
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Respiratory High-Dependency Care Units for the burden of acute respiratory failure.
Scala, Raffaele
2012-06-01
The burden of acute respiratory failure (ARF) has become one of the greatest epidemiological challenges for the modern health systems. Consistently, the imbalance between the increasing prevalence of acutely de-compensated respiratory diseases and the shortage of high-daily cost ICU beds has stimulated new health cost-effective solutions. Respiratory High-Dependency Care Units (RHDCU) provide a specialised environment for patients who require an "intermediate" level of care between the ICU and the ward, where non-invasive monitoring and assisted ventilation techniques are preferentially applied. Since they are dedicated to the management of "mono-organ" decompensations, treatment of ARF patients in RHDCU avoids the dangerous "under-assistance" in the ward and unnecessary "over-assistance" in ICU. RHDCUs provide a specialised quality of care for ARF with health resources optimisation and their spread throughout health systems has been driven by their high-level of expertise in non-invasive ventilation (NIV), weaning from invasive ventilation, tracheostomy care, and discharging planning for ventilator-dependent patients. Copyright © 2011 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
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Louis Simonet, Martine; Kossovsky, Michel P; Chopard, Pierre; Sigaud, Philippe; Perneger, Thomas V; Gaspoz, Jean-Michel
2008-01-01
Background Early identification of patients who need post-acute care (PAC) may improve discharge planning. The purposes of the study were to develop and validate a score predicting discharge to a post-acute care (PAC) facility and to determine its best assessment time. Methods We conducted a prospective study including 349 (derivation cohort) and 161 (validation cohort) consecutive patients in a general internal medicine service of a teaching hospital. We developed logistic regression models predicting discharge to a PAC facility, based on patient variables measured on admission (day 1) and on day 3. The value of each model was assessed by its area under the receiver operating characteristics curve (AUC). A simple numerical score was derived from the best model, and was validated in a separate cohort. Results Prediction of discharge to a PAC facility was as accurate on day 1 (AUC: 0.81) as on day 3 (AUC: 0.82). The day-3 model was more parsimonious, with 5 variables: patient's partner inability to provide home help (4 pts); inability to self-manage drug regimen (4 pts); number of active medical problems on admission (1 pt per problem); dependency in bathing (4 pts) and in transfers from bed to chair (4 pts) on day 3. A score ≥ 8 points predicted discharge to a PAC facility with a sensitivity of 87% and a specificity of 63%, and was significantly associated with inappropriate hospital days due to discharge delays. Internal and external validations confirmed these results. Conclusion A simple score computed on the 3rd hospital day predicted discharge to a PAC facility with good accuracy. A score > 8 points should prompt early discharge planning. PMID:18647410
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The Determinants of the Technical Efficiency of Acute Inpatient Care in Canada.
Wang, Li; Grignon, Michel; Perry, Sheril; Chen, Xi-Kuan; Ytsma, Alison; Allin, Sara; Gapanenko, Katerina
2018-04-17
To evaluate the technical efficiency of acute inpatient care at the pan-Canadian level and to explore the factors associated with inefficiency-why hospitals are not on their production frontier. Canadian Management Information System (MIS) database (CMDB) and Discharge Abstract Database (DAD) for the fiscal year of 2012-2013. We use a nonparametric approach (data envelopment analysis) applied to three peer groups (teaching, large, and medium hospitals, focusing on their acute inpatient care only). The double bootstrap procedure (Simar and Wilson 2007) is adopted in the regression. Information on inpatient episodes of care (number and quality of outcomes) was extracted from the DAD. The cost of the inpatient care was extracted from the CMDB. On average, acute hospitals in Canada are operating at about 75 percent efficiency, and this could thus potentially increase their level of outcomes (quantity and quality) by addressing inefficiencies. In some cases, such as for teaching hospitals, the factors significantly correlated with efficiency scores were not related to management but to the social composition of the caseload. In contrast, for large and medium nonteaching hospitals, efficiency related more to the ability to discharge patients to postacute care facilities. The efficiency of medium hospitals is also positively related to treating more clinically noncomplex patients. The main drivers of efficiency of acute inpatient care vary by hospital peer groups. Thus, the results provide different policy and managerial implications for teaching, large, and medium hospitals to achieve efficiency gains. © Health Research and Educational Trust.
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Socio-economic disadvantage, quality of medical care and admission for acute severe asthma.
Kolbe, J; Vamos, M; Fergusson, W
1997-06-01
In asthma, socio-economic and health care factors may operate by a number of mechanisms to influence asthma morbidity and mortality. To determine the quality of medical care including the patient perception of the doctor-patient relationship, and the level of socio-economic disadvantage in patients admitted to hospital with acute severe asthma. One hundred and thirty-eight patients (15-50 years) admitted to hospital (general ward or intensive care unit) with acute asthma were prospectively assessed using a number of previously validated instruments. The initial subjects had severe asthma on admission (pH = 7.3 +/- 0.2, PaCO2 = 7.1 +/- 5.0 kPa, n = 90) but short hospital stay (3.7 +/- 2.6 days). Although having high morbidity (40% had hospital admission in the last year and 60% had moderate/severe interference with sleep and/or ability to exercise), they had indicators of good ongoing medical care (96% had a regular GP, 80% were prescribed inhaled steroids, 84% had a peak flow meter, GP measured peak flow routinely in 80%, 52% had a written crisis plan and 44% had a supply of steroids at home). However, they were severely economically disadvantaged (53% had experienced financial difficulties in the last year, and for 35% of households the only income was a social security benefit). In the last year 39% had delayed or put off GP visit because of cost. Management of the index attack was compromised by concern about medical costs in 16% and time off work in 20%. Patients admitted to hospital with acute asthma have evidence of good quality on-going medical care, but are economically disadvantaged. If issues such as financial barriers to health care are not acknowledged and addressed, the health care services for asthmatics will not be effectively utilised and the current reductions in morbidity and mortality may not be maintained.
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Gowland, Emily; Ball, Karen Le; Bryant, Catherine; Birns, Jonathan
2016-10-01
Acute care common stem acute medicine (ACCS AM) training was designed to develop competent multi-skilled acute physicians to manage patients with multimorbidity from 'door to discharge' in an era of increasing acute hospital admissions. Recent surveys by the Royal College of Physicians have suggested that acute medical specialties are proving less attractive to trainees. However, data on the career pathways taken by trainees completing core acute medical training has been lacking. Using London as a region with a 100% fill rate for its ACCS AM training programme, this study showed only 14% of trainees go on to higher specialty training in acute internal medicine and a further 10% to pursue higher medical specialty training with dual accreditation with internal medicine. 16% of trainees switched from ACCS AM to emergency medicine or anaesthetics during core ACCS training, and intensive care medicine proved to be the most popular career choice for ACCS AM trainees (21%). The ACCS AM training programme therefore does not appear to be providing what it was set out to do and this paper discusses the potential causes and effects. © Royal College of Physicians 2016. All rights reserved.
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Bruyndonckx, Robin; Hens, Niel; Verheij, Theo Jm; Aerts, Marc; Ieven, Margareta; Butler, Christopher C; Little, Paul; Goossens, Herman; Coenen, Samuel
2018-05-01
Accurate prediction of the course of an acute cough episode could curb antibiotic overprescribing, but is still a major challenge in primary care. The authors set out to develop a new prediction rule for poor outcome (re-consultation with new or worsened symptoms, or hospital admission) in adults presenting to primary care with acute cough. Data were collected from 2604 adults presenting to primary care with acute cough or symptoms suggestive of lower respiratory tract infection (LRTI) within the Genomics to combat Resistance against Antibiotics in Community-acquired LRTI in Europe (GRACE; www.grace-lrti.org) Network of Excellence. Important signs and symptoms for the new prediction rule were found by combining random forest and logistic regression modelling. Performance to predict poor outcome in acute cough patients was compared with that of existing prediction rules, using the models' area under the receiver operator characteristic curve (AUC), and any improvement obtained by including additional test results (C-reactive protein [CRP], blood urea nitrogen [BUN], chest radiography, or aetiology) was evaluated using the same methodology. The new prediction rule, included the baseline Risk of poor outcome, Interference with daily activities, number of years stopped Smoking (> or <45 years), severity of Sputum, presence of Crackles, and diastolic blood pressure (> or <85 mmHg) (RISSC85). Though performance of RISSC85 was moderate (sensitivity 62%, specificity 59%, positive predictive value 27%, negative predictive value 86%, AUC 0.63, 95% confidence interval [CI] = 0.61 to 0.67), it outperformed all existing prediction rules used today (highest AUC 0.53, 95% CI = 0.51 to 0.56), and could not be significantly improved by including additional test results (highest AUC 0.64, 95% CI = 0.62 to 0.68). The new prediction rule outperforms all existing alternatives in predicting poor outcome in adult patients presenting to primary care with acute cough and could not be
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Singer, Kanakadurga; Subbaiah, Perla; Hutchinson, Raymond; Odetola, Folafoluwa; Shanley, Thomas P
2011-11-01
To describe the clinical course, resource use, and mortality of patients with leukemia admitted to the pediatric intensive care unit with sepsis and nonsepsis diagnoses over a 10-yr period. Retrospective analysis. Tertiary medical-surgical pediatric intensive care unit at C.S. Mott Children's Hospital, University of Michigan. All patients with leukemia admitted to the pediatric intensive care unit from January 1, 1998, to December 31, 2008. None; chart review. Clinical course was characterized by demographics, leukemia diagnosis, phase of therapy, leukocyte count on admission, presence of sepsis, steroid administration, intensity of care, and Pediatric Risk of Mortality score on admission to the pediatric intensive care unit. The primary outcome was survival to pediatric intensive care unit discharge. Among 68 single admissions to the pediatric intensive care unit with leukemia during the study period, 33 (48.5%) were admitted with sepsis. Admission to the pediatric intensive care unit for sepsis was associated with greater compromise of hemodynamic and renal function and use of stress dose steroids (p = .016), inotropic and/or vasopressor drugs (p = .01), and renal replacement therapy (p = .028) than nonsepsis admission. There was higher mortality among children with sepsis than other diagnoses (52% vs. 17%, p = .004). Also, mortality among children with sepsis was higher among those with acute lymphoblastic leukemia (60% vs. 44%) compared with acute myelogenous leukemia. Administration of stress dose steroids was associated with higher mortality (50% vs. 17%, p = .005) and neutropenia. Patients with acute lymphoblastic leukemia and sepsis showed the greatest mortality and resource use. Patients with acute leukemia and sepsis had a much higher mortality rate compared with previously described sepsis mortality rates for the general pediatric intensive care unit patient populations. Patients who received steroids had an increased mortality rate, but given the
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Grimaud, Olivier; Leray, Emmanuelle; Lalloué, Benoit; Aghzaf, Radouane; Durier, Jérôme; Giroud, Maurice; Béjot, Yannick
2014-12-01
Neighbourhood deprivation has been shown to be inversely associated with mortality 1 month after stroke. Whether this disadvantage begins while patients are still receiving acute care is unclear. We aimed to study mortality after stroke specifically in the period while patients are under acute care and the ensuing period when they are discharged to home or other care settings. Our sample includes 1760 incident strokes (mean age 75, 48% men, 86% ischaemic) identified between 1998 and 2010 by the population-based stroke registry of Dijon (France). We used Cox regression to study all-cause mortality up to 90 days after stroke occurrence. Overall, 284 (16.1%) patients died during the 90 days following stroke. Prior to stroke, risk factors prevalence (eg, high blood pressure and diabetes) and acute care management did not vary across deprivation levels. There was no association between deprivation and mortality while patients were in acute care (HR comparing the highest to the lowest tertiles of deprivation: 1.01, 95% CI 0.71 to 1.43). After discharge, however, age and gender adjusted mortality gradually increased with deprivation (HR 2.08, 95% CI 1.07 to 4.02). This association was not modified when stroke type and severity were accounted for. The gradient of higher poststroke mortality with increasing neighbourhood deprivation was noticeable only after acute hospital discharge. Quality of postacute care and social support are potential determinants of these variations. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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Grieve, R; Sadique, Z; Gomes, M; Smith, M; Lecky, F E; Hutchinson, P J A; Menon, D K; Rowan, K M; Harrison, D A
2016-08-01
For critically ill adult patients with acute traumatic brain injury (TBI), we assessed the clinical and cost-effectiveness of: (a) Management in dedicated neurocritical care units versus combined neuro/general critical care units within neuroscience centres. (b) 'Early' transfer to a neuroscience centre versus 'no or late' transfer for those who present at a non-neuroscience centre. The Risk Adjustment In Neurocritical care (RAIN) Study included prospective admissions following acute TBI to 67 UK adult critical care units during 2009-11. Data were collected on baseline case-mix, mortality, resource use, and at six months, Glasgow Outcome Scale Extended (GOSE), and quality of life (QOL) (EuroQol 5D-3L). We report incremental effectiveness, costs and cost per Quality-Adjusted Life Year (QALY) of the alternative care locations, adjusting for baseline differences with validated risk prediction models. We tested the robustness of results in sensitivity analyses. Dedicated neurocritical care unit patients (N = 1324) had similar six-month mortality, higher QOL (mean gain 0.048, 95% CI -0.002 to 0.099) and increased average costs compared with those managed in combined neuro/general units (N = 1341), with a lifetime cost per QALY gained of £14,000. 'Early' transfer to a neuroscience centre (N = 584) was associated with lower mortality (odds ratio 0.52, 0.34-0.80), higher QOL for survivors (mean gain 0.13, 0.032-0.225), but positive incremental costs (£15,001, £11,123 to £18,880) compared with 'late or no transfer' (N = 263). The lifetime cost per QALY gained for 'early' transfer was £11,000. For critically ill adult patients with acute TBI, within neuroscience centres management in dedicated neurocritical care units versus combined neuro/general units led to improved QoL and higher costs, on average, but these differences were not statistically significant. This study finds that 'early' transfer to a neuroscience centre is associated with reduced
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Crowley, Ruth A; Dumas, Helene M; Fragala-Pinkham, Maria A; Dougherty, Donald N; Hull, Ellen M; Hughes, Mary Laurette; Hsaio, Eric
2017-07-01
VerbalCare is a mobile software platform for hospital patients and nursing staff to communicate in real-time. The purposes of this study were to (1) identify and evaluate icons for the VerbalCare tablet application and (2) examine use and satisfaction with this tablet application in a paediatric post-acute hospital. Hospital nursing staff were surveyed to identify the most common reasons children use the "nursing call bell". Icons for the VerbalCare tablet application were developed to match the identified call bell requests and be understood by children. Through structured interview, three children provided feedback on the icons. Following staff training, the system was implemented for five patients (8-18 years). Data on frequency of use, types and timing of requests were collected via the internal software. Satisfaction surveys were completed at discharge. The VerbalCare application was used most frequently to communicate the need to use the bathroom (24%) and the need to get something (21%). Request frequency was consistent across morning, afternoon and evening and the tablet was used 40% of available days. These results indicate that children in a paediatric post-acute care hospital were able to use a tablet application for communicating with their nurse and reported satisfaction with the experience. Implications for Rehabilitation The VerbalCare tablet application was developed to allow patients to convey specific messages to nursing staff who are not in the patient's room. Children of varying ages were able to use the VerbalCare tablet application to communicate varying messages to hospital nursing staff and were satisfied with its use.
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Effects of a psychiatric intensive care unit in an acute psychiatric department.
Vaaler, A E; Morken, G; Fløvig, J C; Iversen, V C; Linaker, O M
2006-01-01
Psychiatric acute units use different levels of segregation to satisfy needs for containment and decrease in sensory input for behaviourally disturbed patients. Controlled studies evaluating the effects of the procedure are lacking. The aim of the present study was to compare effects in acutely admitted patients with the use of a psychiatric intensive care unit (PICU) and not in a psychiatric acute department. In a naturalistic study, one group of consecutively referred patients had access only to the PICU, the other group to the whole acute unit. Data were obtained for 56 and 62 patients using several scales. There were significant differences in reduction of behaviour associated with imminent, threatening incidents (Broset Violence Checklist), and actual number of such incidents (Staff Observation Aggression Scale-Revised) in favour of the group that was treated in a PICU. The principles of patient segregation in PICUs have favourable effects on behaviours associated with and the actual numbers of violent and threatening incidents.
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Quality of Care for Acute Myocardial Infarction in Rural and Urban US Hospitals
ERIC Educational Resources Information Center
Baldwin, Laura-Mae; MacLehose, Richard F.; Hart, L. Gary; Beaver, Shelli K.; Every,Nathan; Chan,Leighton
2004-01-01
Context: Acute myocardial infarction (AMI) is a common and important cause of admission to US rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care. Purpose: To examine the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers.…
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What Do Patients Want? Patient Preference in Wound Care
Corbett, Lisa Q.; Ennis, William J.
2014-01-01
Patient preferences are statements made or actions taken by consumers that reflect their desirability of a range of health options. The concept occupies an increasingly prominent place at the center of healthcare reform, and is connected to all aspects of healthcare, including discovery, research, delivery, outcome, and payment. Patient preference research has focused on shared decisions, decisional aids, and clinical practice guideline development, with limited study in acute and chronic wound care populations. The wound care community has focused primarily on patient focused symptoms and quality of life measurement. With increasing recognition of wound care as a medical specialty and as a public health concern that consumes extensive resources, attention to the preferences of end-users with wounds is necessary. This article will provide an overview of related patient-centered concepts and begin to establish a framework for consideration of patient preference in wound care. PMID:25126474
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Edvardsson, David; Watt, Elizabeth; Pearce, Frances
2017-01-01
To explore the extent to which patient ratings of perceived caring and person-centredness are associated with perceived nursing care quality in an acute hospital sample of inpatients. Self-reported patient experiences have had limited attention in conceptualizations of healthcare quality as described in policy and national standards, as well as in health and nursing care practice. The impact of central nursing concepts such as caring and person-centredness on patient ratings of nursing care quality is largely unknown. A descriptive non-experimental correlational design was used to collect and analyse data from a sample of Australian acute hospital inpatients (n = 210) in December 2012. The study collected self-report patient data through a study survey including demographic data and the Caring Behaviours Inventory, the Person-centred Climate Questionnaire, the SF-36 and the Distress thermometer. Descriptive statistics together with Pearson correlation and hierarchical linear regression were used. Perceived caring behaviours of staff and the person-centredness of wards were significantly associated with nursing care quality as evidenced by Pearson correlations being significant and exceeding the pre-set cut-off of r > 0·5. Staff caring behaviours and ward person-centredness also accounted for more than half of the total variance in perceived nursing care quality as evidenced by the final regression model. Knowledgeable and communicable staff, timeliness of assistance and environmental support stood out as most significantly related to patient perceived nursing care quality. Patient experiences of caring and person-centredness seem to have an influential role in the extent to which patients experience the quality of nursing care. Knowledgeable and communicable staff, timeliness of assistance and environmental support stand out as most significantly related to patient-perceived nursing care quality. © 2016 John Wiley & Sons Ltd.
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Transitions of Care Model Inclusive of Unplanned Care Improves the Patient Experience
Cox, Jon; Teague, Stephanie; Beck, Eric
2016-01-01
A major emphasis in health care is creating an experience whereby patients receive the right care at the right time from the right provider in the right setting at the right cost. Over the past several decades, there has been considerable effort in the area of medical management, with prior authorization, gatekeeper utilization management regimens, and other techniques designed to guide patients and caregivers into desired treatment pathways. Alternatively, the concept of demand management may be employed to achieve these desired outcomes by giving patients meaningful, expanded choices beyond traditional acute-care settings. The implementation of a novel, patient-centered, unplanned care delivery model is described along with illustrative case studies. PMID:28725828
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Music as Medicine: The Therapeutic Potential of Music for Acute Stroke Patients.
Supnet, Charlene; Crow, April; Stutzman, Sonja; Olson, DaiWai
2016-04-01
Nurses caring for patients with acute stroke are likely to administer both music and medication with therapeutic intent. The administration of medication is based on accumulated scientific evidence and tailored to the needs of each patient. However, the therapeutic use of music is generally based on good intentions and anecdotal evidence. This review summarizes and examines the current literature regarding the effectiveness of music in the treatment of critically ill patients and the use of music in neurologically injured patients. The rationale for hypothesis-driven research to explore therapeutic music intervention in acute stroke is compelling. ©2016 American Association of Critical-Care Nurses.
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Over 8 years experience on severe acute poisoning requiring intensive care in Hong Kong, China.
Lam, Sin-Man; Lau, Arthur Chun-Wing; Yan, Wing-Wa
2010-09-01
In order to obtain up-to-date information on the pattern of severe acute poisoning and the characteristics and outcomes of these patients, 265 consecutive patients admitted to an intensive care unit in Hong Kong for acute poisoning from January 2000 to May 2008 were studied retrospectively. Benzodiazepine (25.3%), alcohol (23%), tricyclic antidepressant (17.4%), and carbon monoxide (15.1%) were the four commonest poisons encountered. Impaired consciousness was common and intubation was required in 67.9% of admissions, with a median duration of mechanical ventilation of less than 1 day. The overall mortality was 3.0%. Among the 257 survivors, the median lengths of stay in the intensive care unit and acute hospital (excluding days spent in psychiatric ward and convalescent hospital) were less than 1 day and 3 days, respectively. Factors associated with a longer length of stay included age of 65 or older, presence of comorbidity, Acute Physiology and Chronic Health Evaluation II score of 25 or greater, and development of shock, rhabdomyolysis, and aspiration pneumonia, while alcohol intoxication was associated with a shorter stay. This is the largest study of its kind in the Chinese population and provided information on the pattern of severe acute poisoning requiring intensive care admission and the outcomes of the patients concerned.
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[Telemedicine in acute stroke care--a health economics view].
Günzel, F; Theiss, S; Knüppel, P; Halberstadt, S; Rose, G; Raith, M
2010-05-01
Specialized stroke units offer optimal treatment of patients with an acute stroke. Unfortunately, their installation is limited by an acute lack of experienced neurologists and the small number of stroke patients in sparsely populated rural areas. This problem is increasingly being solved by the use of telemedicine, so that neurological expertise is made available to basic and regular care. It has been demonstrated by national and international pilot studies that solidly based and rapid decisions can be made by telemedicine regrading the use of thrombolysis, as the most important acute treatment, but also of other interventions. So far studies have only evaluated improvement in the quality of care achieved by networking, but not of any lasting effect on any economic benefit. Complementary to a medical evaluation, the qualitative economic assessment presented here of German and American concepts of telemetric care indicate no difference in efficacy between various ways of networking. Most noteworthy, when comparing two large American and German studies, is the difference in their priorities. While the American networks achieved targeted improvements in efficacy of care that go beyond the immediate wishes of the doctors involved, this was of only secondary importance in the German studies. Also, in contrast to several American networks, the German telemetry networks have not tended to be organized for future growth. In terms of economic benefits, decentralized organized networks offer a greater potential of efficacy than purely local ones. Furthermore, the integration of inducements into the design of business models is a fundamental factor for achieving successful and lasting existence, especially within a highly competitive market. Georg Thieme Verlag KG Stuttgart.New York.
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An acute stroke service: potential to improve patient outcome without increasing length of stay.
Collins, D; McConaghy, D; McMahon, A; Howard, D; O'Neill, D; McCormack, P M
2000-05-01
Acute stroke is associated with a high morbidity and mortality: up to 24% of patients may not survive their hospital admission. Stroke unit care has been shown in a meta-analysis to reduce this morbidity and mortality. We present a three-year audit of the first acute stroke service in an Irish teaching hospital. The audit was carried out prospectively on 193 patients admitted to the acute stroke service, from July 1996 to end of June 1999. Details regarding patients, type and severity of stroke, length of stay and outcome were collected prospectively on a standard pro-forma. We observed a reduction in mortality from 19% to 15% to 9%, and an increasing percentage of patients discharged home from 55% to 64% to 68%, in year 1, year 2 and year 3 respectively. A trend towards a greater number of patients, younger age and improved outcome with lower mortality was observed from year to year, without significant change in length of stay. This study confirms the value to patients of organised stroke care in terms of reduction in mortality and morbidity without increasing length of stay or disability. We suggest that every acute hospital should have organised stroke care.
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Curley, Martha A Q; Wypij, David; Watson, R Scott; Grant, Mary Jo C; Asaro, Lisa A; Cheifetz, Ira M; Dodson, Brenda L; Franck, Linda S; Gedeit, Rainer G; Angus, Derek C; Matthay, Michael A
2015-01-27
Protocolized sedation improves clinical outcomes in critically ill adults, but its effect in children is unknown. To determine whether critically ill children managed with a nurse-implemented, goal-directed sedation protocol experience fewer days of mechanical ventilation than patients receiving usual care. Cluster randomized trial conducted in 31 US pediatric intensive care units (PICUs). A total of 2449 children (mean age, 4.7 years; range, 2 weeks to 17 years) mechanically ventilated for acute respiratory failure were enrolled in 2009-2013 and followed up until 72 hours after opioids were discontinued, 28 days, or hospital discharge. Intervention PICUs (17 sites; n = 1225 patients) used a protocol that included targeted sedation, arousal assessments, extubation readiness testing, sedation adjustment every 8 hours, and sedation weaning. Control PICUs (14 sites; n = 1224 patients) managed sedation per usual care. The primary outcome was duration of mechanical ventilation. Secondary outcomes included time to recovery from acute respiratory failure, duration of weaning from mechanical ventilation, neurological testing, PICU and hospital lengths of stay, in-hospital mortality, sedation-related adverse events, measures of sedative exposure (wakefulness, pain, and agitation), and occurrence of iatrogenic withdrawal. Duration of mechanical ventilation was not different between the 2 groups (intervention: median, 6.5 [IQR, 4.1-11.2] days; control: median, 6.5 [IQR, 3.7-12.1] days). Sedation-related adverse events including inadequate pain and sedation management, clinically significant iatrogenic withdrawal, and unplanned endotracheal tube/invasive line removal were not significantly different between the 2 groups. Intervention patients experienced more postextubation stridor (7% vs 4%; P = .03) and fewer stage 2 or worse immobility-related pressure ulcers (<1% vs 2%; P = .001). In exploratory analyses, intervention patients had fewer days of opioid administration
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Creating Learning Momentum through Overt Teaching Interactions during Real Acute Care Episodes
ERIC Educational Resources Information Center
Piquette, Dominique; Moulton, Carol-Anne; LeBlanc, Vicki R.
2015-01-01
Clinical supervisors fulfill a dual responsibility towards patient care and learning during clinical activities. Assuming such roles in today's clinical environments may be challenging. Acute care environments present unique learning opportunities for medical trainees, as well as specific challenges. The goal of this paper was to better understand…
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Demar, M; Hommel, D; Djossou, F; Peneau, C; Boukhari, R; Louvel, D; Bourbigot, A-M; Nasser, V; Ajzenberg, D; Darde, M-L; Carme, B
2012-07-01
Atypical Toxoplasma gondii strains, unrelated to archetypal clonal lineages (I, II, III), have been reported more frequently over the last decade in areas other than Europe and North America. A newly described form of toxoplasmosis, 'Amazonian toxoplasmosis' (AT), has been reported since 2002 in French Guiana. It is characterized by severe cases and atypical strains linked to a neotropical forest-based cycle. We report on the cases of AT that required intensive care management. We performed a prospective observational study on hospitalized adults in the Intensive Care Unit (ICU) from 2002 to 2008. Clinical and laboratory data, microbiological findings and outcomes were recorded. Data, including the ICU simplified acute physiology score and the pneumonia severity index, were calculated. Epidemiological risk factors for AT were assessed through questionnaires. Eleven non-immunodeficient patients were admitted to the ICU in Cayenne for life-threatening pneumonia associated with disseminated toxoplasmosis. Mechanical ventilation was necessary in seven patients, four of whom required immediate orotracheal intubation. Cardiac and ophthalmological abnormalities were found in five and four patients, respectively. One patient died from multiple organ failure. The genetic characterization of Toxoplasma DNA using six microsatellite markers revealed unique and atypical genotypes in eight patients. All patients presented epidemiological risk factors for AT. In French Guiana, significant T. gondii-related infectious syndrome associated with the lungs, a high level of LDH activity and the reported risk factors for AT was strongly suggestive of disseminated toxoplasmosis with a possible trend toward life-threatening pneumonia. © 2011 The Authors. Clinical Microbiology and Infection © 2011 European Society of Clinical Microbiology and Infectious Diseases.
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Healthcare Resource Availability, Quality of Care, and Acute Ischemic Stroke Outcomes.
O'Brien, Emily C; Wu, Jingjing; Zhao, Xin; Schulte, Phillip J; Fonarow, Gregg C; Hernandez, Adrian F; Schwamm, Lee H; Peterson, Eric D; Bhatt, Deepak L; Smith, Eric E
2017-02-03
Healthcare resources vary geographically, but associations between hospital-based resources and acute stroke quality and outcomes remain unclear. Using Get With The Guidelines-Stroke and Dartmouth Atlas of Health Care data, we examined associations between healthcare resource availability, stroke care, and outcomes. We categorized hospital referral regions with high-, medium-, or low-resource levels based on the 2006 national per-capita availability median of 6 relevant acute stroke care resources. Using multivariable logistic regression, we examined healthcare resource level and in-hospital quality and outcomes. Of 1 480 308 admitted ischemic stroke patients (2006-2013), 28.8% were hospitalized in low-, 44.4% in medium-, and 26.9% in high-resource hospital referral regions. Quality-of-care/timeliness metrics, adjusted length of stay, and in-hospital mortality were similar across all resource levels. Significant variation exists in regional availability of healthcare resources for acute ischemic stroke treatment, yet among Get With the Guidelines-Stroke hospitals, quality of care and in-hospital outcomes did not differ by regional resource availability. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.
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Bacteriology of aspiration pneumonia in patients with acute coma.
Lauterbach, Enise; Voss, Frederik; Gerigk, Roland; Lauterbach, Michael
2014-12-01
Loss of protective airway reflexes in patients with acute coma puts these patients at risk of aspiration pneumonia complicating the course of the primary disease. Available data vary considerably with regard to bacteriology, role of anaerobic bacteria, and antibiotic treatment. Our objective was to research the bacteriology of aspiration pneumonia in acute coma patients who were not pre-treated with antibiotics or hospitalized within 30 days prior to the event. We prospectively analyzed 127 patient records from adult patients admitted, intubated and ventilated to a tertiary medical intensive care unit with acute coma. Bacteriology and antibiotic resistance testing from tracheal aspirate sampled within 24 h after admission, blood cultures, ICU scores (APACHE II, SOFA), hematology, and clinical chemistry were assessed. Patients were followed up until death or hospital discharge. The majority of patients with acute coma suffered from acute cardiovascular disorders, predominantly myocardial infarction, followed by poisonings, and coma of unknown cause. In a majority of our patients, microaspiration resulted in overt infection. Most frequently S. aureus, H. influenzae, and S. pneumoniae were isolated. Anaerobic bacteria (Bacteroides spec., Fusobacteria, Prevotella spec.) were isolated from tracheal aspirate in a minority of patients, and predominantly as part of a mixed infection. Antibiotic monotherapy with a 2nd generation cephalosporin, or a 3rd generation gyrase inhibitor, was most effective in our patients regardless of the presence of anaerobic bacteria.
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Trends in acute mental health care: comparing psychiatric and substance abuse treatment programs.
Timko, Christine; Lesar, Michelle; Calvi, Noël J; Moos, Rudolf H
2003-01-01
This study compared psychiatric and substance abuse acute care programs, within both inpatient and residential modalities of care, on organization and staffing, clinical management practices and policies, and services and activities. A total of 412 (95% of those eligible) Department of Veterans Affairs' programs were surveyed nationwide. Some 40% to 50% of patients in psychiatric and substance abuse programs, in both inpatient and residential venues of care, had dual diagnoses. Even though psychiatric programs had a sicker patient population, they provided fewer services, including basic components of integrated programs, than substance abuse programs did. Findings also showed that there is a strong emphasis on the use of clinical practice guidelines, performance monitoring, and obtaining client satisfaction and outcome data in mental health programs. The author's suggest how psychiatric programs might better meet the needs of acutely ill and dually diagnosed patients (e.g., by incorporating former patients as role models and mutual help groups, as substance abuse programs do; and by having policies that balance patient choice with program demand).
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Brady, Paul; Gorham, James; Kosti, Angeliki; Seligman, William; Courtney, Alona; Mazan, Karolina; Paterson, Stuart; Ramcharitar, Steve; Chandrasekaran, Badri; Juniper, Mark; Greamspet, Mala; Daniel, Jessica; Chalstrey, Sue; Ahmed, Ijaz; Dasgupta, Tanaji
2015-01-01
Acute kidney injury (AKI) affects up to 20% of all patients admitted to hospital, and is associated with a higher risk of adverse clinical outcomes, increased healthcare costs, as well as long term risks of chronic kidney disease and end stage renal failure. The aim of this project was to improve the quality of care for patients with AKI admitted to the acute medical unit (AMU) at the Great Western Hospital (GWH). We assessed awareness and self reported confidence among physicians in our Trust, in addition to basic aspects of care relevant to AKI on our AMU. A multifaceted quality improvement strategy was developed, which included measures to improve awareness such as a Trust wide AKI awareness day, and reconfiguring the admission proforma on our AMU in order to enhance risk assessment, staging, and early response to AKI. Ancillary measures such as the dissemination of flashcards for lanyards containing core information were also used. Follow up assessments showed that foundation year one (FY1) doctors' self reported confidence in managing AKI increased from 2.8 to 4.2, as measured on a five point Likert scale (P=0.0003). AKI risk assessment increased from 13% to 57% (P=0.07) following a change in the admission proforma. Documentation of the diagnosis of AKI increased from 66% to 95% (P=0.038) among flagged patients. Documentation of urine dip results increased from 33% to 73% (P=0.01), in addition to a rise in appropriate referral for specialist input, although this was not statistically significant. Our results suggest that using the twin approaches of improving awareness, and small changes to systemic factors such as modification of the admission proforma, can lead to significant enhancements in the quality of care of patients with AKI.
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Acute Care Referral Systems in Liberia: Transfer and Referral Capabilities in a Low-Income Country.
Kim, Jimin; Barreix, Maria; Babcock, Christine; Bills, Corey B
2017-12-01
Introduction Following two decades of armed conflict in Liberia, over 95% of health care facilities were partially or completely destroyed. Although the Liberian health system has undergone significant rehabilitation, one particular weakness is the lack of organized systems for referral and prehospital care. Acute care referral systems are a critical component of effective health care delivery and have led to improved quality of care and patient outcomes. Problem This study aimed to characterize the referral and transfer systems in the largest county of Liberia. A cross-sectional, health referral survey of a representative sample of health facilities in Montserrado County, Liberia was performed. A systematic random sample of all primary health care (PHC) clinics, fraction proportional to district population size, and all secondary and tertiary health facilities were included in the study sample. Collected data included baseline information about the health facility, patient flow, and qualitative and quantitative data regarding referral practices. A total of 62 health facilities-41 PHC clinics, 11 health centers (HCs), and 10 referral hospitals (RHs)-were surveyed during the 6-week study period. In sum, three percent of patients were referred to a higher-level of care. Communication between health facilities was largely unsystematic, with lack of specific protocols (n=3; 5.0%) and standardized documentation (n=26; 44.0%) for referral. While most health facilities reported walking as the primary means by which patients presented to initial health facilities (n=50; 81.0%), private vehicles, including commercial taxis (n=37; 60.0%), were the primary transport mechanism for referral of patients between health facilities. This study identified several weaknesses in acute care referral systems in Liberia, including lack of systematic care protocols for transfer, documentation, communication, and transport. However, several informal, well-functioning mechanisms for
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Cost-effectiveness of optimizing acute stroke care services for thrombolysis.
Penaloza-Ramos, Maria Cristina; Sheppard, James P; Jowett, Sue; Barton, Pelham; Mant, Jonathan; Quinn, Tom; Mellor, Ruth M; Sims, Don; Sandler, David; McManus, Richard J
2014-02-01
Thrombolysis in acute stroke is effective up to 4.5 hours after symptom onset but relies on early recognition, prompt arrival in hospital, and timely brain scanning. This study aimed to establish the cost-effectiveness of increasing thrombolysis rates through a series of hypothetical change strategies designed to optimize the acute care pathway for stroke. A decision-tree model was constructed, which relates the acute management of patients with suspected stroke from symptom onset to outcome. Current practice was modeled and compared with 7 change strategies designed to facilitate wider eligibility for thrombolysis. The model basecase consisted of data from consenting patients following the acute stroke pathway recruited in participating hospitals with data on effectiveness of treatment and costs from published sources. All change strategies were cost saving while increasing quality-adjusted life years gained. Using realistic estimates of effectiveness, the change strategy with the largest potential benefit was that of better recording of onset time, which resulted in 3.3 additional quality-adjusted life years and a cost saving of US $46,000 per 100,000 population. All strategies increased the number of thrombolysed patients and the number requiring urgent brain imaging (by 9% to 21% dependent on the scenario). Assuming a willingness-to-pay of US $30,000 per quality-adjusted life year gained, the potential budget available to deliver the interventions in each strategy ranged from US $50,000 to US $144,000. These results suggest that any strategy that increases thrombolysis rates will result in cost savings and improved patient quality of life. Healthcare commissioners could consider this model when planning improvements in stroke care.
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Improved outcomes for elderly patients who received care on a transitional care unit.
Manville, Margaret; Klein, Michael C; Bainbridge, Lesley
2014-05-01
To determine whether providing elderly alternate level of care (ALC) patients with interdisciplinary care on a transitional care unit (TCU) achieves better clinical outcomes and lowers costs compared with providing them with standard hospital care. Before-and-after structured retrospective chart audit. St Joseph's Hospital in Comox, BC. One hundred thirty-five consecutively admitted patients aged 70 years and older with ALC designation during 5-month periods before (n = 49) and after (n = 86) the opening of an on-site TCU. Length of stay, discharge disposition, complications of the acute and ALC portions of the patients' hospital stays, activities of daily living (mobility, transfers, and urinary continence), psychotropic medications and vitamin D prescriptions, and ALC patient care costs, as well as annual hospital savings, were examined. Among the 86 ALC patients receiving care during the postintervention period, 57 (66%) were admitted to the TCU; 29 of the 86 (34%) patients in the postintervention group received standard care (SC). All 86 ALC patients in the postintervention group were compared with the 49 preintervention ALC patients who received SC. Length of stay reduction occurred among the postintervention group during the acute portion of the hospital stay (14.0 days postintervention group vs 22.5 days preintervention group; P < .01). Discharge home or to an assisted-living facility increased among the postintervention group (30% postintervention group vs 12% preintervention group; P < .01). Patients' ability to transfer improved among the postintervention group (55% postintervention group vs 14% preintervention group; P < .01). At discharge, 48% of ALC patients in the postintervention group were able to transfer independently compared with 17% of ALC patients in the preintervention group. Hospital-acquired infections among the postintervention group decreased during the acute phase (14% postintervention group vs 33% preintervention group; P < .01) and in
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Epidemiological profile of acute respiratory distress syndrome patients: A tertiary care experience
Magazine, Rahul; Rao, Shobitha; Chogtu, Bharti; Venkateswaran, Ramkumar; Shahul, Hameed Aboobackar; Goneppanavar, Umesh
2017-01-01
Background: Acute respiratory distress syndrome (ARDS) is seen in critically ill patients. Its etiological spectrum in India is expected to be different from that seen in western countries due to the high prevalence of tropical infections. Aim: To study the epidemiological profile of ARDS patients. Setting: A tertiary care hospital in Karnataka, India. Materials and Methods: Retrospective analysis of 150 out of the 169 ARDS patients diagnosed during 2010–2012. Data collected included the clinical features and severity scoring parameters. Results: The mean age of the study population was 42.92 ± 13.91 years. The causes of ARDS included pneumonia (n = 35, 23.3%), scrub typhus (n = 33, 22%), leptospirosis (n = 11, 7.3%), malaria (n = 6, 4%), influenza (H1N1) (n = 10, 6.7%), pulmonary tuberculosis (n = 2, 1.3%), dengue (n = 1, 0.7%), abdominal sepsis (n = 16, 10.7%), skin infection (n = 3, 2%), unknown cause of sepsis (n = 18, 12%), and nonseptic causes (n = 15, 10%). A total of 77 (51.3%) patients survived, 66 (44%) expired, and 7 (4.7%) were discharged against medical advice (AMA). Preexisting comorbidities (46) were present in 13 survivors, 19 nonsurvivors, and four discharged AMA. History of surgery prior to the onset of ARDS was present in one survivor, 13 nonsurvivors, and one discharge AMA. Mean Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, and Sequential Organ Failure Assessment scores in survivors were 9.06 ± 4.3, 49.22 ± 14, and 6.43 ± 2.5 and in nonsurvivors 21.11 ± 7, 86.45 ± 23.5, and 10.6 ± 10, respectively. Conclusion: The most common cause of ARDS in our study was pneumonia, but a large percentage of cases were due to the tropical infections. Preexisting comorbidity, surgery prior to the onset of ARDS, higher severity scores, and organ failure scores were more frequently observed among nonsurvivors than survivors. PMID:28144059
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Terra, Sandra M
2007-01-01
This research seeks to determine whether there is adequate evidence-based justification for selection of one acute care case management model over another. Acute Inpatient Hospital. This article presents a systematic review of published case management literature, resulting in classification specific to terms of level of evidence. This review examines the best available evidence in an effort to select an acute care case management model. Although no single case management model can be identified as preferred, it is clear that adequate evidence-based literature exists to acknowledge key factors driving the acute care model and to form a foundation for the efficacy of hospital case management practice. Although no single case management model can be identified as preferred, this systematic review demonstrates that adequate evidence-based literature exists to acknowledge key factors driving the acute care model and forming a foundation for the efficacy of hospital case management practice. Distinctive aspects of case management frameworks can be used to guide the development of an acute care case management model. The study illustrates: * The effectiveness of case management when there is direct patient contact by the case manager regardless of disease condition: not only does the quality of care increase but also length of stay (LOS) decreases, care is defragmented, and both patient and physician satisfaction can increase. * The preferred case management models result in measurable outcomes that can directly relate to, and demonstrate alignment with, organizational strategy. * Acute care management programs reduce cost and LOS, and improve outcomes. * An integrated case management program that includes social workers, as well as nursing, is the most effective acute care management model. * The successful case management model will recognize physicians, as well as patients, as valued customers with whom partnership can positively affect financial outcomes in terms of
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Pugh, Judith Dianne; McCoy, Kathleen; Williams, Anne M; Bentley, Brenda; Monterosso, Leanne
2018-04-16
Neurological conditions represent leading causes of non-fatal burden of disease that will consume a large proportion of projected healthcare expenditure. Inconsistent access to integrated healthcare and other services for people with long-term neurological conditions stresses acute care services. The purpose of this rapid evidence assessment, conducted February-June 2016, was to review the evidence supporting community neurological nursing approaches for patients with neurological conditions post-discharge from acute care hospitals. CINAHL Plus with Full Text and MEDLINE were searched for English-language studies published January 2000 to June 2016. Data were extracted using a purpose-designed protocol. Studies describing community neurological nursing care services post-discharge for adults with stroke, dementia, Alzheimer's disease, Parkinson's disease, multiple sclerosis or motor neurone disease were included and their quality was assessed. Two qualitative and three quantitative studies were reviewed. Two themes were identified in the narrative summary of findings: (i) continuity of care and self-management and (ii) variable impact on clinical or impairment outcomes. There was low quality evidence of patient satisfaction, improved patient social activity, depression scores, stroke knowledge and lifestyle modification associated with post-discharge care by neurological nurses as an intervention. There were few studies and weak evidence supporting the use of neurology-generalist nurses to promote continuity of care for people with long-term or progressive, long-term neurological conditions post-discharge from acute care hospital. Further research is needed to provide role clarity to facilitate comparative studies and evaluations of the effectiveness of community neurological nursing models of care. © 2018 John Wiley & Sons Ltd.
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Patel, Amisha; Prabhakaran, Dorairaj; Berendsen, Mark; Mohanan, P P; Huffman, Mark D
2017-04-01
Ischemic heart disease is the leading cause of death in India. In high-income countries, pre-hospital systems of care have been developed to manage acute manifestations of ischemic heart disease, such as acute coronary syndrome (ACS). However, it is unknown whether guidelines, policies, regulations, or laws exist to guide pre-hospital ACS care in India. We undertook a nation-wide document analysis to address this gap in knowledge. From November 2014 to May 2016, we searched for publicly available emergency care guidelines and legislation addressing pre-hospital ACS care in all 29 Indian states and 7 Union Territories via Internet search and direct correspondence. We found two documents addressing pre-hospital ACS care. Though India has legislation mandating acute care for emergencies such as trauma, regulations or laws to guide pre-hospital ACS care are largely absent. Policy makers urgently need to develop comprehensive, multi-stakeholder policies for pre-hospital emergency cardiovascular care in India. Copyright © 2016. Published by Elsevier B.V.
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Wu, Stephanie C; Armstrong, David G
2008-06-01
Diabetic foot ulcers affect millions of people in the United States of America and impose tremendous medical, psychosocial and financial loss or burden. Negative pressure wound therapy (NPWT) is generally well tolerated and appears to stimulate a robust granulation tissue response compared with other wound healing modalities. This device may be a cost-effective adjunctive wound healing therapy. This literature review will focus on the clinical outcome of diabetic foot ulcers treated with NPWT, its implication in the transition from acute care to home care, factors that might influence clinical outcomes in home care as well as quality-of-life aspects in these patients. Patient care for diabetic foot ulceration is complex and necessitates multiprofessional collaboration to provide comprehensive wound care. It is clear that when we strive for limb preservation in this most high-risk population, it is important to have an available versatile, efficacious wound healing modality. There is a need for an easy transition from acute care to home care. Resources need to be combined in a collaborative and synergistic fashion to allow patient to perform many daily living activities while receiving the potential benefits of an advanced wound healing modality.
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Johnson, Erin E.; Borgia, Matthew; Noack, Amy; Yoon, Jean; Gehlert, Elizabeth; Lo, Jeanie
2018-01-01
Introduction Although traditional patient-centered medical homes (PCMHs) are effective for patients with complex needs, it is unclear whether homeless-tailored PCMHs work better for homeless veterans. We examined the impact of enrollment in a Veterans Health Administration (VHA) homeless-tailored PCMH on health services use, cost, and satisfaction compared with enrollment in a traditional, nontailored PCMH. Methods We conducted a prospective, multicenter, quasi-experimental, single-blinded study at 2 VHA medical centers to assess health services use, cost, and satisfaction during 12 months among 2 groups of homeless veterans: 1) veterans receiving VHA homeless-tailored primary care (Homeless-Patient Aligned Care Team [H-PACT]) and 2) veterans receiving traditional primary care services (PACT). A cohort of 266 homeless veterans enrolled from June 2012 through January 2014. Results Compared with PACT patients, H-PACT patients had more social work visits (4.6 vs 2.7 visits) and fewer emergency department (ED) visits for ambulatory care-sensitive conditions (0 vs 0.2 visits); a significantly smaller percentage of veterans in H-PACT were hospitalized (23.1% vs 35.4%) or had mental health–related ED visits (34.1% vs 47.6%). We found significant differences in primary care provider–specific visits (H-PACT, 5.1 vs PACT, 3.6 visits), mental health care visits (H-PACT, 8.8 vs PACT, 13.4 visits), 30-day prescription drug fills (H-PACT, 40.5 vs PACT, 58.8 fills), and use of group therapy (H-PACT, 40.1% vs PACT, 53.7%). Annual costs per patient were significantly higher in the PACT group than the H-PACT group ($37,415 vs $28,036). In logistic regression model of acute care use, assignment to the H-PACT model was protective as was rating health “good” or better. Conclusion Homeless veterans enrolled in the population-tailored primary care approach used less acute care and costs were lower. Tailored-care models have implications for care coordination in the US Department
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Lin, Frances; Chaboyer, Wendy; Wallis, Marianne; Miller, Anne
2013-08-01
Patient flow from intensive care to acute care units is often problematic and many discharges from intensive care to acute care are unsuccessful on the first attempt. The aim of this study was to explore the factors that influence intensive care patient discharge. This ethnographic study was undertaken in an Australian metropolitan tertiary hospital that had a 14-bed level 3 intensive care unit. Intensive care and acute care unit medical and nursing staff, and other hospital staff who were involved in the intensive care patient discharge process participated in this study. A total of 28 discharges were observed, and 56 one on one interviews were conducted. Data collection techniques including direct observations, semi-structured interviews, and collection of existing documents were used. Activity theory was the theoretical framework that underpinned this study. Three patient activity systems were identified: intensive care patient discharge activity, acute care unit accepting patient activity, and hospital bed management activity. Analysis of the interactions among these activity systems revealed conflicting objects (goals), communication breakdowns, and teamwork issues. Discharge delay was found to be a significant problem, which was associated with limited acute care unit bed availability. Strategies to improve acute care unit bed availability are needed. Routine after-hours ICU discharge could raise patient safety concerns which need to be considered. All team members' input in discharge decision making should be encouraged. Problems identified in clinical handover call for actions to change the handover practice. Activity theory successfully guided the study by providing a practical and descriptive framework for the study, facilitating the understanding of the interrelationships among the activity systems. Copyright © 2012 Elsevier Ltd. All rights reserved.
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Harris, Tim; McDonald, Keith
2014-12-01
To benchmark walk-in presentations to emergency departments (ED) with those presenting to other local acute healthcare facilities. A large teaching hospital with an annual ED census of 140, 000 adult patients and surrounding associated acute healthcare providers. A random sample of 384 patients who self-presented to the ED was obtained. Benchmarking data were drawn from two general practices; the Tower Hamlets Community Services walk-in centre (co-located on-site with the ED) and the GP-run out-of-hours service. The case-mix presenting to the ED was characterised by a higher proportion of injuries and chest pain, but fewer simple infections and non-traumatic musculoskeletal conditions as compared to other acute care facilities in our region. Patients with injuries and possible cardiac chest pain were more likely to attend the ED, and those with infection or musculoskeletal problems less likely, as compared with other acute healthcare facilities. The population presenting to the ED is distinct from that presenting to general practice, out-of-hours clinics, or walk-in centres. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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Case management in an acute-care hospital: collaborating for quality, cost-effective patient care.
Grootveld, Kim; Wen, Victoria; Bather, Michelle; Park, Joan
2014-01-01
Case management has recently been advanced as a valuable component in achieving quality patient care that is also cost-effective. At St. Michael's Hospital, in Toronto, Ontario, case managers from a variety of professional backgrounds are central to a new care initiative--Rapid Assessment and Planning to Inform Disposition (RAPID)--in the General Internal Medicine (GIM) Unit that is designed to improve patient care and reconcile high emergency department volumes through "smart bed spacing." Involved in both planning and RAPID, GIM's case managers are the link between patient care and utilization management. These stewards of finite resources strive to make the best use of dollars spent while maintaining a commitment to quality care. Collaborating closely with physicians and others across the hospital, GIM's case managers have been instrumental in bringing about significant improvements in care coordination, utilization management and process redesign. Copyright © 2014 Longwoods Publishing.
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Moss, Travis J; Clark, Matthew T; Calland, James Forrest; Enfield, Kyle B; Voss, John D; Lake, Douglas E; Moorman, J Randall
2017-01-01
Charted vital signs and laboratory results represent intermittent samples of a patient's dynamic physiologic state and have been used to calculate early warning scores to identify patients at risk of clinical deterioration. We hypothesized that the addition of cardiorespiratory dynamics measured from continuous electrocardiography (ECG) monitoring to intermittently sampled data improves the predictive validity of models trained to detect clinical deterioration prior to intensive care unit (ICU) transfer or unanticipated death. We analyzed 63 patient-years of ECG data from 8,105 acute care patient admissions at a tertiary care academic medical center. We developed models to predict deterioration resulting in ICU transfer or unanticipated death within the next 24 hours using either vital signs, laboratory results, or cardiorespiratory dynamics from continuous ECG monitoring and also evaluated models using all available data sources. We calculated the predictive validity (C-statistic), the net reclassification improvement, and the probability of achieving the difference in likelihood ratio χ2 for the additional degrees of freedom. The primary outcome occurred 755 times in 586 admissions (7%). We analyzed 395 clinical deteriorations with continuous ECG data in the 24 hours prior to an event. Using only continuous ECG measures resulted in a C-statistic of 0.65, similar to models using only laboratory results and vital signs (0.63 and 0.69 respectively). Addition of continuous ECG measures to models using conventional measurements improved the C-statistic by 0.01 and 0.07; a model integrating all data sources had a C-statistic of 0.73 with categorical net reclassification improvement of 0.09 for a change of 1 decile in risk. The difference in likelihood ratio χ2 between integrated models with and without cardiorespiratory dynamics was 2158 (p value: <0.001). Cardiorespiratory dynamics from continuous ECG monitoring detect clinical deterioration in acute care patients
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Improved outcomes for elderly patients who received care on a transitional care unit
Manville, Margaret; Klein, Michael C.; Bainbridge, Lesley
2014-01-01
Abstract Objective To determine whether providing elderly alternate level of care (ALC) patients with interdisciplinary care on a transitional care unit (TCU) achieves better clinical outcomes and lowers costs compared with providing them with standard hospital care. Design Before-and-after structured retrospective chart audit. Setting St Joseph’s Hospital in Comox, BC. Participants One hundred thirty-five consecutively admitted patients aged 70 years and older with ALC designation during 5-month periods before (n = 49) and after (n = 86) the opening of an on-site TCU. Main outcome measures Length of stay, discharge disposition, complications of the acute and ALC portions of the patients’ hospital stays, activities of daily living (mobility, transfers, and urinary continence), psychotropic medications and vitamin D prescriptions, and ALC patient care costs, as well as annual hospital savings, were examined. Results Among the 86 ALC patients receiving care during the postintervention period, 57 (66%) were admitted to the TCU; 29 of the 86 (34%) patients in the postintervention group received standard care (SC). All 86 ALC patients in the postintervention group were compared with the 49 preintervention ALC patients who received SC. Length of stay reduction occurred among the postintervention group during the acute portion of the hospital stay (14.0 days postintervention group vs 22.5 days preintervention group; P < .01). Discharge home or to an assisted-living facility increased among the postintervention group (30% postintervention group vs 12% preintervention group; P < .01). Patients’ ability to transfer improved among the postintervention group (55% postintervention group vs 14% preintervention group; P < .01). At discharge, 48% of ALC patients in the postintervention group were able to transfer independently compared with 17% of ALC patients in the preintervention group. Hospital-acquired infections among the postintervention group decreased during the
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Berney, Sue; Stockton, Kellie; Berlowitz, David; Denehy, Linda
2002-01-01
Respiratory complications remain a major cause of morbidity and mortality in the acute quadriplegic patient population. The literature has suggested that early insertion of a tracheostomy facilitated pulmonary management and an earlier discharge from the intensive care unit (ICU). Recently, a change in practice has meant that these patients are considered for extubation and intensive physiotherapy treatment, including an overnight on-call service, rather than tracheostomy. The aim of the present retrospective, case-controlled study was to determine if either practice resulted in a difference in length of stay in intensive care and if an on-call physiotherapy service for these patients was cost effective. A case control design was used. Between April 1997 and November 1999, seven patients who did not require a tracheostomy were identified; case control subjects were matched for severity with seven patients who did receive a tracheostomy. Length of stay in intensive care and on the acute ward, days from injury to fixation and the overall number of respiratory physiotherapy and night physiotherapy treatments were recorded. Five of the seven patients in the non-tracheostomy group received on-call overnight physiotherapy treatment, with an average of five sessions over a total of three nights. This group's length of stay in an ICU was significantly less than patients who were tracheostomized (p = 0.02). The overall number of physiotherapy treatments between the two groups was not significantly different. The results of this study suggest that if extubation and intensive physiotherapy is undertaken for suitable patients, the length of stay in intensive care can be significantly reduced. This represents a considerable cost saving for ICUs and more than covers the added cost of providing an after hours on-call physiotherapy treatment service. A prospective evaluation is required to confirm these findings.
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[Spiritual Care of Patients With Depression].
Kao, Chia-Chan; Lin, Yu-Hua
2018-06-01
Spiritual care is a component of holistic care. Patients with depression often experience body-mind-spirit health problems and may suffer from spiritual crises, particularly during the acute stage of a diseases, due to low self-esteem, negative attitudes toward life goals, daily life issues, and beliefs caused by physical, psychological, and occupational dysfunctions. Nonetheless, psychical care is the main treatment for patients with depression. This paper focuses on patients with depression and addresses the concepts of spiritual needs and spiritual care, identifying the factors that influence spiritual needs, the essentials of spiritual intervention, and the health effects of spiritual intervention outcomes on patients with depression. Courses that teach practical spiritual interventions are recommended for nurses. These courses should address topics such as individual approaches, building trusting relationships, setting diverse goals for spiritual interventions based on disease stage, and spiritual interventions involving the body-mind-spiritual aspects for patients with depression.
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Slatyer, Susan; Pienaar, Catherine; Williams, Anne M; Proctor, Karen; Hewitt, Laura
2015-08-01
To explore the experiences and perceptions of hospital staff caring for dying patients in a dedicated patient/family room (named Lotus Room). Dying in hospital is a common outcome for people across the world. However, noise and activity in acute environments present barriers to quality end-of-life care. This is of concern because care provided to dying patients has been shown to affect both the patients and the bereaved families. A qualitative descriptive approach was used. Semi-structured interviews were conducted with 17 multidisciplinary staff and seven families provided information through an investigator-developed instrument. Qualitative data analysis generated three categories describing: Dying in an hospital; The Lotus Room; and the Outcomes for patients and families. The Lotus Room was seen as a large, private and, ultimately, safe space for patients and families within the public hospital environment. Family feedback supported staff perspectives that the Lotus Room facilitated family presence and communication. The privacy afforded by the Lotus Room within this acute hospital provided benefits for the dying patients and grieving families. Improved outcomes included a peaceful death for patients, which may have assisted the family with their bereavement. This study provides evidence of how the physical environment can address well-established barriers to quality end-of-life care in acute hospitals. © 2015 John Wiley & Sons Ltd.
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Informal caregiving burden and perceived social support in an acute stroke care facility.
Akosile, Christopher Olusanjo; Banjo, Tosin Olamilekan; Okoye, Emmanuel Chiebuka; Ibikunle, Peter Olanrewaju; Odole, Adesola Christiana
2018-04-05
Providing informal caregiving in the acute in-patient and post-hospital discharge phases places enormous burden on the caregivers who often require some form of social support. However, it appears there are few published studies about informal caregiving in the acute in-patient phase of individuals with stroke particularly in poor-resource countries. This study was designed to evaluate the prevalence of caregiving burden and its association with patient and caregiver-related variables and also level of perceived social support in a sample of informal caregivers of stroke survivors at an acute stroke-care facility in Nigeria. Ethical approval was sought and obtained. Fifty-six (21 males, 35 females) consecutively recruited informal caregivers of stroke survivors at the medical ward of a tertiary health facility in South-Southern Nigeria participated in this cross-sectional survey. Participants' level of care-giving strain/burden and perceived social support were assessed using the Caregiver Strain Index and the Multidimensional Scale of Perceived Social Support respectively. Caregivers' and stroke survivors' socio-demographics were also obtained. Data was analysed using frequency count and percentages, independent t-test, analysis of variance (ANOVA) and partial correlation at α =0.05. The prevalence of care-giving burden among caregivers is 96.7% with a high level of strain while 17.9% perceived social support as low. No significant association was found between caregiver burden and any of the caregiver- or survivor-related socio-demographics aside primary level education. Only the family domain of the Multidimensional Scale of Perceived Social Support was significantly correlated with burden (r = - 0.295). Informal care-giving burden was highly prevalent in this acute stroke caregiver sample and about one in every five of these caregivers rated social support low. This is a single center study. Healthcare managers and professionals in acute care facilities
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Analyzing discharge strategies during acute care: a discrete-event simulation study.
Crawford, Elizabeth A; Parikh, Pratik J; Kong, Nan; Thakar, Charuhas V
2014-02-01
We developed a discrete-event simulation model of patient pathway through an acute care hospital that comprises an ED and several inpatient units. The effects of discharge timing on ED waiting and boarding times, ambulance diversions, leave without treatment, and readmissions were explicitly modeled. We then analyzed the impact of 1 static and 2 proactive discharge strategies on these system outcomes. Our analysis indicated that although the 2 proactive discharge strategies significantly reduced ED waiting and boarding times, and several other measures, compared with the static strategy (P < 0.01), the number of readmissions increased substantially. Further analysis indicated that these findings are sensitive to changes in patient arrival rate and conditions for ambulance diversion. Determining the appropriate time to discharge patients not only can affect individual patients' health outcomes, but also can affect various aspects of the hospital. The study improves our understanding of how individual inpatient discharge decisions can be objectively viewed in terms of their impact on other operations, such as ED crowding and readmission, in an acute care hospital.
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Readmission to an Acute Care Hospital During Inpatient Rehabilitation for Traumatic Brain Injury.
Hammond, Flora M; Horn, Susan D; Smout, Randall J; Beaulieu, Cynthia L; Barrett, Ryan S; Ryser, David K; Sommerfeld, Teri
2015-08-01
To assess the incidence of, causes for, and factors associated with readmission to an acute care hospital (RTAC) during inpatient rehabilitation for traumatic brain injury (TBI). Prospective observational cohort. Inpatient rehabilitation. Individuals with TBI admitted consecutively for inpatient rehabilitation (N=2130). Not applicable. RTAC incidence, RTAC causes, rehabilitation length of stay (RLOS), and rehabilitation discharge location. A total of 183 participants (9%) experienced RTAC for a total of 210 episodes. Of 183 participants, 161 patients experienced 1 RTAC episode, 17 had 2, and 5 had 3. The mean time from rehabilitation admission to first RTAC was 22±22 days. The mean duration in acute care during RTAC was 7±8 days. Eighty-four participants (46%) had ≥1 RTAC episodes for medical reasons, 102 (56%) had ≥1 RTAC episodes for surgical reasons, and 6 (3%) participants had RTAC episodes for unknown reasons. Most common surgical RTAC reasons were neurosurgical (65%), pulmonary (9%), infection (5%), and orthopedic (5%); most common medical reasons were infection (26%), neurological (23%), and cardiac (12%). Any RTAC was predicted as more likely for patients with older age, history of coronary artery disease, history of congestive heart failure, acute care diagnosis of depression, craniotomy or craniectomy during acute care, and presence of dysphagia at rehabilitation admission. RTAC was less likely for patients with higher admission FIM motor scores and education less than high school diploma. RTAC occurrence during rehabilitation was significantly associated with longer RLOS and smaller likelihood of discharge home. Approximately 9% of patients with TBI experienced RTAC episodes during inpatient rehabilitation for various medical and surgical reasons. This information may help inform interventions aimed at reducing interruptions in rehabilitation for RTAC. RTACs were associated with longer RLOS and discharge to an institutional setting. Copyright
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Low, Lian Leng; Vasanwala, Farhad Fakhrudin; Ng, Lee Beng; Chen, Cynthia; Lee, Kheng Hock; Tan, Shu Yun
2015-03-14
Improving healthcare utilization is essential as health systems around the world grapple with the escalating demands for acute hospital resources. Evidence suggests that transitional care programs are effective to improve utilization of healthcare. However, the evidence for transitional care programs that enhance the home medical care model and provide multi-disciplinary patient-centered care is not well established. We evaluated if a transitional home care program operated by the Singapore General Hospital was effective in reducing acute hospital utilization. We performed a quasi-experimental study using a pre-post design to evaluate the effectiveness of a transitional home care program in reducing hospital admissions and emergency department attendances of medically complex patients enrolled into the program in a tertiary hospital in Singapore. Patients received a comprehensive needs assessment performed by the physician and a nurse case manager in the home setting, followed by an individualized care plan that included medical and nursing care, patient education and coordination of care with hospital specialists and community services. Primary study outcomes were emergency department attendances and hospital admissions to all hospitals. These were extracted from hospital administrative data and national health records. Wilcoxon Signed Ranks Test was used for assess differences in pre and post continuous data. Overall, 262 patients were enrolled into the program and 259 were analyzed. Patients had a 51.6% and 52.8% reduction in hospital admissions in the three-month and six-month post enrollment, respectively. Similarly, a 47.1% and 48.2% reduction was observed for emergency department attendances in the three and six months post enrollment, respectively. The average difference in per patient hospital bed days in the pre- and post-enrollment periods were 12.05 days and 20.03 days at the 3-month and 6-month periods, respectively. Patients enrolled in the
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Yang, Ming; Hu, Xiaoyi; Wang, Haozhong; Zhang, Lei; Hao, Qiukui; Dong, Birong
2017-04-01
The aim of this study is to assess the prevalence of sarcopenia and investigate the associations between sarcopenia and long-term mortality and readmission in a population of elderly inpatients in acute care wards. We conducted a prospective observational study in the acute care wards of a teaching hospital in western China. The muscle mass was estimated according to a previously validated anthropometric equation. Handgrip strength was measured with a handheld dynamometer, and physical performance was measured via a 4 m walking test. Sarcopenia was defined according to the recommended diagnostic algorithm of the Asia Working Group for Sarcopenia. The survival status and readmission information were obtained via telephone interviews at 12, 24, and 36 months during the 3 year follow-up period following the baseline investigation. Two hundred and eighty-eight participants (mean age: 81.1 ± 6.6 years) were included. Forty-nine participants (17.0%) were identified as having sarcopenia. This condition was similar in men and women (16.9% vs. 17.5%, respectively, P = 0.915). During the 3 year follow-up period, 49 men (22.7%) and 9 women (16.4%) died (P = 0.307). The mortality of sarcopenic participants was significantly increased compared with non-sarcopenic participants (40.8% vs. 17.1%, respectively, P < 0.001). After adjusting for age, sex and other confounders, sarcopenia was an independent predictor of 3 year mortality (adjusted hazard ratio: 2.49; 95% confidential interval: 1.25-4.95) and readmission (adjusted hazard ratio: 1.81; 95% confidential interval: 1.17-2.80). Sarcopenia, which is evaluated by a combination of anthropometric measures, gait speed, and handgrip strength, is valuable to predict hospital readmission and long-term mortality in elderly patients in acute care wards. © 2016 The Authors. Journal of Cachexia, Sarcopenia and Muscle published by John Wiley & Sons Ltd on behalf of the Society on Sarcopenia, Cachexia and
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Tarrant, Carolyn; Sutton, Elizabeth; Angell, Emma; Aldridge, Cassie P; Boyal, Amunpreet; Bion, Julian
2017-04-05
It is now well-recognised that patients admitted to hospital on weekends are at higher risk of death than those admitted during weekdays. However, the causes of this 'weekend effect' are poorly understood. Some contend that there is a deficit of medical staff on weekends resulting in poorer quality care, whereas others find that patients admitted to hospital on weekends are sicker and therefore at higher risk of adverse outcomes. Clarifying the causal pathway is clearly important in order to identify effective solutions. In this article we describe an ethnographic approach to evaluating the organisation and delivery of medical care on weekends compared with weekdays, with a specific focus on the role of medical staff as part of National Health Service England's plan to implement 7-day services. We will conduct an ethnographic study of 20 acute hospitals in England between April 2016 and March 2018 as part of the High-intensity Specialist-Led Acute Care project (www.hislac.org). Data will be collected through observations and shadowing, and interviews with staff, in 10 hospitals with higher intensity specialist (consultant) staffing on weekends and 10 with lower intensity specialist staffing. Interviews will be conducted with up to 20 patients sampled from two high-intensity and two low-intensity sites. We will coordinate, compare and contrast observations across our team of ethnographers. Analysis will be both in-depth and cross-cutting, exploring specific features within individual sites and making comparisons between them. We outline how data collection and analysis will be facilitated and organised. The project has received ethics approval from the South West Wales Research Ethics Committee: Reference 13/WA/0372. Informed consent will be obtained for all interview participants. The findings will be disseminated through peer-reviewed publications in high-quality journals and at national and international conferences. © Article author(s) (or their employer
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Mercedes, Angela; Fairman, Precillia; Hogan, Lisa; Thomas, Rexi; Slyer, Jason T
2016-07-01
Consistent, concise and timely communication between a multidisciplinary team of healthcare providers, patients and families is necessary for the delivery of quality care. Structured multidisciplinary rounding (MDR) using a structured communication tool may positively impact length of stay (LOS) and satisfaction of patients and staff by improving communication, coordination and collaboration among the healthcare team. To evaluate the effectiveness of structured MDR using a structured communication tool in acute care units on LOS and satisfaction of patients and staff. Adult patients admitted to acute care units and healthcare providers who provide direct care for adult patients hospitalized in in-patient acute care units. The implementation of structured MDR utilizing a structured communication tool to enhance and/or guide communication. Quasi-experimental studies and descriptive studies. Length of stay, patient satisfaction and staff satisfaction. The comprehensive search strategy aimed to find relevant published and unpublished quantitative English language studies from the inception of each database searched through June 30, 2015. Databases searched include Cumulative Index to Nursing and Allied Health Literature, PubMed, Excerpta Medica Database, Health Source, Cochrane Central Register of Controlled Trials and Scopus. A search of gray literature was also performed. All reviewers independently evaluated the included studies for methodological quality using critical appraisal tools from the Joanna Briggs Institute (JBI). Data related to the methods, participants, interventions and findings were extracted using a standardized data extraction tool from the JBI. Due to clinical and methodological heterogeneity in the interventions and outcome measures of the included studies, statistical meta-analysis was not possible. Results are presented in narrative form. Eight studies were included, three quasi-experimental studies and five descriptive studies of quality
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A transitional care service for elderly chronic disease patients at risk of readmission.
Brand, Caroline A; Jones, Catherine T; Lowe, Adrian J; Nielsen, David A; Roberts, Carol A; King, Bellinda L; Campbell, Donald A
2004-12-13
Multiple hospital admissions, especially those related to chronic disease, represent a particular challenge to the acute health care sector in Australia. To determine whether a nurse-led chronic disease management model of transitional care reduced readmissions to acute care. A quasi-experimental controlled trial. A large tertiary metropolitan teaching hospital. 166 general medical patients aged > or = 65 years with either a history of readmissions to acute care or multiple medical comorbidities. Implementation of a chronic disease management model of transitional care aimed at improving patient management and reducing readmissions to acute care. Readmission rates and emergency department presentation rates at 3-and 6-month follow up. Secondary outcome measures include quality of life, discharge destination, and primary health care service utilisation. There was no difference in readmission rates, emergency department presentation rates, quality of life, discharge destination or primary health care service utilisation. The difficulties inherent in evaluating this type of multifactorial intervention are discussed and consideration is given to patient factors, the difficulty of influencing readmission rates, and local system issues. The outcomes of this study reflect the tension that exists between implementing multifaceted integrated health service programs and attempting to evaluate them within complex and changing environments using robust research methodologies.
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Early Exercise Rehabilitation of Muscle Weakness in Acute Respiratory Failure Patients
Berry, Michael J.; Morris, Peter E.
2013-01-01
Acute Respiratory Failure patients experience significant muscle weakness which contributes to prolonged hospitalization and functional impairments post-hospital discharge. Based on our previous work, we hypothesize that an exercise intervention initiated early in the intensive care unit aimed at improving skeletal muscle strength could decrease hospital stay and attenuate the deconditioning and skeletal muscle weakness experienced by these patients. Summary Early exercise has the potential to decrease hospital length of stay and improve function in Acute Respiratory Failure patients. PMID:23873130
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Shin, Eun Suk; Hwang, Seon Young; Jeong, Myung Ho; Lee, Eun Sook
2013-12-01
This study was conducted to identify direct and indirect factors influencing self-care compliance in patients with first acute coronary syndrome through examining the relationship among multidimensional factors. Outpatients who made hospital visits to receive a follow-up care at more than 6 months after percutaneous coronary intervention were recruited at a national university hospital in Korea. Data of 430 participants were collected through self-administered questionnaires and analyzed using AMOS version 7.0. The fitness of the hypothetical model and the degree of significance of direct and indirect paths were analyzed. Three paths were found to have a significant effect on self-care compliance in the modified model. Social support indirectly influenced self-care compliance through enhancing self-efficacy, reducing anxiety and increasing perceived benefit. In addition, social support and body function indirectly influenced self-care compliance through reducing depression which affected self-efficacy. Self-efficacy was the most influential factor and played an important role as a mediating variable. Results of this study suggest that nurses' counselling and education as a form of social support should be encouraged to enhance self-efficacy and self-care compliance among outpatients during follow-up care after percutaneous coronary intervention. Copyright © 2013. Published by Elsevier B.V.
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Katz, Jason N; Gore, Joel M; Amin, Alpesh; Anderson, Frederick A; Dasta, Joseph F; Ferguson, James J; Kleinschmidt, Kurt; Mayer, Stephan A; Multz, Alan S; Peacock, W Frank; Peterson, Eric; Pollack, Charles; Sung, Gene Yong; Shorr, Andrew; Varon, Joseph; Wyman, Allison; Emery, Leigh A; Granger, Christopher B
2009-10-01
Limited data are available on the care of patients with acute severe hypertension requiring hospitalization. We characterized contemporary practice patterns and outcomes for this population. STAT is a 25-institution, US registry of consecutive patients with acute severe hypertension (>180 mm Hg systolic and/or >110 mm Hg diastolic; >140 and/or >90 for subarachnoid hemorrhage) treated with intravenous therapy in a critical care setting. One thousand five hundred eighty-eight patients were enrolled (January 2007 to April 2008). Median age was 58 years (interquartile range 49-70 years), 779 (49%) were women, and 892 (56%) were African American; 27% (n = 425) had a prior admission for acute hypertension and 486 (31%) had chronic kidney disease. Median qualifying blood pressure (BP) was 200 (186, 220) systolic and 110 (93, 123) mm Hg diastolic. Initial intravenous antihypertensive therapies used to control BP varied, with 1,009 (64%) patients requiring multiple drugs. Median time to achieve a systolic BP <160 mm Hg (<140 mm Hg for subarachnoid hemorrhage) was 4.0 (0.8, 12) hours; 893 (60%) had reelevation to >180 (>140 for subarachnoid hemorrhage) after initial control; and 63 (4.0%) developed iatrogenic hypotension. Hospital mortality was 6.9% (n = 109) with an aggregate 90-day mortality rate of 11% (174/1,588); 59% (n = 943) had acute/worsening end-organ dysfunction during hospitalization. The 90-day readmission rate was 37% (523/1,415), of which one quarter (132/523) was due to recurrent acute severe hypertension. This study highlights heterogeneity in care, BP control, and outcomes of patients hospitalized with acute severe hypertension.
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Mittal, Chikul; Lee, Hsien Chieh Daniel; Goh, Kiat Sern; Lau, Cheng Kiang Adrian; Tay, Leeanna; Siau, Chuin; Loh, Yik Hin; Goh, Teck Kheng Edward; Sandi, Chit Lwin; Lee, Chien Earn
2018-05-30
To test a population health program which could, through the application of process redesign, implement multiple evidence-based practices across the continuum of care in a functionally integrated health delivery system and deliver highly reliable and consistent evidence-based surgical care for patients with fragility hip fractures in an acute tertiary general hospital. The ValuedCare (VC) program was developed in three distinct phases as an ongoing collaboration between the Geisinger Health System (GHS), USA, and Changi General Hospital (CGH), Singapore, modelled after the GHS ProvenCare® Fragile Hip Fracture Program. Clinical outcome data on consecutive hip fracture patients seen in 12 months pre-intervention were then compared with the post-intervention group. Both pre- and post-intervention groups were followed up across the continuum of care for a period of 12 months. VC patients showed significant improvement in median time to surgery (97 to 50.5 h), as well as proportion of patients operated within 48 h from hospital admission (48% from 18.8%) as compared to baseline pre-intervention data. These patients also had significant reduction (p value < 0.001) of acute inpatient complications such as delirium, pneumonia, urinary tract infections, and pressure sores. VC program has shown significant reduction in median length of stay for acute hospital (13 to 9 days) as well as median combined length of stay for acute and sub-acute rehabilitation hospital (46 to 39 days), thus reducing the total duration of hospitalization and saving total hospital bed days. Operative and inpatient mortality, together with readmission rates, remained low and comparable to international Geriatric Fracture Centers (GFCs). The implementation of VC methodology has enabled consistent delivery of high-quality, reliable and comprehensive evidence-based care for hip fracture patients at Changi General Hospital. This has also reflected successful change management and
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Acute myocardial infarction quality of care: the Strong Heart Study.
Best, Lyle G; Butt, Amir; Conroy, Britt; Devereux, Richard B; Galloway, James M; Jolly, Stacey; Lee, Elisa T; Silverman, Angela; Yeh, Jeun-Liang; Welty, Thomas K; Kedan, Ilan
2011-01-01
Evaluate the quality of care provided patients with acute myocardial infarction and compare with similar national and regional data. Case series. The Strong Heart Study has extensive population-based data related to cardiovascular events among American Indians living in three rural regions of the United States. Acute myocardial infarction cases (72) occurring between 1/1/2001 and 12/31/2006 were identified from a cohort of 4549 participants. The proportion of cases that were provided standard quality of care therapy, as defined by the Healthcare Financing Administration and other national organizations. The provision of quality services, such as administration of aspirin on admission and at discharge, reperfusion therapy within 24 hours, prescription of beta blocker medication at discharge, and smoking cessation counseling were found to be 94%, 91%, 92%, 86% and 71%, respectively. The unadjusted, 30 day mortality rate was 17%. Despite considerable challenges posed by geographic isolation and small facilities, process measures of the quality of acute myocardial infarction care for participants in this American Indian cohort were comparable to that reported for Medicare beneficiaries nationally and within the resident states of this cohort.
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McCormick, Loretta; Godfrey, Christina M; Muscedere, John; Hendrikx, Shawn
2016-09-01
The objective of this review is to identify the evidence on the use of integrated knowledge translation (iKT) strategies in acute care. This information will assist in the identification of the strategies used to engage stakeholders, such as patients and decision makers, in the research process and how their involvement has influenced the implementation or integration of research into practice. The extent to which these iKT activities have occurred in the context of care of the elderly, intensively ill patient will be examined. The question that will guide this review is: What iKT strategies have been used within the acute care environment for the care of an older person, specifically: (a) where have these strategies been used, and (b) how have iKT strategies been implemented?
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Acute care nurses' views on family participation and collaboration in fundamental care.
Mackie, Benjamin R; Marshall, Andrea; Mitchell, Marion
2018-06-01
To understand the beliefs, attitudes and perceptions of nurses regarding family participation and collaboration in the care of their hospitalized adult relative. Family participation in care is known to enhance the quality of patient care. Nurses are uniquely placed to support such participation, including the delivery of fundamental care. However, nurses' attitudes and beliefs may help or hinder participation. A mixed methods approach with an exploratory sequential design was used. A regional referral hospital in Australia. Nurses were eligible to participate in the study if they were permanent staff of the hospital, and who in their day-to-day work had direct contact with adult patients and their families on acute care wards. Observer-as-participant observation data and semi-structured interviews were undertaken. 30 hr of observational data were gathered, and 14 nurses were interviewed. Data collection occurred between September and December 2016. Following separate analysis, data were triangulated. Analysis uncovered two contrasting categories: (i) enacting family participation (four themes); and (ii) hindering family participation (five themes). The findings of our study demonstrated that the practices of nurses do not always align with healthcare policies, and strategies to support nurses to enact patient- and family-centred practices are needed. Nurses can use these findings to make informed evidence-based changes to the way they practice and communicate with families to ensure fundamental care is delivered. © 2017 John Wiley & Sons Ltd.
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Daws, Karen; Punch, Amanda; Winters, Michelle; Posenelli, Sonia; Willis, John; MacIsaac, Andrew; Rahman, Muhammad Aziz; Worrall-Carter, Linda
2014-11-01
Acute coronary syndrome (ACS) contributes to the disparity in life expectancy between Aboriginal and non-Aboriginal Australians. Improving hospital care for Aboriginal patients has been identified as a means of addressing this disparity. This project developed and implemented a working together model of care, comprising an Aboriginal Hospital Liaison Officer and a specialist cardiac nurse, providing care coordination specifically directed at improving attendance at cardiac rehabilitation services for Aboriginal Australians in a large metropolitan hospital in Melbourne. A quality improvement framework using a retrospective case notes audit evaluated Aboriginal patients' admissions to hospital and identified low attendance rates at cardiac rehabilitation services. A working together model of care coordination by an Aboriginal Hospital Liaison Officer and a specialist cardiac nurse was implemented to improve cardiac rehabilitation attendance in Aboriginal patients admitted with ACS to the cardiac wards of the hospital. A retrospective medical records audit showed that there were 68 Aboriginal patients admitted to the cardiac wards with ACS from 1 July 2008 to 30 June 2011. A referral to cardiac rehabilitation was recorded for 42% of these. During the implementation of the model of care, 13 of 15 patients (86%) received a referral to cardiac rehabilitation and eight of the 13 (62%) attended. Implementation of the working together model demonstrated improved referral to and attendance at cardiac rehabilitation services, thereby, has potential to prevent complications and mortality. WHAT IS KNOWN ABOUT THE TOPIC?: Aboriginal Australians experience disparities in access to recommended care for acute coronary syndrome. This may contribute to the life expectancy gap between Aboriginal and non-Aboriginal Australians. WHAT DOES THIS PAPER ADD?: This paper describes a model of care involving an Aboriginal Hospital Liaisons Officer and a specialist cardiac nurse working
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Middleton, Addie; Graham, James E; Lin, Yu-Li; Goodwin, James S; Bettger, Janet Prvu; Deutsch, Anne; Ottenbacher, Kenneth J
2016-12-01
The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 stipulates that standardized functional status (self-care and mobility) and cognitive function data will be used for quality reporting in post-acute care settings. Thirty-day post-discharge unplanned rehospitalization is an established quality metric that has recently been extended to post-acute settings. The relationships between the functional domains in the IMPACT Act and 30-day unplanned rehospitalization are poorly understood. To determine the degree to which discharge mobility, self-care, and cognitive function are associated with 30-day unplanned rehospitalization following discharge from post-acute care. This was a retrospective cohort study. Inpatient rehabilitation facilities submitting claims and assessment data to the Centers for Medicare and Medicaid Services in 2012-2013. Medicare fee-for-service enrollees discharged from post-acute rehabilitation in 2012-2013. The sample included community-dwelling adults admitted for rehabilitation following an acute care stay who survived for 32 days following discharge (N = 252,406). Not applicable. Thirty-day unplanned rehospitalization following post-acute rehabilitation. The unadjusted 30-day unplanned rehospitalization rate was 12.0 % (n = 30,179). Overall, patients dependent at discharge for mobility had a 50 % increased odds of rehospitalization (OR = 1.50, 95 % CI: 1.42-1.59), patients dependent for self-care a 36 % increased odds (OR = 1.36, 95 % CI: 1.27-1.47), and patients dependent for cognition a 19 % increased odds (OR = 1.19, 95 % CI: 1.09-1.29). Patients dependent for both self-care and mobility at discharge (n = 8312, 3.3 %) had a 16.1 % (95 % CI: 15.3-17.0 %) adjusted rehospitalization rate versus 8.5 % (95 % CI: 8.3-8.8 %) for those independent for both (n = 74,641; 29.6 %). The functional domains identified in the IMPACT Act were associated with 30-day unplanned
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Maben, Jill; Adams, Mary; Peccei, Riccardo; Murrells, Trevor; Robert, Glenn
2012-06-01
Few empirical studies have directly examined the relationship between staff experiences of providing healthcare and patient experience. Present concerns over the care of older people in UK acute hospitals - and the reported attitudes of staff in such settings - highlight an important area of study. AIMS AND OBJECTIVES. To examine the links between staff experience of work and patient experience of care in a 'Medicine for Older People' (MfOP) service in England. A mixed methods case study undertaken over 8 months incorporating a 149-item staff survey (66/192 - 34% response rate), a 48-item patient survey (26/111 - 23%), 18 staff interviews, 18 patient and carer interviews and 41 hours of non-participant observation. Variation in patient experience is significantly influenced by staff work experiences. A high-demand/low-control work environment, poor staffing, ward leadership and co-worker relationships can each add to the inherent difficulties staff face when caring for acutely ill older people. Staff seek to alleviate the impact of such difficulties by finding personal satisfaction from caring for 'the poppets'; those patients they enjoy caring for and for whom they feel able to 'make a difference'. Other patients - noting dehumanising aspects of their care - felt like 'parcels'. Patients are aware of being seen by staff as 'difficult' or 'demanding' and seek to manage their relationships with nursing staff accordingly. The work experiences of staff in a MfOP service impacted directly on patient care experience. Poor ward and patient care climates often lead staff to seek job satisfaction through caring for 'poppets', leaving less favoured - and often more complex patients - to receive less personalised care. Implications for practice. Investment in staff well-being and ward climate is essential for the consistent delivery of high-quality care for older people in acute settings. © 2012 Blackwell Publishing Ltd.
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Ido, Moges Seyoum; Bayakly, Rana; Frankel, Michael; Lyn, Rodney; Okosun, Ike S
2015-01-15
Tracking the vital status of stroke patients through death data is one approach to assessing the impact of quality improvement in stroke care. We assessed the feasibility of linking Georgia hospital discharge data with mortality data to evaluate the effect of participation in the Georgia Coverdell Acute Stroke Registry on survival rates among acute ischemic stroke patients. Multistage probabilistic matching, using a fine-grained record integration and linkage software program and combinations of key variables, was used to link Georgia hospital discharge data for 2005 through 2009 with mortality data for 2006 through 2010. Data from patients admitted with principal diagnoses of acute ischemic stroke were analyzed by using the extended Cox proportional hazard model. The survival times of patients cared for by hospitals participating in the stroke registry and of those treated at nonparticipating hospitals were compared. Average age of the 50,579 patients analyzed was 69 years, and 56% of patients were treated in Georgia Coverdell Acute Stroke Registry hospitals. Thirty-day and 365-day mortality after first admission for stroke were 8.1% and 18.5%, respectively. Patients treated at nonparticipating facilities had a hazard ratio for death of 1.14 (95% confidence interval, 1.03-1.26; P = .01) after the first week of admission compared with patients cared for by hospitals participating in the registry. Hospital discharge data can be linked with death data to assess the impact of clinical-level or community-level chronic disease control initiatives. Hospitals need to undertake quality improvement activities for a better patient outcome.
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El Hajj, Maguy Saffouh; Jaam, Myriam Jihad; Awaisu, Ahmed
2018-06-01
The impact of collaborative and multidisciplinary health care on the outcomes of care in patients with acute coronary syndromes (ACS) is well-established in the literature. However, there is lack of high quality evidence on the role of pharmacist care in this setting. This systematic review aimed to evaluate the impact of pharmacist care on patient outcomes (readmission, mortality, emergency visits, and medication adherence) in patients with ACS at or post-discharge. The following electronic databases and search engines were searched from their inception to September 2016: PubMed, EMBASE, Cochrane Central Register of Controlled Trials, ISI Web of Science, Scopus, Campbell Library, Database of Abstracts of Reviews of Effects (DARE), Health System Evidence, Global Health Database, Joanna Briggs Institute Evidence-Based Practice Database, Academic Search Complete, ProQuest, PROSPERO, and Google Scholar. Studies were included if they evaluated the impact of pharmacist's care (compared with no pharmacist's care or usual care) on the outcomes of rehospitalization, mortality, and medication adherence in patients post-ACS discharge. Comparison of the outcomes with relevant statistics was summarized and reported. A total of 17 studies [13 randomized controlled trials (RCTs) and four non-randomized clinical studies] involving 8391 patients were included in the review. The studies were of variable quality (poor to good quality) or risk of bias (moderate to critical risk). The nature and intensity of pharmacist interventions varied among the studies including medication reconciliation, medication therapy management, discharge medication counseling, motivational interviewing, and post-discharge face-to-face or telephone follow-up. Pharmacist-delivered interventions significantly improved medication adherence in four out of 12 studies. However, these did not translate to significant improvements in the rates of readmissions, hospitalizations, emergency visits, and mortality
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Prone position in patients with acute respiratory distress syndrome
Setten, Mariano; Plotnikow, Gustavo Adrián; Accoce, Matías
2016-01-01
Acute respiratory distress syndrome occupies a great deal of attention in intensive care units. Despite ample knowledge of the physiopathology of this syndrome, the focus in intensive care units consists mostly of life-supporting treatment and avoidance of the side effects of invasive treatments. Although great advances in mechanical ventilation have occurred in the past 20 years, with a significant impact on mortality, the incidence continues to be high. Patients with acute respiratory distress syndrome, especially the most severe cases, often present with refractory hypoxemia due to shunt, which can require additional treatments beyond mechanical ventilation, among which is mechanical ventilation in the prone position. This method, first recommended to improve oxygenation in 1974, can be easily implemented in any intensive care unit with trained personnel. Prone position has extremely robust bibliographic support. Various randomized clinical studies have demonstrated the effect of prone decubitus on the oxygenation of patients with acute respiratory distress syndrome measured in terms of the PaO2/FiO2 ratio, including its effects on increasing patient survival. The members of the Respiratory Therapists Committee of the Sociedad Argentina de Terapia Intensiva performed a narrative review with the objective of discovering the available evidence related to the implementation of prone position, changes produced in the respiratory system due to the application of this maneuver, and its impact on mortality. Finally, guidelines are suggested for decision-making. PMID:27925054
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Acute Respiratory Failure in Cardiac Transplant Recipients.
Komurcu, Ozgur; Ozdemirkan, Aycan; Camkiran Firat, Aynur; Zeyneloglu, Pinar; Sezgin, Atilla; Pirat, Arash
2015-11-01
This study sought to evaluate the incidence, risk factors, and outcomes of acute respiratory failure in cardiac transplant recipients. Cardiac transplant recipients >15 years of age and readmitted to the intensive care unit after cardiac transplant between 2005 and 2015 were included. Thirty-nine patients were included in the final analyses. Patients with acute respiratory failure and without acute respiratory failure were compared. The most frequent causes of readmission were routine intensive care unit follow-up after endomyocardial biopsy, heart failure, sepsis, and pneumonia. Patients who were readmitted to the intensive care unit were further divided into 2 groups based on presence of acute respiratory failure. Patients' ages and body weights did not differ between groups. The groups were not different in terms of comorbidities. The admission sequential organ failure assessment scores were higher in patients with acute respiratory failure. Patients with acute respiratory failure were more likely to use bronchodilators and n-acetylcysteine before readmission. Mean peak inspiratory pressures were higher in patients in acute respiratory failure. Patients with acute respiratory failure developed sepsis more frequently and they were more likely to have hypotension. Patients with acute respiratory failure had higher values of serum creatinine before admission to intensive care unit and in the first day of intensive care unit. Patients with acute respiratory failure had more frequent bilateral opacities on chest radiographs and positive blood and urine cultures. Duration of intensive care unit and hospital stays were not statistically different between groups. Mortality in patients with acute respiratory failure was 76.5% compared with 0% in patients without acute respiratory failure. A significant number of cardiac transplant recipients were readmitted to the intensive care unit. Patients presenting with acute respiratory failure on readmission more frequently
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Lamas, Daniela J; Owens, Robert L; Nace, R Nicholas; Massaro, Anthony F; Pertsch, Nathan J; Moore, Susan T; Bernacki, Rachelle E; Block, Susan D
2017-07-01
The chronically critically ill have survived acute critical illness but require prolonged mechanical ventilation. These patients are frequently transferred from acute care to long-term acute care hospitals (LTACHs) for prolonged recovery, yet many suffer setbacks requiring readmission to acute care. The patient's relatively improved condition while at the LTACH might be an opportunity for communication regarding care goals; however, there have been no prior studies of the feasibility of such conversations in the LTACH. To determine the feasibility, acceptability, and potential usefulness of conversations about serious illness with chronic critical illness patients or their surrogate decision makers after LTACH admission. We adapted an existing conversation guide for use in chronically critically ill (defined by tracheotomy for prolonged ventilation) LTACH patients or their surrogates to explore views about quality of life, understanding of medical conditions, expectations, and planning for setbacks. These conversations were conducted by one interviewer and summarized for the patients' clinicians. We surveyed patients, surrogates, and clinicians to assess acceptability. A total of 70 subjects were approached and 50 (71%) were enrolled, including 30 patients and 20 surrogates. The median duration of the conversation was 14 minutes 45 seconds [IQR 12:46, 19]. The presence of ongoing mechanical ventilation did not lead to longer conversations; in fact, conversations with patients were shorter than those with surrogates. The majority of subjects (81%) described the conversation as worthwhile. The majority of clinicians (73%) reported that the conversation offered a new and significant understanding of the patient's preferences if a setback were to occur. Conversations about serious illness care goals can be accomplished in a relatively short period of time, are acceptable to chronically critically ill patients and their surrogate decision makers in the LTACH, and are
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Clark, Matthew T.; Calland, James Forrest; Enfield, Kyle B.; Voss, John D.; Lake, Douglas E.; Moorman, J. Randall
2017-01-01
Background Charted vital signs and laboratory results represent intermittent samples of a patient’s dynamic physiologic state and have been used to calculate early warning scores to identify patients at risk of clinical deterioration. We hypothesized that the addition of cardiorespiratory dynamics measured from continuous electrocardiography (ECG) monitoring to intermittently sampled data improves the predictive validity of models trained to detect clinical deterioration prior to intensive care unit (ICU) transfer or unanticipated death. Methods and findings We analyzed 63 patient-years of ECG data from 8,105 acute care patient admissions at a tertiary care academic medical center. We developed models to predict deterioration resulting in ICU transfer or unanticipated death within the next 24 hours using either vital signs, laboratory results, or cardiorespiratory dynamics from continuous ECG monitoring and also evaluated models using all available data sources. We calculated the predictive validity (C-statistic), the net reclassification improvement, and the probability of achieving the difference in likelihood ratio χ2 for the additional degrees of freedom. The primary outcome occurred 755 times in 586 admissions (7%). We analyzed 395 clinical deteriorations with continuous ECG data in the 24 hours prior to an event. Using only continuous ECG measures resulted in a C-statistic of 0.65, similar to models using only laboratory results and vital signs (0.63 and 0.69 respectively). Addition of continuous ECG measures to models using conventional measurements improved the C-statistic by 0.01 and 0.07; a model integrating all data sources had a C-statistic of 0.73 with categorical net reclassification improvement of 0.09 for a change of 1 decile in risk. The difference in likelihood ratio χ2 between integrated models with and without cardiorespiratory dynamics was 2158 (p value: <0.001). Conclusions Cardiorespiratory dynamics from continuous ECG monitoring detect
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Klein, Lauren R; Cole, Jon B; Driver, Brian E; Battista, Christopher; Jelinek, Ryan; Martel, Marc L
2018-03-01
Emergency department (ED) visits for acute alcohol intoxication are common, but this population is at risk for decompensation and occult critical illness. The purpose of this study is to describe the incidence and predictors of unsuspected critical illness among patients with acute alcohol intoxication. This was a retrospective observational study of ED patients from 2011 to 2016 with acute alcohol intoxication. The study cohort included patients presenting for alcohol intoxication, whose initial assessment was uncomplicated alcohol intoxication without any other active acute medical or traumatic complaints. The primary outcome was defined as the unanticipated subsequent use of critical care resources during the encounter or admission to an ICU. We investigated potential predictors for this outcome with generalized estimating equations. We identified 31,364 eligible patient encounters (median age 38 years; 71% men; median breath alcohol concentration 234 mg/dL); 325 encounters (1%) used critical care resources. The most common diagnoses per 1,000 ED encounters were acute hypoxic respiratory failure (3.1), alcohol withdrawal (1.7), sepsis or infection (1.1), and intracranial hemorrhage (1.0). Three patients sustained a cardiac arrest. Presence of the following had an increased adjusted odds ratio (aOR) of developing critical illness: hypoglycemia (aOR 9.2), hypotension (aOR 3.8), tachycardia (aOR 1.8), fever (aOR 7.6), hypoxia (aOR 3.8), hypothermia (aOR 4.2), and parenteral sedation (aOR 2.4). The initial blood alcohol concentration aOR was 1.0. Critical care resources were used for 1% of ED patients with alcohol intoxication who were initially assessed by physicians to have low risk. Abnormal vital signs, hypoglycemia, and chemical sedation were associated with increased odds of critical illness. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
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Brady, Paul; Gorham, James; Kosti, Angeliki; Seligman, William; Courtney, Alona; Mazan, Karolina; Paterson, Stuart; Ramcharitar, Steve; Chandrasekaran, Badri; Juniper, Mark; Greamspet, Mala; Daniel, Jessica; Chalstrey, Sue; Ahmed, Ijaz; Dasgupta, Tanaji
2015-01-01
Acute kidney injury (AKI) affects up to 20% of all patients admitted to hospital, and is associated with a higher risk of adverse clinical outcomes, increased healthcare costs, as well as long term risks of chronic kidney disease and end stage renal failure. The aim of this project was to improve the quality of care for patients with AKI admitted to the acute medical unit (AMU) at the Great Western Hospital (GWH). We assessed awareness and self reported confidence among physicians in our Trust, in addition to basic aspects of care relevant to AKI on our AMU. A multifaceted quality improvement strategy was developed, which included measures to improve awareness such as a Trust wide AKI awareness day, and reconfiguring the admission proforma on our AMU in order to enhance risk assessment, staging, and early response to AKI. Ancillary measures such as the dissemination of flashcards for lanyards containing core information were also used. Follow up assessments showed that foundation year one (FY1) doctors’ self reported confidence in managing AKI increased from 2.8 to 4.2, as measured on a five point Likert scale (P=0.0003). AKI risk assessment increased from 13% to 57% (P=0.07) following a change in the admission proforma. Documentation of the diagnosis of AKI increased from 66% to 95% (P=0.038) among flagged patients. Documentation of urine dip results increased from 33% to 73% (P=0.01), in addition to a rise in appropriate referral for specialist input, although this was not statistically significant. Our results suggest that using the twin approaches of improving awareness, and small changes to systemic factors such as modification of the admission proforma, can lead to significant enhancements in the quality of care of patients with AKI. PMID:26734401
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Maeda, Keisuke; Koga, Takayuki; Akagi, Junji
2018-01-01
Background Little is known about the association between malnutrition and the chances of returning home from post-acute facilities in older adult patients. This study aimed to understand whether malnutrition and malnutrition-related factors would be determinants for returning home and activities of daily living (ADL) at discharge after post-acute care. Methods Patients aged ≥65 years living at home before the onset of an acute disease and admitted to a post-acute ward were enrolled (n=207) in this prospective observational study. Malnutrition was defined based on the criteria of the European Society for Clinical Nutrition and Metabolism. Nutritional parameters included the nutritional intake at the time of admission and oral conditions evaluated by the Oral Health Assessment Tool (OHAT). The Barthel Index was used to assess daily activities. A Cox regression analysis of the length of stay was performed. Multivariable linear regression analyses to determine associations between malnutrition, returning home, and ADL at discharge were performed, after adjusting the variables of acute care setting. Results The mean patient age was 84.7±6.7 years; 38% were men. European Society for Clinical Nutrition and Metabolism-defined malnutrition was observed in 129 (62.3%) patients, and 118 (57.0%) of all patients returned home. Multivariable regression analyses showed that malnutrition was a negative predictor of returning home (hazard ratio: 0.517 [0.351–0.761], p=0.001), and an increase in the nutritional intake (kcal/kg/d) was a positive predictor of the Barthel Index at discharge (coefficient: 0.34±0.15, p=0.021). The OHAT was not associated with returning home and ADL. Conclusion Malnutrition and nutritional intake are associated with returning home and ADL at discharge, respectively, after post-acute care. Further studies investigating the effects of a nutritional intervention for post-acute patients would be necessary. PMID:29416323
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Kilpatrick, Kelley; Lavoie-Tremblay, Mélanie; Lamothe, Lise; Ritchie, Judith A; Doran, Diane
2013-01-01
This article describes a new conceptual framework for acute care nurse practitioner role enactment, boundary work and perceptions of team effectiveness. Acute care nurse practitioners contribute positively to patient care by enacting an expanded scope of practise. Researchers have found both positive and negative reactions to the introduction of acute care nurse practitioners in healthcare teams. The process of role enactment, shifting role boundaries, and perceptions of team effectiveness has been studied disparately. A framework linking team structures and processes to desirable outcomes is needed. Literature was obtained by searching CINAHL, PsycInfo, MedLine, PubMed, British Nursing Index, Cochrane Library, JSTOR Archive, Web of Science, and Google Scholar from 1985-2010. A descriptive multiple-case study was completed from March 2009-May 2009. A new conceptual framework describing how role enactment and boundary work affect perceptions of team effectiveness was developed by combining theoretical and empirical sources. The framework proposes proximal indicators used by team members to assess their team's performance. The framework identifies the inter-related dimensions and concepts that different stakeholders need to consider when introducing nurse practitioners in healthcare teams. Further study is needed to identify team-level outcomes that reflect the contributions of all providers to quality patient care, and explore the patients' and families' perceptions of team effectiveness following the introduction of acute care nurse practitioners. The new framework can guide decision-making and research related to the structures, processes, and outcomes of nurse practitioner roles in healthcare teams. © 2012 Blackwell Publishing Ltd.
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Eindhoven, Daniëlle C; Borleffs, C Jan Willem; Dietz, Marlieke F; Schalij, Martin J; Brouwers, Corline; de Bruijne, Martine C
2017-03-20
Numerous studies have shown that a substantial number of patients suffer from adverse events (AEs) as a result of hospital care. However, specific data on AEs in acute cardiac care are scarce. The current manuscript describes the development and validation of a specific instrument to evaluate patient safety of a predefined care track for patients with acute myocardial infarction (AMI). Retrospective patient record review study. A total of 879 hospital admissions treated in a tertiary care centre for an AMI (age 64±12 years, 71% male). In the first phase, the medical records of patients with AMI warranting coronary angiography or coronary intervention were analysed for process deviations. In the second phase, the medical records of these patients were checked for any harm that had occurred which was caused by the healthcare provider or the healthcare organisation (AE) and whether the harm that occurred was preventable. Of all 879 patients included in the analysis, 40% (n=354) had 1 or more process deviation. Of these 354 patients, 116 (33%) had an AE. Patients with AE experienced more process deviations compared with patients without AE (2±1.7 vs 1.5±0.9 process deviations per patient, p=0.005). Inter-rater reliability in assessing a causal relation of healthcare with the origin of an AE showed a κ of 0.67 (95% CI 0.51 to 0.83). This study shows that it is possible to develop a reliable method, which can objectively assess process deviations and the occurrence of AEs in a specified population. This method could be a starting point for developing an electronic tracking system for continuous monitoring in strictly predefined care tracks. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
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Providing care for critically ill surgical patients: challenges and recommendations.
Tisherman, Samuel A; Kaplan, Lewis; Gracias, Vicente H; Beilman, Gregory J; Toevs, Christine; Byrnes, Matthew C; Coopersmith, Craig M
2013-07-01
Providing optimal care for critically ill and injured surgical patients will become more challenging with staff shortages for surgeons and intensivists. This white paper addresses the historical issues behind the present situation, the need for all intensivists to engage in dedicated critical care per the intensivist model, and the recognition that intensivists from all specialties can provide optimal care for the critically ill surgical patient, particularly with continuing involvement by the surgeon of record. The new acute care surgery training paradigm (including trauma, surgical critical care, and emergency general surgery) has been developed to increase interest in trauma and surgical critical care, but the number of interested trainees remains too few. Recommendations are made for broadening the multidisciplinary training and practice opportunities in surgical critical care for intensivists from all base specialties and for maintaining the intensivist model within acute care surgery practice. Support from academic and administrative leadership, as well as national organizations, will be needed.
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Lin, Shin-Yi; Tang, Sung-Chun; Tsai, Li-Kai; Yeh, Shin-Joe; Shen, Li-Jiuan; Wu, Fe-Lin Lin; Jeng, Jiann-Shing
2015-01-01
Abstract Mannitol, an osmotic diuretic, is commonly used to treat patients with acute brain edema, but its use also increases the risk of developing acute kidney injury (AKI). In this study, we investigated the incidence and risk factors of mannitol-related AKI in acute stroke patients. A total of 432 patients (ischemic stroke 62.3%) >20 years of age who were admitted to the neurocritical care center in a tertiary hospital and received mannitol treatment were enrolled in this study. Clinical parameters including the scores of National Institutes of Health Stroke Scale (NIHSS) at admission, vascular risk factors, laboratory data, and concurrent nephrotoxic medications were registered. Acute kidney injury was defined as an absolute elevation in the serum creatinine (Scr) level of ≥0.3 mg/dL from the baseline or a ≥50% increase in Scr. The incidence of mannitol-related AKI was 6.5% (95% confidence interval, 4.5%–9.3%) in acute stroke patients, 6.3% in patients with ischemic stroke, and 6.7% in patients with intracerebral hemorrhage. Multivariate analysis revealed that diabetes, lower estimated glomerular filtration rate at baseline, higher initial NIHSS score, and concurrent use of diuretics increased the risk of mannitol-related AKI. When present, the combination of these elements displayed an area under the receiver operating characteristic curve of 0.839 (95% confidence interval, 0.770–0.909). In conclusion, mannitol-related AKI is not uncommon in the treatment of acute stroke patients, especially in those with vulnerable risk factors. PMID:26632702
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Nymark, C; Saboonchi, F; Mattiasson, A-C; Henriksson, P; Kiessling, A
2017-03-01
Reducing patient delay for patients afflicted by an acute myocardial infarction is a task of great complexity, which might be alleviated if more factors that influence this delay could be identified. Although a number of self-reported instruments associated with patient delay exist, none of these taps the content of the appraisal process related to patients' subjective emotions. The aim of this study was to develop and validate a questionnaire aimed at assessing patients' appraisal, emotions and action tendencies when afflicted by an acute myocardial infarction. An item pool was generated based on themes conceptualized in a recent qualitative study of acute myocardial infarction patients' thoughts, feelings and actions preceding the decision to seek medical care. The 'Think-Aloud Protocol' and test-retest analysis at item level were performed. The modified item pool was administered to 96 patients when treated for acute myocardial infarction. Explorative factor analysis and principal component analysis with the non-linear iterative partial least squares algorithm were performed to examine the underlying factor structure of the items. The findings indicated three core dimensions corresponding to three subscales, namely, 'symptom appraisal'; 'perceived inability to act'; 'autonomy preservation'. The results demonstrated acceptable measures of reliability and validity Conclusions: The PA-AMI questionnaire demonstrated satisfactory psychometric properties. Assessment of the included core dimensions may contribute to greater understanding of the appraisal processes for patients afflicted by an acute myocardial infarction.
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Kornhaber, Rachel; Walsh, Kenneth; Duff, Jed; Walker, Kim
2016-01-01
Therapeutic interpersonal relationships are the primary component of all health care interactions that facilitate the development of positive clinician-patient experiences. Therapeutic interpersonal relationships have the capacity to transform and enrich the patients' experiences. Consequently, with an increasing necessity to focus on patient-centered care, it is imperative for health care professionals to therapeutically engage with patients to improve health-related outcomes. Studies were identified through an electronic search, using the PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO databases of peer-reviewed research, limited to the English language with search terms developed to reflect therapeutic interpersonal relationships between health care professionals and patients in the acute care setting. This study found that therapeutic listening, responding to patient emotions and unmet needs, and patient centeredness were key characteristics of strategies for improving therapeutic interpersonal relationships.
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Chen, Jersey; Rathore, Saif S; Wang, Yongfei; Radford, Martha J; Krumholz, Harlan M
2006-01-01
BACKGROUND Patients and purchasers prefer board-certified physicians, but whether these physicians provide better quality of care and outcomes for hospitalized patients is unclear. OBJECTIVE We evaluated whether care by board-certified physicians after acute myocardial infarction (AMI) was associated with higher use of clinical guideline recommended therapies and lower 30-day mortality. SUBJECTS AND METHODS We examined 101,251 Medicare patients hospitalized for AMI in the United States and compared use of aspirin, β-blockers, and 30-day mortality according to the attending physicians' board certification in family practice, internal medicine, or cardiology. RESULTS Board-certified family practitioners had slightly higher use of aspirin (admission: 51.1% vs 46.0%; discharge: 72.2% vs 63.9%) and β-blockers (admission: 44.1% vs 37.1%; discharge: 46.2% vs 38.7%) than nonboard-certified family practitioners. There was a similar pattern in board-certified Internists for aspirin (admission: 53.7% vs 49.6%; discharge: 78.2% vs 68.8%) and β-blockers (admission: 48.9% vs 44.1%; discharge: 51.2% vs 47.1). Board-certified cardiologists had higher use of aspirin compared with cardiologists certified in internal medicine only or without any board certification (admission: 61.3% vs 53.1% vs 52.1%; discharge: 82.2% vs 71.8% vs 71.5%) and β-blockers (admission: 52.9% vs 49.6% vs 41.5%; discharge: 54.7% vs 50.6% vs 42.5%). In multivariate regression analyses, board certification was not associated with differences in 30-day mortality. CONCLUSIONS Treatment by a board-certified physician was associated with modestly higher quality of care for AMI, but not differences in mortality. Regardless of board certification, all physicians had opportunities to improve quality of care for AMI. PMID:16637823
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ADHD in acute care psychiatric inpatients.
Lines, Katherine L; Sadek, Joseph
2018-06-01
Attention-deficit hyperactivity disorder (ADHD) is a neurocognitive disorder characterized by symptoms of inattention, impulsivity and motor hyperactivity. The worldwide prevalence of ADHD, in the general adult population, has been estimated to be 2.8%. Patients with ADHD have a high incidence of comorbidity with other psychiatric disorders. Those with a psychiatric disorder as well as ADHD have more psychosocial difficulties than those without ADHD. Despite knowing that ADHD is often comorbid with other psychiatric diagnoses, there are currently no studies elucidating the prevalence of ADHD in the inpatient psychiatric population, nor is there significant information about its impact. The lack of research into this topic suggests more needs to be done in the field of adult ADHD, especially in the inpatient psychiatric population and with respect to impairment in patient function. Knowing the prevalence of ADHD and its impact on quality of life in adult inpatients will help lay the groundwork for effective screening and management. The purpose of this study was to understand the prevalence rates of ADHD among psychiatric acute care inpatients. Other objectives included comparing the quality of life and functioning between patients with a primary psychiatric diagnosis and ADHD (treated or untreated) versus those with a primary psychiatric diagnosis and no ADHD. Thirty-three (N = 31) psychiatric inpatients were screened using the Adult ADHD Self-Report Scale. Those that screened positive for ADHD received a full diagnostic assessment for ADHD. All patients completed the Weiss Functional Impairment Rating Scale (WFIRS) to assess level of functioning and a Clinical Global Impression of Severity/Improvement Scale (on admission and discharge). Demographic information was also obtained. Of the 31 patients analyzed, 12 had a diagnosis of ADHD (36.4%). The participants diagnosed with ADHD scored significantly higher on the WFIRS, suggesting decreased functioning compared
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The Emergency Medical Care of Patients With Acute Myocardial Infarction.
Stockburger, Martin; Maier, Birga; Fröhlich, Georg; Rutsch, Wolfgang; Behrens, Steffen; Schoeller, Ralph; Theres, Heinz; Poloczek, Stefan; Plock, Gerd; Schühlen, Helmut
2016-07-25
Optimizing the emergency medical care chain might shorten the time to treatment of patients with ST-elevation myocardial infarction (STEMI). The initial care by a physician, and, in particular, correct ECG interpretation, are critically important factors. From 1999 onward, data on the care of patients with myocardial infarction have been recorded and analyzed in the Berlin Myocardial Infarction Registry. In the First Medical Contact Study, data on initial emergency medical care were obtained on 1038 patients who had been initially treated by emergency physicians in 2012. Their pre-hospital ECGs were re-evaluated in a blinded fashion according to the criteria of the European Society of Cardiology. The retrospective re-evaluation of pre-hospital ECGs revealed that 756 of the 1038 patients had sustained a STEMI. The emergency physicians had correctly diagnosed STEMI in 472 patients (62.4%), and they had correctly diagnosed ventricular fibrillation in 85 patients (11.2%); in 199 patients (26.3%), the ECG interpretation was unclear. The pre-hospital ECG interpretation was significantly associated with the site of initial hospitalization and the ensuing times to treatment. In particular, the time from hospital admission to cardiac catheterization was longer in patients with an unclear initial ECG interpretation than in those with correctly diagnosed STEMI (121 [54; 705] vs. 36 [19; 60] minutes, p <0.001). After multivariate adjustment, this corresponded to a hazard ratio* of 2.67 [2.21; 3.24]. Pre-hospital ECG interpretation in patients with STEMI was a trigger factor with a major influence on the time to treatment in the hospital. The considerable percentage of pre-hospital ECGs whose interpretation was unclear implies that there is much room for improvement.
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An Innovative Approach to Health Care Delivery for Patients with Chronic Conditions.
Clarke, Janice L; Bourn, Scott; Skoufalos, Alexis; Beck, Eric H; Castillo, Daniel J
2017-02-01
Although the health care reform movement has brought about positive changes, lingering inefficiencies and communication gaps continue to hamper system-wide progress toward achieving the overarching goal-higher quality health care and improved population health outcomes at a lower cost. The multiple interrelated barriers to improvement are most evident in care for the population of patients with multiple chronic conditions. During transitions of care, the lack of integration among various silos and inadequate communication among providers cause delays in delivering appropriate health care services to these vulnerable patients and their caregivers, diminishing positive health outcomes and driving costs ever higher. Long-entrenched acute care-focused treatment and reimbursement paradigms hamper more effective deployment of existing resources to improve the ongoing care of these patients. New models for care coordination during transitions, longitudinal high-risk care management, and unplanned acute episodic care have been conceived and piloted with promising results. Utilizing existing resources, Mobile Integrated Healthcare is an emerging model focused on closing these care gaps by means of a round-the-clock, technologically sophisticated, physician-led interprofessional team to manage care transitions and chronic care services on-site in patients' homes or workplaces.
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Mercadante, Sebastiano; Porzio, Giampiero; Caruselli, Amanda; Aielli, Federica; Adile, Claudio; Girelli, Nicola; Casuccio, Alessandra
2015-02-01
Cancer patients with a history of alcoholism may be problematic. The frequency of alcoholism among patients with advanced cancer has never been reported in Italy or other European countries. The aim of this prospective study was to determine the frequency of alcoholism, assessed with a simple and validated instrument, among patients with advanced cancer who were referred to two different palliative care settings: an acute inpatient palliative care unit (PCU) of a comprehensive cancer center in a metropolitan area and a home care program (HCP) in a territorial district, localized in the mountains of Italy. A consecutive sample of patients admitted to an inpatient PCU and to an HCP was assessed for a period of eight months. Each patient who agreed to be interviewed completed the Cut down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire. Patients were then interviewed informally to gather information about their history with alcohol. In total, 443 consecutive patients were surveyed; data from 249 to 194 patients were collected in the PCU and HCP, respectively, in the eight-month period. The mean age was 66.4 (SD 12.7) years, and 207 were males. The mean Karnofsky level was 54.2 (SD 14.6). Eighteen patients were CAGE positive (4.06%). Males (Pearson Chi-squared, P = 0.027) and younger patients (analysis of variance test, P = 0.009) were more likely to be CAGE positive. Informal interviews revealed that 17 patients (3.83%) were alcoholics or had a history of alcoholism, and that alcoholism was strongly correlated with CAGE (Pearson Chi-squared, P < 0.0001). Only a minority of patients were CAGE positive, with a similar frequency in the PCU and HCP settings. CAGE-positive patients were more likely to be male and younger, independent of diagnosis and performance status. CAGE was positively correlated with informal interviews for detecting alcoholism. As CAGE patients express more symptom distress, it is important to detect this problem with a simple tool that has a
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Neighborhood Child Opportunity and Individual-Level Pediatric Acute Care Use and Diagnoses.
Kersten, Ellen E; Adler, Nancy E; Gottlieb, Laura; Jutte, Douglas P; Robinson, Sarah; Roundfield, Katrina; LeWinn, Kaja Z
2018-05-01
: media-1vid110.1542/5751513300001PEDS-VA_2017-2309 Video Abstract OBJECTIVES: Although health care providers and systems are increasingly interested in patients' nonmedical needs as a means to improve health, little is known about neighborhood conditions that contribute to child health problems. We sought to determine if a novel, publicly available measure of neighborhood context, the Child Opportunity Index, was associated with pediatric acute care visit frequency and diagnoses. This cross-sectional study included San Francisco residents <18 years of age with an emergency department and/or urgent care visit to any of 3 medical systems ( N = 47 175) between 2007 and 2011. Hot-spot analysis was used to compare the spatial distribution of neighborhood child opportunity and income. Generalized estimating equation logistic regression models were used to examine independent associations between neighborhood child opportunity and frequent acute care use (≥4 visits per year) and diagnosis group after adjusting for neighborhood income and patient age, sex, race and/or ethnicity, payer, and health system. Neighborhood child opportunity and income had distinct spatial distributions, and we identified different clusters of high- and low-risk neighborhoods. Children living in the lowest opportunity neighborhoods had significantly greater odds of ≥4 acute care visits per year (odds ratio 1.33; 95% confidence interval 1.03-1.73) compared with those in the highest opportunity neighborhoods. Neighborhood child opportunity was negatively associated with visits for respiratory conditions, asthma, assault, and ambulatory care-sensitive conditions but positively associated with injury-related visits. The Child Opportunity Index could be an effective tool for identifying neighborhood factors beyond income related to child health. Copyright © 2018 by the American Academy of Pediatrics.
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Herasevich, V; Yilmaz, M; Khan, H; Chute, C G; Gajic, O
2007-10-11
Early detection of specific critical care syndromes, such as sepsis or acute lung injury (ALI)is essential for timely implementation of evidence based therapies. Using a near-real time copy of the electronic medical records ("ICU data mart") we developed and validated custom electronic alert (ALI"sniffer") in a cohort of 485 critically ill medical patients. Compared with the gold standard of prospective screening, ALI "sniffer" demonstrated good sensitivity, 93% (95% CI 90 to 95) and specificity, 90% (95% CI 87 to 92). It is not known if the bedside implementation of ALI "sniffer" will improve the adherence to evidence-based therapies and outcome of patients with ALI.
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Kornhaber, Rachel; Walsh, Kenneth; Duff, Jed; Walker, Kim
2016-01-01
Therapeutic interpersonal relationships are the primary component of all health care interactions that facilitate the development of positive clinician–patient experiences. Therapeutic interpersonal relationships have the capacity to transform and enrich the patients’ experiences. Consequently, with an increasing necessity to focus on patient-centered care, it is imperative for health care professionals to therapeutically engage with patients to improve health-related outcomes. Studies were identified through an electronic search, using the PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO databases of peer-reviewed research, limited to the English language with search terms developed to reflect therapeutic interpersonal relationships between health care professionals and patients in the acute care setting. This study found that therapeutic listening, responding to patient emotions and unmet needs, and patient centeredness were key characteristics of strategies for improving therapeutic interpersonal relationships. PMID:27789958
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Boonyasiri, Adhiratha; Thamlikitkul, Visanu
2014-03-01
To implement multifaceted interventions to promote rational use of antibiotics for out-patients with upper respiratory tract infection (URI) and acute diarrhea. The present study was conducted at ambulatory care facility for patients under Social Security Healthcare Benefit Scheme and Universal Health Coverage Scheme of Siriraj Hospital from January to April 2012. Multifaceted interventions were: Training responsible healthcare personnel on rational use of antibiotics, Clinical practice guidelines, Preprinted medical record forms for patients, Throat swab or stool culture to be taken from the patients (if responsible physicians needed these); and provision of brochures containing causes, necessity and harm of antibiotics for URI and acute diarrhea to patients as well as their relatives while waiting for receiving care. Pre-printed medical records were collected every day. Each patient was called on day 3 after receiving care by an investigator to determine clinical responses. There were 1,241 episodes of URI and 210 episodes of acute diarrhea during the study period. Rates of antibiotic prescriptions were 13.0% for URI and 19.1% for acute diarrhea. Throat swab cultures recovered group A beta-hemolytic streptococci in 3.8% of URI patients and non-typhoidal Salmonella spp. in 14.6% of acute diarrhea patients. Clinical responses of the patients on day 3 after receiving care revealed that more than 97% of the patients who received antibiotics and who did not receive antibiotics were cured or improved. Multifaceted interventions are very effective for promoting rational use of antibiotics for out-patients with URI and acute diarrhea at Siriraj Hospital.
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Wang, Yiyang; Tang, Jun; Zhou, Feiya; Yang, Lei; Wu, Jianbin
2017-06-01
The aim of the current meta-analysis was to assess the treatment effect of comprehensive geriatric care in reducing acute perioperative delirium in older patients with hip fractures, compared with the effect of a routine orthopedic treatment protocol. We conducted a search of multiple databases to identify randomized controlled trials (RCTs) and quasi-RCTs comparing comprehensive geriatric care and routine orthopedic treatment regarding the following outcomes: incidence of delirium, assessment of cognitive status, and duration of delirium. Odds ratios (ORs) and mean differences (MDs) were pooled using either a fixed-effects or a random-effects model, depending on the heterogeneity of the trials included in the analysis. Six RCTs and 1 quasi-RCT provided data from 1840 patients. These data revealed that comprehensive geriatric care may reduce the incidence of perioperative delirium (OR = 0.71; 95% confidence interval [CI], 0.57-0.89; P = .003) and that it was associated with higher cognitive status during hospitalization or at 1 month postoperatively (MD = 1.03; 95% CI, 0.93-1.13; P ≤ .00001). There was no significant difference in duration of perioperative delirium between the 2 treatment groups (MD = -2.48; 95% CI, -7.36 to 2.40; P = .32). Based on the quality of evidence provided, comprehensive geriatric care may reduce the incidence of perioperative delirium. To obtain evidence regarding the merits of comprehensive geriatric care in reducing severity of delirium and shortening the duration of delirium, there is a need for multicenter RCTs with high methodological quality.
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Das, Stephanie L M; Papachristou, George I; De Campos, Tercio; Panek, Jozefa; Poves Prim, Ignasi; Serrablo, Alejandro; Parks, Rowan W; Uomo, Generoso; Windsor, John A; Petrov, Maxim S
2013-09-10
Organ failure is a major determinant of mortality in patients with acute pancreatitis. These patients usually require admission to high dependency or intensive care units and consume considerable health care resources. Given a low incidence rate of organ failure and a lack of large non-interventional studies in the field of acute pancreatitis, the characteristics of organ failure that influence outcomes of patients with acute pancreatitis remain largely unknown. Therefore, the Pancreatitis Across Nations Clinical Research and Education Alliance (PANCREA) aims to conduct a meta-analysis of individual patient data from prospective non-interventional studies to determine the influence of timing, duration, sequence, and combination of different organ failures on mortality in patients with acute pancreatitis. Pancreatologists currently active with acute pancreatitis clinical research will be invited to contribute. To be eligible for inclusion patients will have to meet the criteria of acute pancreatitis, develop at least one organ failure during the first week of hospitalization, and not be enrolled into an intervention study. Raw data will then be collated and checked. Individual patient data analysis based on a logistic regression model with adjustment for confounding variables will be done. For all analyses, corresponding 95% confidence intervals and P values will be reported. This collaborative individual patient data meta-analysis will answer important clinical questions regarding patients with acute pancreatitis that develop organ failure. Information derived from this study will be used to optimize routine clinical management and improve care strategies. It can also help validate outcome definitions, allow comparability of results and form a more accurate basis for patient allocation in further clinical studies.
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Knight, Thomas; Ahn, Shin; Rice, Terry W; Cooksley, Tim
2017-11-01
Cancer care has become increasingly specialized and advances in therapy have resulted in a larger number of patients receiving care. There has been a significant increase in the number of patients presenting with cancer related emergencies including treatment toxicities and those directly related to the malignancy. Suspected neutropenic sepsis is an acute medical emergency and empirical antibiotic therapy should be administered immediately. The goal of empirical therapy is to cover the most likely pathogens that will cause life-threatening infections in neutropenic patients. Patients with febrile neutropenia are a heterogeneous group with only a minority of treated patients developing significant medical complications. Outpatient management of low risk febrile neutropenia patients identified by the MASCC score is a safe and effective strategy. Immunotherapy with "checkpoint inhibitors" has significantly improved outcomes for patients with metastatic melanoma and evidence of benefit in a wide range of malignancies is developing. Despite these clinical benefits a number of immune related adverse events have been recognised which can affect virtually all organ systems and are potentially fatal. The timing of the onset of the adverse events is dependent on the organ system affected and unlike anti-neoplastic therapy can be delayed significantly after initiation or completion of therapy. The field of Acute Oncology is changing rapidly. Alongside, the traditional challenge of neutropenic sepsis there are many emerging toxicities. Further research into the optimal management, strategies and pathways of acutely unwell patients with cancer is required. Copyright © 2017 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
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Clark, Brendan J; Smart, Alexandra; House, Robert; Douglas, Ivor; Burnham, Ellen L; Moss, Marc
2012-03-01
Unhealthy alcohol use predisposes to multiple conditions that frequently result in critical illness and is present in up to one-third of patients admitted to a medical intensive care unit (ICU). We sought to determine the baseline readiness to change in medical ICU patients with unhealthy alcohol use and hypothesized that the severity of acute illness would be independently associated with higher scores on readiness to change scales. We further sought to determine whether this effect is modified by the severity of unhealthy alcohol use. We performed a cross-sectional observational study of current regular drinkers in 3 medical ICUs. The Alcohol Use Disorders Identification Test was used to differentiate low-risk and unhealthy alcohol use and further categorize patients into risky alcohol use or an alcohol use disorder. The severity of a patient's acute illness was assessed by calculating the Acute Physiologic and Chronic Health Evaluation II (APACHE II) score at the time of admission to the medical ICU. Readiness to change was assessed using standardized questionnaires. Of 101 medical ICU patients who were enrolled, 65 met the criteria for unhealthy alcohol use. The association between the severity of acute illness and readiness to change depended on the instrument used. A higher severity of illness measured by APACHE II score was an independent predictor of readiness to change as assessed by the Stages of Change Readiness and Treatment Eagerness Scale (Taking Action scale; p < 0.01). When a visual analog scale was used to assess readiness to change, there was a significant association with severity of acute illness (p < 0.01) that was modified by the severity of unhealthy alcohol use (p = 0.04 for interaction term). Medical ICU patients represent a population where brief interventions require further study. Studies of brief intervention should account for the severity of acute illness and the severity of unhealthy alcohol use as potential effect modifiers
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Nurse students learning acute care by simulation - Focus on observation and debriefing.
Abelsson, Anna; Bisholt, Birgitta
2017-05-01
Simulation creates the possibility to experience acute situations during nursing education which cannot easily be achieved in clinical settings. To describe how nursing students learn acute care of patients through simulation exercises, based on observation and debriefing. The study was designed as an observational study inspired by an ethnographic approach. Data was collected through observations and interviews. Data was analyzed using an interpretive qualitative content analysis. Nursing students created space for reflection when needed. There was a positive learning situation when suitable patient scenarios were presented. Observations and discussions with peers gave the students opportunities to identify their own need for knowledge, while also identifying existing knowledge. Reflections could confirm or reject their preparedness for clinical practice. The importance of working in a structured manner in acute care situations became apparent. However, negative feedback to peers was avoided, which led to a loss of learning opportunity. High fidelity simulation training as a method plays an important part in the nursing students' learning. The teacher also plays a key role by asking difficult questions and guiding students towards accurate knowledge. This makes it possible for the students to close knowledge gaps, leading to improved patient safety. Copyright © 2017 Elsevier Ltd. All rights reserved.
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Jeffs, Lianne; Kitto, Simon; Merkley, Jane; Lyons, Renee F; Bell, Chaim M
2012-01-01
To explore patients' and family members' perspectives on how safety threats are detected and managed across care transitions and strategies that improve care transitions from acute care hospitals to complex continuing care and rehabilitation health care organizations. Poorly executed care transitions can result in additional health care spending due to adverse outcomes and delays as patients wait to transfer from acute care to facilities providing different levels of care. Patients and their families play an integral role in ensuring they receive safe care, as they are the one constant in care transitions processes. However, patients' and family members' perspectives on how safety threats are detected and managed across care transitions from health care facility to health care facility remain poorly understood. This qualitative study used semistructured interviews with patients (15) and family members (seven) who were transferred from an acute care hospital to a complex continuing care/rehabilitation care facility. Data were analyzed using a directed content analytical approach. OUR RESULTS REVEALED THREE KEY OVERARCHING THEMES IN THE PERCEPTIONS: lacking information, getting "funneled through" too soon, and difficulty adjusting to the shift from total care to almost self-care. Several patients and families described their expectations and experiences associated with their interfacility care transitions as being uninformed about their transfer or that transfer happened too early. In addition, study participants identified the need for having a coordinated approach to care transitions that engages patients and family members. Study findings provide patients' and family members' perspectives on key safety threats and how to improve care transitions. Of particular importance is the need for patients and family members to play a more active role in their care transition planning and self-care management.
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Frueh, B Christopher; Grubaugh, Anouk L; Lo Sasso, Anthony T; Jones, Walter J; Oldham, John M; Lindrooth, Richard C
2012-01-01
The role of acute care inpatient psychiatry, public and private, has changed dramatically since the 1960s, especially as recent market forces affecting the private sector have had ripple effects on publicly funded mental health care. Key stakeholders' experiences, perceptions, and opinions regarding the role of acute care psychiatry in distressed markets of publicly funded mental health care were examined. A qualitative research study was conducted using semi-structured thematic interviews with 52 senior mental health system administrators, clinical directors and managers, and nonclinical policy specialists. Participants were selected from markets in six regions of the United States that experienced recent significant closures of acute care psychiatric beds. Qualitative data analyses yielded findings that clustered around three sets of higher order themes: structure of care, service delivery barriers, and outcomes. Structure of care suggests that acute care psychiatry is seen as part of a continuum of services; service delivery barriers inhibit effective delivery of services and are perceived to include economic, regulatory, and political factors; outcomes include fragmentation of mental health care services across the continuum, the shift of mental health care to the criminal justice system, and market-specific issues affecting mental health care. Findings delineate key stakeholders' perceptions regarding the role acute care psychiatry plays in the continuum of care for publicly funded mental health and suggest that public mental health care is inefficacious. Results carry implications for policy makers regarding strategies/policies to improve optimal utilization of scarce resources for mental health care, including greater focus on psychotherapy.
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Frueh, B. Christopher; Grubaugh, Anouk L.; Lo Sasso, Anthony T.; Jones, Walter J.; Oldham, John M.; Lindrooth, Richard C.
2017-01-01
The role of acute care inpatient psychiatry, public and private, has changed dramatically since the 1960s, especially as recent market forces affecting the private sector have had ripple effects on publicly funded mental health care. Key stakeholders’ experiences, perceptions, and opinions regarding the role of acute care psychiatry in distressed markets of publicly funded mental health care were examined. A qualitative research study was conducted using semi-structured thematic interviews with 52 senior mental health system administrators, clinical directors and managers, and nonclinical policy specialists. Participants were selected from markets in six regions of the United States that experienced recent significant closures of acute care psychiatric beds. Qualitative data analyses yielded findings that clustered around three sets of higher order themes: structure of care, service delivery barriers, and outcomes. Structure of care suggests that acute care psychiatry is seen as part of a continuum of services; service delivery barriers inhibit effective delivery of services and are perceived to include economic, regulatory, and political factors; outcomes include fragmentation of mental health care services across the continuum, the shift of mental health care to the criminal justice system, and market-specific issues affecting mental health care. Findings delineate key stakeholders’ perceptions regarding the role acute care psychiatry plays in the continuum of care for publicly funded mental health and suggest that public mental health care is inefficacious. Results carry implications for policy makers regarding strategies/policies to improve optimal utilization of scarce resources for mental health care, including greater focus on psychotherapy. PMID:22409204
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Acute care surgery: impact on practice and economics of elective surgeons.
Miller, Preston R; Wildman, Elizabeth A; Chang, Michael C; Meredith, J Wayne
2012-04-01
The creation of an acute care surgery service provides a rich operative experience for acute care surgeons. Elective surgeons typically have concerns about whether their practice volume will be restored with elective cases. Acute care surgery has financial implications for both groups. The aim of this project is to examine the impact in terms of work relative value units (wRVUs), collections, and cases in both groups with creation of an acute care surgery service at our institution. Work RVUs, collections, and case volume were examined from departmental records for 2 groups before and after acute care surgery service creation. The service began on September 1, 2008. Before this time, emergency surgical consults went to the general surgeon on call. After this date, all emergency consults were seen by acute care surgeons. The number of operations performed by the acute care surgery group increased significantly when the mean of the 2 years after institution of acute care surgery were compared with the mean of the 2 years preceding the service creation (1,639 vs 790/year; p = 0.007). There was no change in total operations done by the elective surgery group (2,763 vs 2,496/year: p = 0.13). Elective caseload, however, did increase by 23% in the elective surgery group. In the acute care surgery group, wRVUs increased by 140% and elective surgery group wRVUs decreased by 8%. Collections increased in both groups (acute care surgery 129%, elective surgery 7%) and the combined collections of the groups increased by $2,138,00 in the year after service creation. Acute care surgery service creation took emergency business from the elective surgery group, but this was almost immediately replaced with elective cases. This resulted in higher collections for both groups and a resultant significant increase in collections in aggregate. Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
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Crary, Michael A; Carnaby, Giselle D; Shabbir, Yasmeen; Miller, Leslie; Silliman, Scott
2016-02-01
Acute stroke patients with dysphagia are at increased risk for poor hydration. Dysphagia management practices may directly impact hydration status. This study examined clinical factors that might impact hydration status in acute ischemic stroke patients with dysphagia. A retrospective chart review was completed on 67 ischemic stroke patients who participated in a prior study of nutrition and hydration status during acute care. Prior results indicated that patients with dysphagia demonstrated elevated BUN/Cr compared to non-dysphagia cases during acute care and that BUN/Cr increased selectively in dysphagic patients. This chart review evaluated clinical variables potentially impacting hydration status: diuretics, parenteral fluids, tube feeding, oral diet, and nonoral (NPO) status. Exposure to any variable and number of days of exposure to each variable were examined. Dysphagia cases demonstrated significantly more NPO days, tube fed days, and parenteral fluid days, but not oral fed days, or days on diuretics. BUN/Cr values at discharge were not associated with NPO days, parenteral fluid days, oral fed days, or days on diuretics. Patients on modified solid diets had significantly higher mean BUN/Cr values at discharge (27.12 vs. 17.23) as did tube fed patients (28.94 vs. 18.66). No difference was noted between these subgroups at baseline (regular diet vs. modified solids diets). Any modification of solid diets (31.11 vs. 17.23) or thickened liquids (28.50 vs. 17.81) resulted in significantly elevated BUN/Cr values at discharge. Liquid or diet modifications prescribed for acute stroke patients with dysphagia may impair hydration status in these patients.
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Management of Acute Respiratory Failure in the Patient with Sepsis or Septic Shock.
Moore, Sarah; Weiss, Brian; Pascual, Jose L; Kaplan, Lewis J
Sepsis and septic shock are each commonly accompanied by acute respiratory failure and the need for invasive as well as non-invasive ventilation throughout a patient's intensive care unit course. We explore the underpinnings of acute respiratory failure of pulmonary as well as non-pulmonary origin in the context of invasive and non-invasive management approaches. Both pharmacologic and non-pharmacologic adjuncts to ventilatory and oxygenation support are highlighted as well. Finally, rescue modalities are positioned within the intensivist's armamentarium for global care of support of the critically ill or injured patient with sepsis or septic shock.
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Abdul Aziz, Aznida Firzah; Mohd Nordin, Nor Azlin; Ali, Mohd Fairuz; Abd Aziz, Noor Azah; Sulong, Saperi; Aljunid, Syed Mohamed
2017-01-13
Lack of intersectoral collaboration within public health sectors compound efforts to promote effective multidisciplinary post stroke care after discharge following acute phase. A coordinated, primary care-led care pathway to manage post stroke patients residing at home in the community was designed by an expert panel of specialist stroke care providers to help overcome fragmented post stroke care in areas where access is limited or lacking. Expert panel discussions comprising Family Medicine Specialists, Neurologists, Rehabilitation Physicians and Therapists, and Nurse Managers from Ministry of Health and acadaemia were conducted. In Phase One, experts chartered current care processes in public healthcare facilities, from acute stroke till discharge and also patients who presented late with stroke symptoms to public primary care health centres. In Phase Two, modified Delphi technique was employed to obtain consensus on recommendations, based on current evidence and best care practices. Care algorithms were designed around existing work schedules at public health centres. Indication for patients eligible for monitoring by primary care at public health centres were identified. Gaps in transfer of care occurred either at post discharge from acute care or primary care patients diagnosed at or beyond subacute phase at health centres. Essential information required during transfer of care from tertiary care to primary care providers was identified. Care algorithms including appropriate tools were summarised to guide primary care teams to identify patients requiring further multidisciplinary interventions. Shared care approaches with Specialist Stroke care team were outlined. Components of the iCaPPS were developed simultaneously: (i) iCaPPS-Rehab© for rehabilitation of stroke patients at community level (ii) iCaPPS-Swallow© guided the primary care team to screen and manage stroke related swallowing problems. Coordinated post stroke care monitoring service for patients
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McDonall, Jo; de Steiger, Richard; Reynolds, John; Redley, Bernice; Livingston, Patricia; Botti, Mari
2016-07-18
Patient participation is an important indicator of quality care. Currently, there is little evidence to support the belief that participation in care is possible for patients during the acute postoperative period. Previous work indicates that there is very little opportunity for patients to participate in care in the acute context. Patients require both capability, in terms of having the required knowledge and understanding of how they can be involved in their care, and the opportunity, facilitated by clinicians, to engage in their acute postoperative care. This cluster randomised crossover trial aims to test whether a multimedia intervention improves patient participation in the acute postoperative context, as determined by pain intensity and recovery outcomes. A total of 240 patients admitted for primary total knee replacement surgery will be invited to participate in a cluster randomised, crossover trial and concurrent process evaluation in at least two wards at a major non-profit private hospital in Melbourne, Australia. Patients admitted to the intervention ward will receive the multimedia intervention daily from Day 1 to Day 5 (or day of discharge, if prior). The intervention will be delivered by nurses via an iPad™, comprising information on the goals of care for each day following surgery. Patients admitted to the control ward will receive usual care as determined by care pathways currently in use across the organization. The primary endpoint is the "worst pain experienced in the past 24 h" on Day 3 following TKR surgery. Pain intensity will be measured using the numerical rating scale. Secondary outcomes are interference of pain on activities of daily living, length of stay in hospital, function and pain following TKR surgery, overall satisfaction with hospitalisation, postoperative complications and hospital readmission. The results of this study will contribute to our understanding of the effectiveness of interventions that provide knowledge and
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Fields, Christina J.; Fernandez, Natalia
2010-01-01
Background Acute care physical therapists contribute to the complex process of patient discharge planning. As physical therapists are experts at evaluating functional abilities and are able to incorporate various other factors relevant to discharge planning, it was expected that physical therapists’ recommendations of patient discharge location would be both accurate and appropriate. Objective This study determined how often the therapists’ recommendations for patient discharge location and services were implemented, representing the accuracy of the recommendations. The impact of unimplemented recommendations on readmission rate was examined, reflecting the appropriateness of the recommendations. Design This retrospective study included the discharge recommendations of 40 acute care physical therapists for 762 patients in a large academic medical center. The frequency of mismatch between the physical therapist's recommendation and the patient's actual discharge location and services was calculated. The mismatch variable had 3 levels: match, mismatch with services lacking, or mismatch with different services. Regression analysis was used to test whether mismatch status, patient age, length of admission, or discharge location predicted patient readmittance. Results Overall, physical therapists’ discharge recommendations were implemented 83% of the time. Patients were 2.9 times more likely to be readmitted when the therapist's discharge recommendation was not implemented and recommended follow-up services were lacking (mismatch with services lacking) compared with patients with a match. Limitations This study was limited to one facility. Limited information about the patients was collected, and data on patient readmission to other facilities were not collected. Conclusions This study supports the role of physical therapists in discharge planning in the acute care setting. Physical therapists demonstrated the ability to make accurate and appropriate discharge
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Hincapié, Cesar A; Tomlinson, George A; Côté, Pierre; Rampersaud, Y Raja; Jadad, Alejandro R; Cassidy, J David
2017-10-16
Chiropractic care is popular for low back pain, but may increase the risk for acute lumbar disc herniation (LDH). Low back pain is a common early (prodromal) symptom of LDH and commonly precedes LDH diagnosis. Our objective was to investigate the association between chiropractic care and acute LDH with early surgical intervention, and contrast this with the association between primary care physician (PCP) care and acute LDH with early surgery. Using a self-controlled case series design and population-based healthcare databases in Ontario, Canada, we investigated all adults with acute LDH requiring emergency department (ED) visit and early surgical intervention from April 1994 to December 2004. The relative incidence of acute LDH with early surgery in exposed periods after chiropractic visits relative to unexposed periods was estimated within individuals, and compared with the relative incidence of acute LDH with early surgery following PCP visits. 195 cases of acute LDH with early surgery (within 8 weeks) were identified in a population of more than 100 million person-years. Strong positive associations were found between acute LDH and both chiropractic and PCP visits. The risk for acute LDH with early surgery associated with chiropractic visits was no higher than the risk associated with PCP visits. Both chiropractic and primary medical care were associated with an increased risk for acute LDH requiring ED visit and early surgery. Our analysis suggests that patients with prodromal back pain from a developing disc herniation likely seek healthcare from both chiropractors and PCPs before full clinical expression of acute LDH. We found no evidence of excess risk for acute LDH with early surgery associated with chiropractic compared with primary medical care.
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Standardizing the care of detox patients to achieve quality outcomes.
Becker, Kathy; Semrow, Sue
2006-03-01
Providing appropriate treatment for detoxification patients is both challenging and difficult because alcohol abuse and dependence are largely underestimated in the acute hospital setting. Alcohol withdrawal syndrome is treated not only by addictionologists on chemical dependency units, but also by primary care physicians in acute inpatient settings. The need for consistent inpatient treatment through the use of identified protocols can help provide safe and effective care. The need for consistent, inpatient medical-surgical detoxification treatment in our organization became apparent with the staff's identification of patient care concerns. Using an organizational approach, a multidisciplinary team was created to standardize the care of detoxification patients, beginning with patient admission and ending with discharge and referral for outpatient management. Standardization would ensure consistent assessment and intervention, and improve communication among the clinical team members. A protocol was developed for both the emergency department and the inpatient units. The goals of the team were to decrease the adverse events related to detoxification, such as seizures and aggression, and provide a consistent method of treatment for staff to follow.
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Stressful life events and acute kidney injury in intensive and semi-intensive care unities.
Diniz, Denise Para; Marques, Daniella Aparecida; Blay, Sérgio Luis; Schor, Nestor
2012-03-01
Several studies point out that pathophysiological changes related to stress may influence renal function and are associated with disease onset and evolution. However, we have not found any studies about the influence of stress on renal function and acute kidney injury. To evaluate the association between stressful life events and acute kidney injury diagnosis, specifying the most stressful classes of events for these patients in the past 12 months. Case-control study. The study was carried out at Hospital São Paulo, in Universidade Federal de São Paulo and at Hospital dos Servidores do Estado de São Paulo, in Brazil. Patients with acute kidney injury and no chronic disease, admitted to the intensive or semi-intensive care units were included. Controls included patients in the same intensive care units with other acute diseases, except for the acute kidney injury, and also with no chronic disease. Out of the 579 patients initially identified, 475 answered to the Social Readjustment Rating Scale (SRRS) questionnaire and 398 were paired by age and gender (199 cases and 199 controls). The rate of stressful life events was statistically similar between cases and controls. The logistic regression analysis to detect associated effects of the independent variables to the stressful events showed that: increasing age and economic classes A and B in one of the hospitals (Hospital São Paulo - UNIFESP) increased the chance of a stressful life event (SLE). This study did not show association between the Acute Kidney Injury Group with a higher frequency of stressful life events, but that old age, higher income, and type of clinical center were associated.
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Reid, Colette; Gibbins, Jane; Bloor, Sophia; Burcombe, Melanie; McCoubrie, Rachel; Forbes, Karen
2015-12-01
The quality of end-of-life (EOL) care in acute hospitals is variable and interventions to improve this care, such as EOL care pathways, are not always used. The underlying reasons for this variability are not fully understood. We explored healthcare professionals' views on delivering EOL care within an acute hospital trust in the South West of England. We employed qualitative methods (focus groups, in-depth interviews and questerviews) within a study investigating the impact of a simple EOL tool on the care of dying patients. We invited a range of staff of all grades with experience in caring for dying patients from medicine, surgery and care of the elderly teams to participate. Six focus groups, seven interviews and five questerviews were conducted. Two main themes emerged: (a) delays (difficulties and avoidance) in diagnosing dying and (b) the EOL tool supporting staff in caring for the dying. Staff acknowledged that the diagnosis of dying was often made late; this was partly due to prognostic uncertainty but compounded by a culture that did not acknowledge death as a possible outcome until death was imminent. Both the medical and nursing staff found the EOL tool useful as a means of communicating ceilings of care, ensuring appropriate prescribing for EOL symptoms, and giving nurses permission to approach the bedside of a dying patient. The culture of avoiding death and dying in acute hospitals remains a significant barrier to providing EOL care, even when EOL tools are available and accepted by staff. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
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The views of older people and health professionals about dignity in acute hospital care.
Tauber-Gilmore, Marcelle; Addis, Gulen; Zahran, Zainab; Black, Sally; Baillie, Lesley; Procter, Sue; Norton, Christine
2018-01-01
To report the findings from interviews conducted as part of a wider study on interventions to support dignified care in older people in acute hospital care. The data in this study present the interview data. Dignity is a complex concept. Despite a plethora of recommendations on how to achieve dignified care, it remains unclear how to attain this in practice and what the priorities of patients and staff are in relation to dignity. A purposive sample of older patients and staff took part in semi-structured interviews and gave their insight on the meaning of dignity and examples of what sustains and breaches a patient's dignity in acute hospital care. Thirteen patients and 38 healthcare professionals in a single metropolitan hospital in the UK interviewed. Interviews were transcribed verbatim and underwent a thematic analysis. The meaning of dignity was broadly agreed on by patients and staff. Three broad themes were identified: the meaning of dignity, staffing level and its impact on dignity, and organisational culture and dignity. Registered staff of all healthcare discipline and student nurses report very little training on dignity or care of the older person. There remain inconsistencies in the application of dignified care. Staff behaviour, a lack of training and the organisational processes continue to result in breaches to dignity of older people. Clinical nurses have a major role in ensuring dignified care for older people in hospital. There needs to be systematic dignity-related training with regular refreshers. This education coupled with measures to change the cultural attitudes in an organisation towards older peoples' care should result in long-term improvements in the level of dignified care. Hospital managers have an important role in changing system to ensure that staff deliver the levels of care they aspire to. © 2017 John Wiley & Sons Ltd.
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Lancia, Loreto; Toccaceli, Andrea; Petrucci, Cristina; Romano, Silvio; Penco, Maria
2018-05-01
The purpose of the study was to compare the EASI system with the standard 12-lead surface electrocardiogram (ECG) for the accuracy in detecting the main electrocardiographic parameters (J point, PR, QT, and QRS) commonly monitored in patients with acute coronary syndromes or heart failure. In this observational comparative study, 253 patients who were consecutively admitted to the coronary care unit with acute coronary syndrome or heart failure were evaluated. In all patients, two complete 12-lead ECGs were acquired simultaneously. A total of 6,072 electrocardiographic leads were compared (3,036 standard and 3,036 EASI). No significant differences were found between the investigate parameters of the two measurement methods, either in patients with acute coronary syndrome or in those with heart failure. This study confirmed the accuracy of the EASI system in monitoring the main ECG parameters in patients admitted to the coronary care unit with acute coronary syndrome or heart failure.
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Miladinia, Mojtaba; Baraz, Shahram; Shariati, Abdolali; Malehi, Amal Saki
Patients with acute leukemia usually experience pain, fatigue, and sleep disorders, which affect their quality of life. Massage therapy, as a nondrug approach, can be useful in controlling such problems. However, very few studies have been conducted on the effects of massage therapy on the complications of leukemia. The aim of this study was to examine the effects of slow-stroke back massage (SSBM) on the symptom cluster in acute leukemia adult patients undergoing chemotherapy. In this randomized controlled trial, 60 patients with acute leukemia were allocated randomly to either the intervention or control group. The intervention group received SSBM 3 times a week (every other day for 10 minutes) for 4 weeks. The pain, fatigue, and sleep disorder intensities were measured using the numeric rating scale. The sleep quality was measured using the Pittsburgh Sleep Quality Index. Statistical tests of χ, t test, and the repeated-measure analysis of variance were used for data analysis. Results showed that the SSBM intervention significantly reduced the progressive sleep disorder, pain, fatigue, and improved sleep quality over time. Slow-stroke back massage, as a simple, noninvasive, and cost-effective approach, along with routine nursing care, can be used to improve the symptom cluster of pain, fatigue, and sleep disorders in leukemia patients. Oncology nurses can increase their knowledge regarding this symptom cluster and work to diminish the cluster components by using SSBM in adult leukemia patients.
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[The right to die with dignity in an acute-care hospital: a qualitative study].
Sepúlveda-Sánchez, Juana María; Morales-Asencio, Jose Miguel; Morales-Gil, Isabel María; Canca-Sánchez, José Carlos; Crespillo-García, Eva; Timonet-Andreu, Eva María
2014-01-01
To examine the perceptions and beliefs of doctors and nurses, and the barriers and facilitators they must address as regards the right to die with dignity in an acute-care hospital, and to consider the applicability of the provisions of Law 2/2010 of 8 April in this respect. A qualitative descriptive study, based on the focus group technique, using discourse analysis of the views of doctors and nurses responsible for the health care of terminal cancer and non-cancer patients in an acute-care hospital. The results obtained show that there are diverse obstacles to assure the rights of terminal patients, and to ensure the proper performance of their duties by healthcare professionals and institutions. The nature and impact of these difficulties depend on the characteristics of the patients and their families, the health workers involved, the organisation of health care, and cultural factors. The study highlights the need to improve the process of communication with patients and their families, to facilitate shared decision making and to establish measures to clarify issues such as palliative sedation and treatment limitation. It is necessary to improve the applicability of the law on living wills and dignified death in non-cancer specialist areas. Further training is needed regarding ethical, spiritual and anthropological aspects of care in these situations. Copyright © 2013 Elsevier España, S.L. All rights reserved.
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Ford, Karen; Tesch, Leigh; Dawborn, Jacqueline; Courtney-Pratt, Helen
2018-06-01
To evaluate the impact of an arts in health programme delivered by a specialised artist within an acute older person's unit. Acute hospitals must meet the increasingly complex needs of older people who experience multiple comorbidities, often including cognitive impairment, either directly related to their admission or longer term conditions, including dementia. A focus on physical illness, efficiency and tasks within an acute care environment can all divert attention from the psychosocial well-being of patients. This focus also decreases capacity for person-centred approaches that acknowledge and value the older person, their life story, relationships and the care context. The importance of arts for health and wellness, including responsiveness to individual need, is well established: however, there is little evidence about its effectiveness for older people in acute hospital settings. We report on a collaborative arts in health programme on an acute medical ward for older people. The qualitative study used collaborative enquiry underpinned by a constructivist approach to evaluate an arts programme that involved participatory art-making activities, customised music, song and illustration work, and enlivening the unit environment. Data sources included observation of art activities, semi-structured interviews with patients and family members, and focus groups with staff. Data were transcribed and thematically analysed using a line by line approach. The programme had positive impacts for the environment, patients, families and staff. The environment exhibited changes as a result of programme outputs; patients and families were engaged and enjoyed activities that aided recovery from illness; and staff also enjoyed activities and importantly learnt new ways of working with patients. An acute care arts in health programme is a carefully nuanced programme where the skills of the arts health worker are critical to success. Utilising such skill, continued focus on person
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Transthyretin Concentrations in Acute Stroke Patients Predict Convalescent Rehabilitation.
Isono, Naofumi; Imamura, Yuki; Ohmura, Keiko; Ueda, Norihide; Kawabata, Shinji; Furuse, Motomasa; Kuroiwa, Toshihiko
2017-06-01
For stroke patients, intensive nutritional management is an important and effective component of inpatient rehabilitation. Accordingly, acute care hospitals must detect and prevent malnutrition at an early stage. Blood transthyretin levels are widely used as a nutritional monitoring index in critically ill patients. Here, we had analyzed the relationship between the transthyretin levels during the acute phase and Functional Independence Measure in stroke patients undergoing convalescent rehabilitation. We investigated 117 patients who were admitted to our hospital with acute ischemic or hemorrhagic stroke from February 2013 to October 2015 and subsequently transferred to convalescent hospitals after receiving acute treatment. Transthyretin concentrations were evaluated at 3 time points as follows: at admission, and 5 and 10 days after admission. After categorizing patients into 3 groups according to the minimum transthyretin level, we analyzed the association between transthyretin and Functional Independence Measure. In our patients, transthyretin levels decreased during the first 5 days after admission and recovered slightly during the subsequent 5 days. Notably, Functional Independence Measure efficiency was significantly associated with the decrease in transthyretin levels during the 5 days after admission. Patients with lower transthyretin levels had poorer Functional Independence Measure outcomes and tended not to be discharged to their own homes. A minimal transthyretin concentration (<10 mg/dL) is predictive of a poor outcome in stroke patients undergoing convalescent rehabilitation. In particular, an early decrease in transthyretin levels suggests restricted rehabilitation efficiency. Accordingly, transthyretin levels should be monitored in acute stroke patients to indicate mid-term rehabilitation prospects. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.
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Bartiaux, M; Mols, P
2017-01-01
patient management in the acute and sub-acute setting of an Emergency Department is challenging. An assessment of the quality of provided care enables an evaluation of failings. It contributes to the identification of areas for improvement. to obtain an analysis, by hospital-ward physicians, of adult patient care management quality, as well as of the correctness of diagnosis made during emergency admissions. To evaluate the consequences of inadequate patient care management on morbidity, mortality and cost and duration of hospitalization. prospective data analysis obtained between the 1/12/2009 and the 21/12/2009 from physicians using a questionnaire on adult-patient emergency admissions and subsequent hospitalization. questionnaires were completed for 332 patients. Inadequate management of patient care were reported for 73/332 (22 %) cases. Incorrect diagnoses were reported for 20/332 (6 %) cases. 35 cases of inadequate care management (10.5 % overall) were associated with morbidity (34 cases) or mortality (1 case), including 4 cases (1.2 % ) that required emergency intensive-care or surgical interventions. this quality study analyzed the percentage of patient management cases and incorrect diagnoses in the emergency department. The data for serious outcome and wrong diagnosis are comparable with current literature. To improve performance, we consider the process for establishing a diagnosis and therapeutic care.
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Hammond, Simon P; Cross, Jane L; Shepstone, Lee; Backhouse, Tamara; Henderson, Catherine; Poland, Fiona; Sims, Erika; MacLullich, Alasdair; Penhale, Bridget; Howard, Robert; Lambert, Nigel; Varley, Anna; Smith, Toby O; Sahota, Opinder; Donell, Simon; Patel, Martyn; Ballard, Clive; Young, John; Knapp, Martin; Jackson, Stephen; Waring, Justin; Leavey, Nick; Howard, Gregory; Fox, Chris
2017-12-04
Health and social care provision for an ageing population is a global priority. Provision for those with dementia and hip fracture has specific and growing importance. Older people who break their hip are recognised as exceptionally vulnerable to experiencing confusion (including but not exclusively, dementia and/or delirium and/or cognitive impairment(s)) before, during or after acute admissions. Older people experiencing hip fracture and confusion risk serious complications, linked to delayed recovery and higher mortality post-operatively. Specific care pathways acknowledging the differences in patient presentation and care needs are proposed to improve clinical and process outcomes. This protocol describes a multi-centre, feasibility, cluster-randomised, controlled trial (CRCT) to be undertaken across ten National Health Service hospital trusts in the UK. The trial will explore the feasibility of undertaking a CRCT comparing the multicomponent PERFECTED enhanced recovery intervention (PERFECT-ER), which acknowledges the differences in care needs of confused older patients experiencing hip fracture, with standard care. The trial will also have an integrated process evaluation to explore how PERFECT-ER is implemented and interacts with the local context. The study will recruit 400 hip fracture patients identified as experiencing confusion and will also recruit "suitable informants" (individuals in regular contact with participants who will complete proxy measures). We will also recruit NHS professionals for the process evaluation. This mixed methods design will produce data to inform a definitive evaluation of the intervention via a large-scale pragmatic randomised controlled trial (RCT). The trial will provide a preliminary estimate of potential efficacy of PERFECT-ER versus standard care; assess service delivery variation, inform primary and secondary outcome selection, generate estimates of recruitment and retention rates, data collection difficulties, and
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Acute Vilazodone Toxicity in a Pediatric Patient.
Acker, Emily C; Sinclair, Elizabeth A; Beardsley, Andrew L; Ahmed, Sheikh S; Froberg, Blake A
2015-09-01
Vilazodone is a selective serotonin reuptake inhibitor and 5HT1A agonist recently approved to treat depression in adults. To date, there are minimal data available regarding the expected course and treatment of acute vilazodone ingestions. We report a case of a previously healthy 19-month-old girl who presented after an acute ingestion of an estimated 37 mg/kg vilazodone. She was taken to an outside emergency department approximately 1 h after an unwitnessed ingestion. Initially, the patient was noted to have decreased responsiveness, sluggish but reactive pupils, altered mental status, and reported seizure activity. She was given intravenous lorazepam for seizure control, intubated, and transferred to a pediatric tertiary care facility, where she continued to show signs of serotonin toxicity and received treatment with benzodiazepines and cyproheptadine. Despite vilazodone's long half-life and the large amount ingested, the patient was extubated within 10 h of presentation, had returned to baseline mental status by 22 h, and was discharged home approximately 57 h after ingestion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Accidental ingestions are common in the pediatric population. Emergency physicians need to be aware of the signs and symptoms of acute medication toxicities, the expected clinical course, and the necessary supportive measures used to treat these patients. Because vilazodone is a recently approved medication, there is little experience with acute vilazodone ingestions. This report considerably increases the understanding of vilazodone's effects in the setting of an acute ingestion. Copyright © 2015 Elsevier Inc. All rights reserved.
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Factors affecting the healing of pressure ulcers in a Korean acute care hospital.
Sung, Young Hee; Park, Kyung Hee
2011-01-01
We sought to determine the factors affecting pressure ulcer (PU) healing in an acute care facility in Korea. Data were collected between October 1, 2006, and September 30, 2007, regarding PU status and factors hypothesized to influence wound healing. We developed a form that queried factors thought to affect PU healing based on literature review. We also administered the Pressure Ulcer Scale for Healing (PUSH) tool to assess healing of PUs and calculated change in PUSH scale as the outcome variable reflecting the magnitude of the healing of PU. One hundred fifty eight patients with a total of 326 PUs in an acute care hospital located in Seoul, Korea, comprised the sample. The variables found to significantly affect PU healing included mean arterial pressure (MAP), serum albumin level, urinary incontinence, consultation with nutritionist, Braden Scale scale, wound size, and exudate amount. Pressure ulcer healing was improved when the MAP was higher (B = 0.034) and the serum albumin level was more than 2.8 g/dL (20.8 grams/liter) (B = 1.107). When managing patients in an acute care setting, PU healing may be improved by maintaining MAP and providing protein supplements to keep serum albumin level greater than 2.8 g/dL (20.8 grams/liter).
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Clark, Brendan J.; Smart, Alexandra; House, Robert; Douglas, Ivor; Burnham, Ellen L.; Moss, Marc
2011-01-01
Introduction Unhealthy alcohol use predisposes to multiple conditions that frequently result in critical illness and is present in up to one-third of patients admitted to a medical intensive care unit (ICU). We sought to determine the baseline readiness to change in medical ICU patients with unhealthy alcohol use and hypothesized that the severity of acute illness would be independently associated with higher scores on readiness to change scales. We further sought to determine whether this effect is modified by the severity of unhealthy alcohol use. Materials and Methods We performed a cross-sectional observational study of current regular drinkers in three medical ICUs. The Alcohol Use Disorders Identification Test was used to differentiate low risk and unhealthy alcohol use and further categorize patients into risky alcohol use or an alcohol use disorder. The severity of a patient’s acute illness was assessed by calculating the Acute Physiology and Chronic Healthy Evaluation II score at the time of admission to the medical ICU. Readiness to change was assessed using standardized questionnaires. Results Of 101 medical ICU patients who were enrolled, 65 met the criteria for unhealthy alcohol use. The association between the severity of acute illness and readiness to change depended on the instrument used. A higher severity of illness measured by APACHEII score was an independent predictor of readiness to change as assessed by the Stages of Change Readiness and Treatment Eagerness Scale (Taking Action scale) (p< 0.01). When a visual analog scale was used to assess readiness to change, there was a significant association with severity of acute illness (p < 0.01) that was modified by the severity of unhealthy alcohol use (p = 0.04 for interaction term). Conclusion Medical ICU patients represent a population where brief interventions require further study. Studies of brief intervention should account for the severity of acute illness and the severity of unhealthy
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Do, Nga T T; Ta, Ngan T D; Tran, Ninh T H; Than, Hung M; Vu, Bich T N; Hoang, Long B; van Doorn, H Rogier; Vu, Dung T V; Cals, Jochen W L; Chandna, Arjun; Lubell, Yoel; Nadjm, Behzad; Thwaites, Guy; Wolbers, Marcel; Nguyen, Kinh V; Wertheim, Heiman F L
2016-09-01
Inappropriate antibiotic use for acute respiratory tract infections is common in primary health care, but distinguishing serious from self-limiting infections is difficult, particularly in low-resource settings. We assessed whether C-reactive protein point-of-care testing can safely reduce antibiotic use in patients with non-severe acute respiratory tract infections in Vietnam. We did a multicentre open-label randomised controlled trial in ten primary health-care centres in northern Vietnam. Patients aged 1-65 years with at least one focal and one systemic symptom of acute respiratory tract infection were assigned 1:1 to receive either C-reactive protein point-of-care testing or routine care, following which antibiotic prescribing decisions were made. Patients with severe acute respiratory tract infection were excluded. Enrolled patients were reassessed on day 3, 4, or 5, and on day 14 a structured telephone interview was done blind to the intervention. Randomised assignments were concealed from prescribers and patients but not masked as the test result was used to assist treatment decisions. The primary outcome was antibiotic use within 14 days of follow-up. All analyses were prespecified in the protocol and the statistical analysis plan. All analyses were done on the intention-to-treat population and the analysis of the primary endpoint was repeated in the per-protocol population. This trial is registered under number NCT01918579. Between March 17, 2014, and July 3, 2015, 2037 patients (1028 children and 1009 adults) were enrolled and randomised. One adult patient withdrew immediately after randomisation. 1017 patients were assigned to receive C-reactive protein point-of-care testing, and 1019 patients were assigned to receive routine care. 115 patients in the C-reactive protein point-of-care group and 72 patients in the routine care group were excluded in the intention-to-treat analysis due to missing primary endpoint. The number of patients who used antibiotics
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Tan, Woan Shin; Lee, Angel; Yang, Sze Yee; Chan, Susan; Wu, Huei Yaw; Ng, Charis Wei Ling; Heng, Bee Hoon
2016-07-01
Terminally ill patients at the end-of-life do transit between care settings due to their complex care needs. Problems of care fragmentation could result in poor quality of care. We aimed to evaluate the impact of an integrated hospice home care programme on acute care service usage and on the share of home deaths. The retrospective study cohort comprised patients who were diagnosed with cancer, had an expected prognosis of 1 year or less, and were referred to a home hospice. The intervention group comprised deceased patients enrolled in the integrated hospice home care programme between September 2012 and June 2014. The historical comparison group comprised deceased patients who were referred to other home hospices between January 2007 and January 2011. There were 321 cases and 593 comparator subjects. Relative to the comparator group, the share of hospital deaths was significantly lower for programme participants (12.1% versus 42.7%). After adjusting for differences at baseline, the intervention group had statistically significantly lower emergency department visits at 30 days (incidence rate ratio: 0.38; 95% confidence interval: 0.31-0.47), 60 days (incidence rate ratio: 0.61; 95% confidence interval: 0.54-0.69) and 90 days (incidence rate ratio: 0.69; 95% confidence interval: 0.62-0.77) prior to death. Similar results held for the number of hospitalisations at 30 days (incidence rate ratio: 0.48; 95% confidence interval: 0.40-0.58), 60 days (incidence rate ratio: 0.71; 95% confidence interval: 0.62-0.82) and 90 days (incidence rate ratio: 0.77; 95% confidence interval: 0.68-0.88) prior to death. Our results demonstrated that by integrating services between acute care and home hospice care, a reduction in acute care service usage could occur. © The Author(s) 2016.
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Tabit, Corey E; Coplan, Mitchell J; Spencer, Kirk T; Alcain, Charina F; Spiegel, Thomas; Vohra, Adam S; Adelman, Daniel; Liao, James K; Sanghani, Rupa Mehta
2017-09-01
Re-hospitalization after discharge for acute decompensated heart failure is a common problem. Low-socioeconomic urban patients suffer high rates of re-hospitalization and often over-utilize the emergency department (ED) for their care. We hypothesized that early consultation with a cardiologist in the ED can reduce re-hospitalization and health care costs for low-socioeconomic urban patients with acute decompensated heart failure. There were 392 patients treated at our center for acute decompensated heart failure who received standardized education and follow-up. Patients who returned to the ED received early consultation with a cardiologist; 392 patients who received usual care served as controls. Thirty- and 90-day re-hospitalization, ED re-visits, heart failure symptoms, mortality, and health care costs were recorded. Despite guideline-based education and follow-up, the rate of ED re-visits was not different between the groups. However, the rate of re-hospitalization was significantly lower in patients receiving the intervention compared with controls (odds ratio 0.592), driven by a reduction in the risk of readmission from the ED (0.56 vs 0.79, respectively). Patients receiving the intervention accumulated 14% fewer re-hospitalized days than controls and 57% lower 30-day total health care cost. Despite the reduction in health care resource consumption, mortality was unchanged. After accounting for the total cost of intervention delivery, the health care cost savings was substantially greater than the cost of intervention delivery. Early consultation with a cardiologist in the ED as an adjunct to guideline-based follow-up is associated with reduced re-hospitalization and health care cost for low-socioeconomic urban patients with acute decompensated heart failure. Copyright © 2017 Elsevier Inc. All rights reserved.
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Richard-Denis, Andréane; Ehrmann Feldman, Debbie; Thompson, Cynthia; Bourassa-Moreau, Étienne; Mac-Thiong, Jean-Marc
2017-07-01
Acute spinal cord injury (SCI) centers aim to optimize outcome following SCI. However, there is no timeframe to transfer patients from regional to SCI centers in order to promote cost-efficiency of acute care. Our objective was to compare costs and length of stay (LOS) following early and late transfer to the SCI center. A retrospective cohort study involving 116 individuals was conducted. Group 1 (n = 87) was managed in an SCI center promptly after the trauma, whereas group 2 (n = 29) was transferred to the SCI center only after surgery. Direct comparison and multivariate linear regression analyses were used to assess the relationship between costs, LOS, and timing to transfer to the SCI center. Length of stay was significantly longer for group 2 (median, 93.0 days) as compared with group 1 (median, 40.0 days; P < 10), and average costs were also higher (median, Canadian $17,920.0 vs. $10,521.6; P = 0.004) for group 2, despite similar characteristics. Late transfer to the SCI center was the main predictive factor of longer LOS and increased costs. Early admission to the SCI center was associated with shorter LOS and lower costs for patients sustaining tetraplegia. Early referral to an SCI center before surgery could lower the financial burden for the health care system. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Determine the optimal timing for transfer of individuals with cervical traumatic spinal cord injury (SCI) in order to decrease acute care resource utilization; (2) Determine benefits of a complete perioperative management in a specialized SCI center; and (3) Identify factors that may influence resource utilization for acute care following motor-complete tetraplegia. Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide
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Wiese, C H R; Vagts, D A; Kampa, U; Pfeiffer, G; Grom, I-U; Gerth, M A; Graf, B M; Zausig, Y A
2011-02-01
At the end of life acute exacerbations of medical symptoms (e.g. dyspnea) in palliative care patients often result in emergency medical services being alerted. The goals of this study were to discuss cooperation between emergency medical and palliative care structures to optimize the quality of care in emergencies involving palliative care patients. For data collection an open discussion of the main topics by experts in palliative and emergency medical care was employed. Main outcome measures and recommendations included responses regarding current practices related to expert opinions and international literature sources. As the essential points of consensus the following recommendations for optimization of care were named: (1) integration of palliative care in the emergency medicine curricula for pre-hospital emergency physicians and paramedics, (2) development of outpatient palliative care, (3) integration of palliative care teams into emergency medical structures, (4) cooperation between palliative and emergency medical care, (5) integration of crisis intervention into outpatient palliative emergency medical care, (6) provision of emergency plans and emergency medical boxes, (7) provision of palliative crisis cards and do not attempt resuscitation (DNAR) orders, (8) psychosocial aspects concerning palliative emergencies and (9) definition of palliative patients and their special situation by the physician responsible for prior treatment. Prehospital emergency physicians are confronted with emergencies in palliative care patients every day. In the treatment of these emergencies there are potentially serious conflicts due to the different therapeutic concepts of palliative medical care and emergency medical services. This study demonstrates that there is a need for regulated criteria for the therapy of palliative patients and patients at the end of life in emergency situations. Overall, more clinical investigations concerning end-of-life care and unresponsive
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Patients' Care Needs: Documentation Analysis in General Hospitals.
Paans, Wolter; Müller-Staub, Maria
2015-10-01
The purpose of the study is (a) to describe care needs derived from records of patients in Dutch hospitals, and (b) to evaluate whether nurses employed the NANDA-I classification to formulate patients' care needs. A stratified cross-sectional random-sampling nursing documentation audit was conducted employing the D-Catch instrument in 10 hospitals comprising 37 wards. The most prevalent nursing diagnoses were acute pain, nausea, fatigue, and risk for impaired skin integrity. Most care needs were determined in physiological health patterns and few in psychosocial patterns. To perform effective interventions leading to high-quality nursing-sensitive outcomes, nurses should also diagnose patients' care needs in the health management, value-belief, and coping stress patterns. © 2014 NANDA International, Inc.
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Chew, Brendan Wk; Tiew, Lay Hwa; Creedy, Debra K
2016-09-01
To investigate acute care nurses' perceptions of spirituality and spiritual care and relationships with nurses' personal and professional characteristics. Spirituality and spiritual care are often neglected or absent in daily nursing practice. Nurses' perceptions of spirituality can be influenced by personal, professional and social factors and affect the provision of spiritual care. A cross-sectional, exploratory, nonexperimental design was used. All nursing staff (n = 1008) from a large acute care hospital in Singapore were invited to participate. Participants completed a demographic form and the Spiritual Care-Giving Scale. Completed surveys were received from 767 staff yielding a response rate of 76%. Descriptive statistics and General Linear Modelling were used to analyse data. Acute care nurses reported positive perceptions of spirituality and spiritual care. Religion, area of clinical practice and view of self as spiritual were associated with nurses' reported perspectives of spirituality and spiritual care. Nurses working in this acute care hospital in Singapore reported positive perceptions of spirituality and spiritual care. Respondents tended to equate religion with spirituality and were often unclear about what constituted spiritual care. They reported a sense of readiness to apply an interprofessional approach to spiritual care. However, positive perceptions of spirituality may not necessarily translate into practice. Spiritual care can improve health outcomes. Nurses' understanding of spirituality is essential for best practice. Interprofessional collaboration with clinicians, administrators, educators, chaplains, clergy and spiritual leaders can contribute to the development of practice guidelines and foster spiritual care by nurses. Further research is needed on the practical applications of spiritual care in nursing. © 2016 John Wiley & Sons Ltd.
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Panduranga, Prashanth; Sulaiman, Kadhim; Al-Zakwani, Ibrahim; Alazzawi, Aouf AbdlRahman; Abraham, Abraham; Singh, Prit Pal; Narayan, Narayan Anantha; Rajarao, Mamatha Punjee; Khdir, Mohammed Ahmed; Abdlraheem, Mohamad; Siddiqui, Aftab Ahmed; Soliman, Hisham; Elkadi, Osama Abdellatif; Bichu, Ruchir Kumar; Al Lawati, Kumayl Hasan
2016-01-01
Objectives We sought to describe the demographics, clinical characteristics, management and outcomes of patients in Oman with acute heart failure (AHF) as part of the Gulf aCute heArt failuRe rEgistry (CARE) project. Methods Data were analyzed from 988 consecutive patients admitted with AHF to 12 hospitals in Oman between 14 February and 14 November 2012. Results The mean age of our patients was 63±12 years. Over half (57%) were male and 95% were Omani citizens. Fifty-seven percent of patients presented with acute decompensated chronic heart failure (ADCHF) while 43% had new-onset AHF. The primary comorbid conditions were hypertension (72%), coronary artery disease (55%), and diabetes mellitus (53%). Ischemic heart disease (IHD), hypertensive heart disease, and idiopathic cardiomyopathy were the most common etiologies of AHF in Oman. The median left ventricular ejection fraction of the cohort was 36% (27–45%) with 56% of the patients having heart failure with reduced ejection fraction (< 40%). Atrial fibrillation was seen in 15% of patients. Acute coronary syndrome (ACS) and non-compliance with medications were the most common precipitating factors. At discharge, angiotensin converting enzyme inhibitors and beta-blockers were prescribed adequately, but aldosterone antagonists were under prescribed. Within 12-months follow-up, one in two patients were rehospitalized for AHF. In-hospital mortality was 7.1%, which doubled to 15.7% at three months and reached 26.4% at one-year post discharge. Conclusions Oman CARE was the first prospective multicenter registry of AHF in Oman and showed that heart failure (HF) patients present at a younger age with recurrent ADCHF and HF with reduced ejection fraction. IHD was the most common etiology of HF with a low prevalence of AHF, but a high prevalence of acute coronary syndrome and non-compliance with medications precipitating HF. A quarter of patients died at one-year follow-up even though at discharge medical therapy was
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Dresser, Caleb; Periyanayagam, Usha; Dreifuss, Brad; Wangoda, Robert; Luyimbaazi, Julius; Bisanzo, Mark
2017-09-01
Acute surgical care services in rural Sub-Saharan Africa suffer from human resource and systemic constraints. Developing emergency care systems and task sharing aspects of acute surgical care addresses many of these issues. This paper investigates the degree to which specialized non-physicians practicing in a dedicated Emergency Department contribute to the effective and efficient management of acute surgical patients. This is a retrospective review of an electronic quality assurance database of patients presenting to an Emergency Department in rural Uganda staffed by non-physician clinicians trained in emergency care. Relevant de-identified clinical data on patients admitted directly to the operating theater from 2011 to 2014 were analyzed in Microsoft Excel. Overall, 112 Emergency Department patients were included in the analysis and 96% received some form of laboratory testing, imaging, medication, or procedure in the ED, prior to surgery. 72% of surgical patients referred by ED received preoperative antibiotics, and preoperative fluid resuscitation was initiated in 65%. Disposition to operating theater was accomplished within 3 h of presentation for 73% of patients. 79% were successfully followed up to assess outcomes at 72 h. 92% of those with successful follow-up reported improvement in their clinical condition. The confirmed mortality rate was 5%. Specialized non-physician clinicians practicing in a dedicated Emergency Department can perform resuscitation, bedside imaging and laboratory studies to aid in diagnosis of acute surgical patients and arrange transfer to an operating theater in an efficient fashion. This model has the potential to sustainably address structural and human resources problems inherent to Sub-Saharan Africa's current acute surgical care model and will benefit from further study and expansion.
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CCC meets ICU: redefining the role of critical care of cancer patients.
von Bergwelt-Baildon, Michael; Hallek, Michael J; Shimabukuro-Vornhagen, Alexander A; Kochanek, Matthias
2010-11-08
Currently the majority of cancer patients are considered ineligible for intensive care treatment and oncologists are struggling to get their patients admitted to intensive care units. Critical care and oncology are frequently two separate worlds that communicate rarely and thus do not share novel developments in their fields. However, cancer medicine is rapidly improving and cancer is eventually becoming a chronic disease. Oncology is therefore characterized by a growing number of older and medically unfit patients that receive numerous novel drug classes with unexpected side effects. All of these changes will generate more medically challenging patients in acute distress that need to be considered for intensive care. An intense exchange between intensivists, oncologists, psychologists and palliative care specialists is warranted to communicate the developments in each field in order to improve triage and patient treatment. Here, we argue that "critical care of cancer patients" needs to be recognized as a medical subspecialty and that there is an urgent need to develop it systematically. As prognosis of cancer improves, novel therapeutic concepts are being introduced and more and more older cancer patients receive full treatment the number of acutely ill patients is growing significantly. This development a major challenge to current concepts of intensive care and it needs to be redefined who of these patients should be treated, for how long and how intensively.
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Güngen, Adil Can; Aydemir, Yusuf; Güngen, Belma Dogan; Yazar, Esra Ertan; Yağız, Orhan; Aras, Yeşim Güzey; Gümüş, Hatice; Erkorkmaz, Ünal
2017-08-01
In this study, we aimed to evaluate the effects of the development of aspiration pneumonia (AP) on the intensive care unit (ICU) requirements and in-hospital mortality of patients hospitalised in the neurology ward due to an acute cerebrovascular accident (CVA). Five hundred and three patients hospitalised in the neurology ward following an acute CVA were retrospectively analysed. The patients were divided into two groups: those with AP (group 1) and those without AP (group 2). Demographic characteristics and physical and radiological findings, including the localisation, lateralisation and aetiology of the infarction, in addition to ICU requirements and mortality, were evaluated. Aspiration pneumonia was detected in 80 (15.9%) patients during the in-hospital stay. Transfer to the ICU for any reason was required in 37.5% of the patients in group 1 and 4.7% of those in group 2 ( p < 0.001). In-hospital mortality occurred in 7.5% and 1.4% of the patients in group 1 and group 2, respectively ( p = 0.006). The incidence of AP was highest in patients with an infarction of the medial cerebral artery (MCA) ( p < 0.001). The AP was associated with older age ( p < 0.001), hypertension ( p = 0.007), echocardiography findings ( p = 0.032) and the modified Rankin Scale (mRS) score ( p < 0.001). Our findings suggest that the requirement rate for transfer to the ICU and the mortality rate appear to be significantly higher in patients with a diagnosis of AP. Precautions should be taken, starting from the first day of hospitalisation, to decrease the incidence of AP in patients with acute CVA, focusing especially on older patients and those with a severe mRS score.
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Measuring patients' experiences with palliative care: the Consumer Quality Index Palliative Care.
Claessen, Susanne J J; Francke, Anneke L; Sixma, Herman J; de Veer, Anke J E; Deliens, Luc
2012-12-01
The Consumer Quality Index Palliative Care (CQ-index PC) is a structured questionnaire for measuring the quality of palliative care from the perspective of care users. CQ-indices assess which care aspects need quality improvement by relating answers about actual care experiences to answers about the importance of certain aspects of care. To improve the chance that the new instrument has good content validity, a literature study and individual and group discussions were performed, and a steering committee was consulted to establish the instrument's face and content validity. The questionnaire was administered to patients with a life expectancy of 6 months or less and/or who were receiving palliative treatment. Descriptive analyses were carried out on the items about actual care experiences and the importance of care aspects, and on 'need for improvement' scores. 15 care organisations participated. 133 patients met the inclusion criteria (net response n=85). Patients considered the following aspects the most important: 'offering help in good time in acute situations', 'caregivers having the necessary expertise' and 'caregivers taking the patient seriously'. The three care aspects with the highest 'need for improvement' scores were: 'support when the patient feels depressed', 'support when the patient is anxious' and 'support when the patient has shortness of breath'. The CQ-index PC provides opportunities for care organisations to assess which care aspects have the highest priority for quality improvement within their organisation. Further research is needed to assess whether the instrument has enough discriminative power to assess differences between organisations.
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O'Toole, Thomas P; Johnson, Erin E; Aiello, Riccardo; Kane, Vincent; Pape, Lisa
2016-03-31
Although the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a "homeless medical home" initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites. We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services. More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies. Integrating social determinants of health into clinical care can be effective for high-risk homeless veterans.
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McIntosh, Nathalie; Oppel, Eva; Mohr, David; Meterko, Mark
2017-09-01
Improving patient care quality in intensive care units is increasingly important as intensive care unit services account for a growing proportion of hospital services. Organizational factors associated with quality of patient care in such units have been identified; however, most were examined in isolation, making it difficult to assess the relative importance of each. Furthermore, though most intensive care units now use a closed model, little research has been done in this specific context. To examine the relative importance of organizational factors associated with patient care quality in closed intensive care units. In a national exploratory, cross-sectional study focused on intensive care units at US Veterans Health Administration acute care hospitals, unit directors were surveyed about nurse and physician staffing, work resources and training, patient care coordination, rounding, and perceptions of patient care quality. Administrative records yielded data on patient volume and facility teaching status. Descriptive statistics, bivariate analyses, and regression modeling were used for data analysis. Sixty-nine completed surveys from directors of closed intensive care units were returned. Regression model results showed that better patient care coordination (β = 0.43; P = .01) and having adequate work resources (β = 0.26; P = .02) were significantly associated with higher levels of patient care quality in such units ( R 2 = 0.22). Augmenting work resources and/or focusing limited hospital resources on improving patient care coordination may be the most productive ways to improve patient care quality in closed intensive care units. ©2017 American Association of Critical-Care Nurses.
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An exploratory study about meaningful work in acute care nursing.
Pavlish, Carol; Hunt, Roberta
2012-01-01
To develop deeper understandings about nurses' perceptions of meaningful work and the contextual factors that impact finding meaning in work. Much has been written about nurses' job satisfaction and the impact on quality of health care. However, scant qualitative evidence exists regarding nurses' perceptions of meaningful work and how factors in the work environment influence their perceptions. The literature reveals links among work satisfaction, retention, quality of care, and meaningfulness in work. Using a narrative design, researchers interviewed 13 public health nurses and 13 acute care nurses. Categorical-content analysis with Atlas.ti data management software was conducted separately for each group of nurses. This article reports results for acute care nurses. Twenty-four stories of meaningful moments were analyzed and categorized. Three primary themes of meaningful work emerged: connections, contributions, and recognition. Participants described learning-focused environment, teamwork, constructive management, and time with patients as facilitators of meaningfulness and task-focused environment, stressful relationships, and divisive management as barriers. Meaningful nursing roles were advocate, catalyst and guide, and caring presence. Nurse administrators are the key to improving quality of care by nurturing opportunities for nurses to find meaning and satisfaction in their work. Study findings provide nurse leaders with new avenues for improving work environments and job satisfaction to potentially enhance healthcare outcomes. © 2012 Wiley Periodicals, Inc.
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Fabreau, Gabriel E; Leung, Alexander A; Southern, Danielle A; James, Matthew T; Knudtson, Merrill L; Ghali, William A; Ayanian, John Z
2016-02-23
Metropolitan versus nonmetropolitan status and area median income may independently affect care for and outcomes of acute coronary syndromes. We sought to determine whether location of care modifies the association among area income, receipt of cardiac catheterization, and mortality following an acute coronary syndrome in a universal health care system. We studied a cohort of 14 012 acute coronary syndrome patients admitted to cardiology services between April 18, 2004, and December 31, 2011, in southern Alberta, Canada. We used multivariable logistic regression to determine the odds of cardiac catheterization within 1 day and 7 days of admission and the odds of 30-day and 1-year mortality according to area median household income quintile for patients presenting at metropolitan and nonmetropolitan hospitals. In models adjusting for area income, patients who presented at nonmetropolitan facilities had lower adjusted odds of receiving cardiac catheterization within 1 day of admission (odds ratio 0.22, 95% CI 0.11-0.46, P<0.001). Among nonmetropolitan patients, when examined by socioeconomic status, each incremental decrease in income quintile was associated with 10% lower adjusted odds of receiving cardiac catheterization within 7 days (P<0.001) and 24% higher adjusted odds of 30-day mortality (P=0.008) but no significant difference for 1-year mortality (P=0.12). There were no differences in adjusted mortality among metropolitan patients. Within a universal health care system, the association among area income and receipt of cardiac catheterization and 30-day mortality differed depending on the location of initial medical care for acute coronary syndromes. Care protocols are required to improve access to care and outcomes in patients from low-income nonmetropolitan communities. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.
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Understanding and safeguarding patient dignity in intensive care.
Nyholm, Linda; Koskinen, Camilla A-L
2017-06-01
Dignity has been highlighted in previous research as one of the most important ethical concerns in nursing care. According to Eriksson, dignified caring is related to treating the patient as a unique human being and respecting human value. Intensive care unit patients are vulnerable to threatened dignity, and maintaining dignity may be challenging as a consequence of critical illness. The aim is to highlight how nurses in an intensive care setting understand patient dignity, what threatens patient dignity and how nurses can safeguard patient dignity. Research design and participants: Data materials were collected through a survey questionnaire which contained open questions about patient dignity, and the text was analysed using hermeneutic reading and text interpretation. Totally, 25 nurses employed in an intensive care unit in Finland participated in the study. Ethical considerations: The study follows the guidelines for good scientific practice by the Finnish Advisory Board on Research Integrity and the ethical principles according to the Declaration of Helsinki. Findings revealed that nurses recognize the patients' absolute dignity by regarding them as unique human beings. The nurses also recognize the importance of shared humanity in preserving patient dignity. Intensive care patients' dignity is threatened by negative attitudes and when their integrity is not being protected. Dignity is also threatened when patients and nurses are not part of the patients' care and patient care decisions, when patients receive care against their will and because of the acute nature of intensive care.
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Geelen, Sven Jacobus Gertruda; Valkenet, Karin; Veenhof, Cindy
2018-05-12
To evaluate the construct validity and the inter-rater reliability of the Dutch Activity Measure for Post-Acute Care "6-clicks" Basic Mobility short form measuring the patient's mobility in Dutch hospital care. First, the "6-clicks" was translated by using a forward-backward translation protocol. Next, 64 patients were assessed by the physiotherapist to determine the validity while being admitted to the Internal Medicine wards of a university medical center. Six hypotheses were tested regarding the construct "mobility" which showed that: Better "6-clicks" scores were related to less restrictive pre-admission living situations (p = 0.011), less restrictive discharge locations (p = 0.001), more independence in activities of daily living (p = 0.001) and less physiotherapy visits (p < 0.001). A correlation was found between the "6-clicks" and length of stay (r= -0.408, p = 0.001), but not between the "6-clicks" and age (r= -0.180, p = 0.528). To determine the inter-rater reliability, an additional 50 patients were assessed by pairs of physiotherapists who independently scored the patients. Intraclass Correlation Coefficients of 0.920 (95%CI: 0.828-0.964) were found. The Kappa Coefficients for the individual items ranged from 0.649 (walking stairs) to 0.841 (sit-to-stand). The Dutch "6-clicks" shows a good construct validity and moderate-to-excellent inter-rater reliability when used to assess the mobility of hospitalized patients. Implications for Rehabilitation Even though various measurement tools have been developed, it appears the majority of physiotherapists working in a hospital currently do not use these tools as a standard part of their care. The Activity Measure for Post-Acute Care "6-clicks" Basic Mobility is the only tool which is designed to be short, easy to use within usual care and has been validated in the entire hospital population. This study shows that the Dutch version of the Activity Measure for Post-Acute Care "6-clicks
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Chuang, Elizabeth; Hope, Aluko A; Allyn, Katherine; Szalkiewicz, Elissa; Gary, Brittany; Gong, Michelle N
2017-11-01
Previous research has identified a large unmet need in provision of specialist-level palliative care services in the hospital. How much of this gap is filled by primary palliative care provided by generalists or nonpalliative specialists has not been quantified. Estimates of racial and ethnic disparities have been inconsistent. The objective of this study was to 1) estimate primary and specialty palliative care delivery and to measure unmet needs in the inpatient setting and 2) explore racial and ethnic disparities in palliative care delivery. This was a cross-sectional, retrospective study of 55,658 adult admissions to two acute care hospitals in the Bronx in 2013. Patients with palliative care needs were identified by criteria adapted from the literature. The primary outcomes were delivery of primary and specialist-level palliative care. In all, 18.5% of admissions met criteria for needing palliative care. Of those, 18% received specialist-level palliative care, an estimated 30% received primary palliative care, and 37% had no evidence of palliative care or advance care planning. Black and Hispanic patients were not less likely to receive specialist-level palliative care (adjusted odds ratio [OR] black patients = 1.18, 95% CI 0.98, 1.42; adjusted OR Hispanic patients = 1.24, 95% CI 1.04, 1.48), but they were less likely to receive primary palliative care (adjusted OR black patients = 0.41, 95% CI 0.20, 0.84; adjusted OR Hispanic patients = 0.48, 95% CI 0.25, 0.94). Even when considering primary and specialty palliative care, hospitalized patients have a high prevalence of unmet palliative care need. Further research is needed understand racial and ethnic disparities in palliative care delivery. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
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Patient classification in home health care: are we ready?
Cox, C L; Wood, J E; Montgomery, A C; Smith, P C
1990-09-01
This longitudinal descriptive study retrospectively profiled the acutely ill patient in home health care and explored the utility of using patient record data in predicting agency resource use and patient outcome. The findings suggest that those variables traditionally relied on for reimbursement qualification and as components of patient-classification schemes may not be wholly adequate to explain resource use and patient outcome in the home health setting. Professional nursing judgment of the patient's prognosis was found to be the most sensitive variable predicting outcome. Selected diagnoses and self-care capacity of the patient were the major predictors of resource use. Suggestions are offered for further studies that may move public health nursing more quickly toward the development of consistent and accurate home health care case mix measures.
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Online personal medical records: are they reliable for acute/critical care?
Schneider, J H
2001-08-01
To provide an introduction to Internet-based Online Personal Medical Records (OPMRs), to assess their use and limitations in acute/critical care situations, and to identify potential improvements that could increase their usefulness. A review of publicly available Internet-based OPMRs conducted in April 2001. Twenty-nine OPMR sites were identified in March 2000 using ten Internet search engines with the search term "Personal Medical Records." Through 2000 and 2001, an additional 37 sites were identified using lists obtained from trade journals and through the author's participation in standards-setting meetings. Each publicly available site was reviewed to assess suitability for acute/critical care situations using four measures developed by the author and for general use using eight measures developed in a standards-setting process described in the article. Of the 66 companies identified, only 16 still offer OPMRs that are available to the public on the Internet. None of these met all of the evaluation measures. Only 19% had rapid emergency access capabilities and only 63% provided medical summaries of the record. Security and confidentiality issues were well addressed in 94% of sites. Data portability was virtually nonexistent because all OPMRs lacked the ability to exchange data electronically with other OPMRs, and only two OPMRs permitted data transfer from physician electronic medical records. Controls over data accuracy were poor: 81% of sites allowed entry of dates for medical treatment before the patient's date of birth, and one site actually gave incorrect medical advice. OPMRs were periodically inaccessible because of programming deficiencies. Finally, approximately 40 sites ceased providing OPMRs in the past year, with the probable loss of patient information. Most OPMRs are not ready for use in acute/critical care situations. Many are just electronic versions of the paper-based health record notebooks that patients have used for years. They have
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Managing patients with acute liver failure: developing a tool for practitioners.
O'Neal, Helen; Olds, Jane; Webster, Nicola
2006-01-01
Patients with acute liver failure (ALF) are treated on the general intensive care unit (ICU) within this regional centre for hepatology and liver transplantation. This group of patients are at high risk of developing cerebral oedema, but because of the associated coagulopathy, intracranial pressure is not measured invasively. The safe management of these patients is vital to their outcome, and yet, there is no national or local guidance on the best practice for this group of patients. An absence of guidelines, or evidence base specific to caring for hepatology patients, was highlighted as we reviewed local clinical practices and those at other liver specialty centres, the British Liver Trust and published literature. We identified a need to develop evidence-based guidance for staff caring for patients with ALF within ICUs. A systematic approach enabled us to identify best practice to support the development of a structured evidence-based approach to care.
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The effect of contact precautions on healthcare worker activity in acute care hospitals.
Morgan, Daniel J; Pineles, Lisa; Shardell, Michelle; Graham, Margaret M; Mohammadi, Shahrzad; Forrest, Graeme N; Reisinger, Heather S; Schweizer, Marin L; Perencevich, Eli N
2013-01-01
Contact precautions are a cornerstone of infection prevention but have also been associated with less healthcare worker (HCW) contact and adverse events. We studied how contact precautions modified HCW behavior in 4 acute care facilities. Prospective cohort study. Four acute care facilities in the United States performing active surveillance for methicillin-resistant Staphylococcus aureus. Trained observers performed "secret shopper" monitoring of HCW activities during routine care, using a standardized collection tool and fixed 1-hour observation periods. A total of 7,743 HCW visits were observed over 1,989 hours. Patients on contact precautions had 36.4% fewer hourly HCW visits than patients not on contact precautions (2.78 vs 4.37 visits per hour; [Formula: see text]) as well as 17.7% less direct patient contact time with HCWs (13.98 vs 16.98 minutes per hour; [Formula: see text]). Patients on contact precautions tended to have fewer visitors (23.6% fewer; [Formula: see text]). HCWs were more likely to perform hand hygiene on exiting the room of a patient on contact precautions (63.2% vs 47.4% in rooms of patients not on contact precautions; [Formula: see text]). Contact precautions were found to be associated with activities likely to reduce transmission of resistant pathogens, such as fewer visits and better hand hygiene at exit, while exposing patients on contact precautions to less HCW contact, less visitor contact, and potentially other unintended outcomes.
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Managing family centered palliative care in aged and acute settings.
Street, Annette Fay; Love, Anthony; Blackford, Jeanine
2005-03-01
This paper reports on the management of family centered palliative care in different aged care and acute Australian inpatient settings, following the integration of palliative care with mainstream services. Eighty-eight semistructured interviews were conducted and 425 questionnaires (Palliative Care Practices Questionnaire--PCPQ) were returned, completed from 12 regional and metropolitan locations. Transcribed interviews were analyzed using QSR NVivo and mean PCPQ scores from the four settings were compared. Scores on items from the PCPQ related to family centered care confirmed the analyses. Interviews revealed that factors contributing to the level of support for families offered in the various settings included the core business of the unit; the length of stay of the patients or residents; the acuity or symptom burden; and the coordinated involvement of the multidisciplinary team. Strategies for improving supportive family care are proposed.
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Importance of direct patient care in advanced pharmacy practice experiences.
Rathbun, R Chris; Hester, E Kelly; Arnold, Lindsay M; Chung, Allison M; Dunn, Steven P; Harinstein, Lisa M; Leber, Molly; Murphy, Julie A; Schonder, Kristine S; Wilhelm, Sheila M; Smilie, Kristine B
2012-04-01
The Accreditation Council for Pharmacy Education issued revised standards (Standards 2007) for professional programs leading to the Doctor of Pharmacy degree in July 2007. The new standards require colleges and schools of pharmacy to provide pharmacy practice experiences that include direct interaction with diverse patient populations. These experiences are to take place in multiple practice environments (e.g., community, ambulatory care, acute care medicine, specialized practice areas) and must include face-to-face interactions between students and patients, and students and health care providers. In 2009, the American College of Clinical Pharmacy (ACCP) identified concerns among their members that training for some students during the fourth year of pharmacy curriculums are essentially observational experiences rather than encounters where students actively participate in direct patient care activities. These ACCP members also stated that there is a need to identify effective mechanisms for preceptors to balance patient care responsibilities with students' educational needs in order to fully prepare graduates for contemporary, patient-centered practice. The 2010 ACCP Educational Affairs Committee was charged to provide recommendations to more effectively foster the integration of pharmacy students into direct patient care activities during advanced pharmacy practice experiences (APPEs). In this commentary, the benefits to key stakeholders (pharmacy students, APPE preceptors, clerkship sites, health care institutions, academic pharmacy programs) of this approach are reviewed. Recommendations for implementation of direct patient care experiences are also provided, together with discussion of the practical issues associated with delivery of effective APPE. Examples of ambulatory care and acute care APPE models that successfully integrate pharmacy students into the delivery of direct patient care are described. Enabling students to engage in high-quality patient care
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Liu, Wei; Gerdtz, Marie; Manias, Elizabeth
2016-10-01
This paper examines the communication strategies that nurses, doctors, pharmacists and patients use when managing medications. Patient-centred medication management is best accomplished through interdisciplinary practice. Effective communication about managing medications between clinicians and patients has a direct influence on patient outcomes. There is a lack of research that adopts a multidisciplinary approach and involves critical in-depth analysis of medication interactions among nurses, doctors, pharmacists and patients. A critical ethnographic approach with video reflexivity was adopted to capture communication strategies during medication activities in two general medical wards of an acute care hospital in Melbourne, Australia. A mixed ethnographic approach combining participant observations, field interviews, video recordings and video reflexive focus groups and interviews was employed. Seventy-six nurses, 31 doctors, 1 pharmacist and 27 patients gave written consent to participate in the study. Data analysis was informed by Fairclough's critical discourse analytic framework. Clinicians' use of communication strategies was demonstrated in their interpersonal, authoritative and instructive talk with patients. Doctors adopted the language discourse of normalisation to standardise patients' illness experiences. Nurses and pharmacists employed the language discourses of preparedness and scrutiny to ensure that patient safety was maintained. Patients took up the discourse of politeness to raise medication concerns and question treatment decisions made by doctors, in their attempts to challenge decision-making about their health care treatment. In addition, the video method revealed clinicians' extensive use of body language in communication processes for medication management. The use of communication strategies by nurses, doctors, pharmacists and patients created opportunities for improved interdisciplinary collaboration and patient-centred medication
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Halm, Margo A
2018-05-14
Proficiency in evidence-based practice (EBP) is essential for relevant research findings to be integrated into clinical care when congruent with patient preferences. Few valid and reliable tools are available to evaluate the effectiveness of educational programs in advancing EBP attitudes, knowledge, skills, or behaviors, and ongoing competency. The Fresno test is one objective method to evaluate EBP knowledge and skills; however, the original and modified versions were validated with family physicians, physical therapists, and speech and language therapists. To adapt the Modified Fresno-Acute Care Nursing test and develop a psychometrically sound tool for use in academic and practice settings. In Phase 1, modified Fresno (Tilson, 2010) items were adapted for acute care nursing. In Phase 2, content validity was established with an expert panel. Content validity indices (I-CVI) ranged from .75 to 1.0. Scale CVI was .95%. A cross-sectional convenience sample of acute care nurses (n = 90) in novice, master, and expert cohorts completed the Modified Fresno-Acute Care Nursing test administered electronically via SurveyMonkey. Total scores were significantly different between training levels (p < .0001). Novice nurses scored significantly lower than master or expert nurses, but differences were not found between the latter cohorts. Total score reliability was acceptable: (interrater [ICC (2, 1)]) = .88. Cronbach's alpha was 0.70. Psychometric properties of most modified items were satisfactory; however, six require further revision and testing to meet acceptable standards. The Modified Fresno-Acute Care Nursing test is a 14-item test for objectively assessing EBP knowledge and skills of acute care nurses. While preliminary psychometric properties for this new EBP knowledge measure for acute care nursing are promising, further validation of some of the items and scoring rubric is needed. © 2018 Sigma Theta Tau International.
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Bellani, Giacomo; Laffey, John G; Pham, Tài; Fan, Eddy; Brochard, Laurent; Esteban, Andres; Gattinoni, Luciano; van Haren, Frank; Larsson, Anders; McAuley, Daniel F; Ranieri, Marco; Rubenfeld, Gordon; Thompson, B Taylor; Wrigge, Hermann; Slutsky, Arthur S; Pesenti, Antonio
2016-02-23
Limited information exists about the epidemiology, recognition, management, and outcomes of patients with the acute respiratory distress syndrome (ARDS). To evaluate intensive care unit (ICU) incidence and outcome of ARDS and to assess clinician recognition, ventilation management, and use of adjuncts-for example prone positioning-in routine clinical practice for patients fulfilling the ARDS Berlin Definition. The Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) was an international, multicenter, prospective cohort study of patients undergoing invasive or noninvasive ventilation, conducted during 4 consecutive weeks in the winter of 2014 in a convenience sample of 459 ICUs from 50 countries across 5 continents. Acute respiratory distress syndrome. The primary outcome was ICU incidence of ARDS. Secondary outcomes included assessment of clinician recognition of ARDS, the application of ventilatory management, the use of adjunctive interventions in routine clinical practice, and clinical outcomes from ARDS. Of 29,144 patients admitted to participating ICUs, 3022 (10.4%) fulfilled ARDS criteria. Of these, 2377 patients developed ARDS in the first 48 hours and whose respiratory failure was managed with invasive mechanical ventilation. The period prevalence of mild ARDS was 30.0% (95% CI, 28.2%-31.9%); of moderate ARDS, 46.6% (95% CI, 44.5%-48.6%); and of severe ARDS, 23.4% (95% CI, 21.7%-25.2%). ARDS represented 0.42 cases per ICU bed over 4 weeks and represented 10.4% (95% CI, 10.0%-10.7%) of ICU admissions and 23.4% of patients requiring mechanical ventilation. Clinical recognition of ARDS ranged from 51.3% (95% CI, 47.5%-55.0%) in mild to 78.5% (95% CI, 74.8%-81.8%) in severe ARDS. Less than two-thirds of patients with ARDS received a tidal volume 8 of mL/kg or less of predicted body weight. Plateau pressure was measured in 40.1% (95% CI, 38.2-42.1), whereas 82.6% (95% CI, 81.0%-84.1%) received a positive end
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Early definitive treatment rate as a quality indicator of care in acute gallstone pancreatitis.
Green, R; Charman, S C; Palser, T
2017-11-01
Early definitive treatment (cholecystectomy or endoscopic sphincterotomy in the same admission or within 2 weeks after discharge) of gallstone disease after a biliary attack of acute pancreatitis is standard of care. This study investigated whether compliance with early definitive treatment for acute gallstone pancreatitis can be used as a care quality indicator for the condition. A retrospective cohort study was conducted using the Hospital Episode Statistics database. All emergency admissions to National Health Service hospitals in England with a first time diagnosis of acute gallstone pancreatitis in the financial years 2008, 2009 and 2010 were examined. Trends in early definitive treatment between hospital trusts were examined and patient morbidity outcomes were determined. During the study interval there were 19 510 patients with an overall rate of early definitive treatment at 34·7 (range 9·4-84·7) per cent. In the 1-year follow-up period, 4661 patients (23·9 per cent) had one or more emergency readmissions for complications related to gallstone pancreatitis. Of these, 2692 (57·8 per cent) were readmissions for acute pancreatitis; 911 (33·8 per cent) were within the first 2 weeks of discharge, with the remaining 1781 (66·2 per cent) occurring after the point at which definitive treatment should have been received. Early definitive treatment resulted in a 39 per cent reduction in readmission risk (adjusted risk ratio (RR) 0·61, 95 per cent c.i. 0·58 to 0·65). The risk was further reduced for acute pancreatitis readmissions to 54 per cent in the early definitive treatment group (adjusted RR 0·46, 0·42 to 0·51). In acute gallstone pancreatitis, compliance with recommended early definitive treatment varied considerably, with associated variation in outcomes. Compliance should be used as a quality indicator to improve care. © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.
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Acute porphyrias: clinical spectrum of hospitalized patients.
Sheerani, Mughis; Urfy, Mian Zainulsajadeen; Hassan, Ali; Islam, Zunaira; Baig, Shahid
2007-11-01
To determine characteristics, clinical features and triggers of acute porphyria in hospitalized patients presenting to a tertiary care center in Pakistan. Case series. The Aga Khan University Hospital, Karachi, from 1988 to 2003. Case records of 26 patients hospitalized with diagnosis were identified through computerized hospital patients' data. The diagnosis of acute porphyria was based on pertinent clinical features and laboratory investigations after exclusion of other alternative diagnosis and patients previously diagnosed as porphyric. The data was analyzed through SPSS software version 11.0. Twelve patients (46.2%) were males. Mean age was 21 years. Most common manifestation were gastrointestinal (n=22; 88.5%) followed by neurological symptoms (n=14; 54%). Neurological manifestations included seizures (n=9; 34.6%) and neuropathy (n=6; 23%). One patient presented with depression and insomnia. Family history was positive in (n=8; 30.8%). Eighteen (69%) had history of previous attacks at their presentation to the hospital. Most common precipitating factor was 'eating outside' (n=18; 69%). Porphyrias are uncommon and cryptic group of diseases. This study shows a slightly different gender distribution, earlier onset of symptoms, higher number of neuropsychiatric symptoms (especially seizures), more distal neuropathies and different precipitant in the studied subset of patients than described previously in the western studies.
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Televisitation: Virtual Transportation of Family to the Bedside in an Acute Care Setting
Nicholas, Bonnie
2013-01-01
Televisitation is the virtual transportation of a patient’s family to the bedside, regardless of the patient’s location within an acute care setting. This innovation in the Telemedicine Program at Thunder Bay Regional Health Sciences Centre (TBRHSC) in Ontario, Canada, embraces the concept of patient- and family-centered care and has been identified as a leading practice by Accreditation Canada. The need to find creative ways to link patients to their family and friend supports hundreds of miles away was identified more than ten years ago. The important relationship between health outcomes and the psychosocial needs of patients and families has been recognized more recently. TBRHSC’s patient- and family-centered model of care focuses on connecting patients with their families. First Nations renal patients with family in remote communities were some of the earliest users of videoconferencing technology for this purpose. PMID:23596369
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Rural Implications of Medicare's Post-Acute-Care Transfer Payment Policy
ERIC Educational Resources Information Center
Schoenman, Julie A.; Mueller, Curt D.
2005-01-01
Under the Medicare post-acute-care (PAC) transfer policy, acute-care hospitals are reimbursed under a per-diem formula whenever beneficiaries are discharged from selected diagnosis-related groups (DRGs) to a skilled nursing facility, home health care, or a prospective payment system (PPS)-excluded facility. Total per-diem payments are below the…
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Fox, Jennifer; Windsor, Carol; Connell, Shirley; Yates, Patsy
2016-06-01
The positioning and meaning of palliative care within the healthcare system lacks clarity which adds a level of complexity to the process of transition to palliative care. This study explores the transition to the palliative care process in the acute care context of metastatic melanoma. A theoretical framework drawing on interpretive and critical traditions informs this research. The pragmatism of symbolic interactionism and the critical theory of Habermas brought a broad orientation to the research. Integration of the theoretical framework and grounded-theory methods facilitated data generation and analysis of 29 interviews with patients, family carers, and healthcare professionals. The key analytical findings depict a scope of palliative care that was uncertain for users of the system and for those working within the system. Becoming "palliative" is not a defined event; nor is there unanimity around referral to a palliative care service. As such, ambiguity and tension contribute to the difficulties involved in negotiating the transition to palliative care. Our findings point to uncertainty around the scopes of practice in the transition to palliative care. The challenge in the transition process lies in achieving greater coherency of care within an increasingly specialized healthcare system. The findings may not only inform those within a metastatic melanoma context but may contribute more broadly to palliative practices within the acute care setting.
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Does a biomedical research centre affect patient care in local hospitals?
Lichten, Catherine A; Marsden, Grace; Pollitt, Alexandra; Kiparoglou, Vasiliki; Channon, Keith M; Sussex, Jon
2017-01-21
Biomedical research can have impacts on patient care at research-active hospitals. We qualitatively evaluated the impact of the Oxford Biomedical Research Centre (Oxford BRC), a university-hospital partnership, on the effectiveness and efficiency of healthcare in local hospitals. Effectiveness and efficiency are conceptualised in terms of impacts perceived by clinicians on the quality, quantity and costs of patient care they deliver. First, we reviewed documentation from Oxford BRC and literature on the impact of research activity on patient care. Second, we interviewed leaders of the Oxford BRC's research to identify the direct and indirect impacts they expected their activity would have on local hospitals. Third, this information was used to inform interviews with senior clinicians responsible for patient care at Oxford's acute hospitals to discover what impacts they observed from research generally and from Oxford BRC's research work specifically. We compared and contrasted the results from the two sets of interviews using a qualitative approach. Finally, we identified themes emerging from the senior clinicians' responses, and compared them with an existing taxonomy of mechanisms through which quality of healthcare may be affected in research-active settings. We were able to interview 17 research leaders at the Oxford BRC and 19 senior clinicians at Oxford's acute hospitals. The research leaders identified a wide range of beneficial impacts that they expected might be felt at local hospitals as a result of their research activity. They expected the impact of their research activity on patient care to be generally positive. The senior clinicians responsible for patient care at those hospitals presented a more mixed picture, identifying many positive impacts, but also a smaller number of negative impacts, from research activity, including that of the Oxford BRC. We found the existing taxonomy of benefit types to be helpful in organising the findings, and propose
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[Acute care of patients with bacterial meningitis].
Stetefeld, H R; Dohmen, C
2016-04-01
Bacterial meningitis is a life-threatening emergency that is still associated with high mortality and poor outcome. The purpose of this article is to provide a review of clinical presentation, diagnostic procedure, therapy, and prognosis in bacterial meningitis. Prognostic factors which could be influenced positively are identified and a focused procedure in the emergency setting and for the treatment of complications are provided. This work is based on a literature search (PubMed, guidelines) and personal experience (standard operating procedures, SOP). Despite improved health care, bacterial meningitis is still associated with high mortality and poor neurological outcome, which has remained largely unaltered during recent decades. Diagnosis and, more importantly, effective therapy of bacterial meningitis are often delayed, having an immediate negative influence on clinical outcome. Neurological and nonneurological complications often necessitate intensive care and may occur rapidly or in the further course of the disease. Immediate initiation of effective therapy is crucial to positively influence mortality and neurological outcome. Antibiotics should be administered within 30 min after admission. To achieve this, a focused and well-organized procedure in the emergency setting is necessary. Because of intra- and extracranial complications, patients need to be treated on intensive care units including neurological expertise and interdisciplinary support.
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Pintado, María-Consuelo; Trascasa, María; Arenillas, Cristina; de Zárate, Yaiza Ortiz; Pardo, Ana; Blandino Ortiz, Aaron; de Pablo, Raúl
2016-05-01
The updated Atlanta Classification of acute pancreatitis (AP) in adults defined three levels of severity according to the presence of local and/or systemic complications and presence and length of organ failure. No study focused on complications and mortality of patients with moderately severe AP admitted to intensive care unit (ICU). The main aim of this study is to describe the complications developed and outcomes of these patients and compare them to those with severe AP. Prospective, observational study. We included patients with acute moderately severe or severe AP admitted in a medical-surgical ICU during 5years. We collected demographic data, admission criteria, pancreatitis etiology, severity of illness, presence of organ failure, local and systemic complications, ICU length of stay, and mortality. Fifty-six patients were included: 12 with moderately severe AP and 44 with severe. All patients developed some kind of complications without differences on complications rate between moderately severe or severe AP. All the patients present non-infectious systemic complications, mainly acute respiratory failure and hemodynamic failure. 82.1% had an infectious complication, mainly non-pancreatic infection (66.7% on moderately severe AP vs. 79.5% on severe, p=0.0443). None of the patients with moderately severe AP died during their intensive care unit stay vs. 29.5% with severe AP (p=0.049). Moderately severe AP has a high rate of complications with similar rates to patients with severe AP admitted to ICU. However, their ICU mortality remains very low, which supports the existence of this new group of pancreatitis according to their severity. Copyright © 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
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Hamaker, Marije E; Buurman, Bianca M; van Munster, Barbara C; Kuper, Ingeborg M J A; Smorenburg, Carolien H; de Rooij, Sophia E
2011-01-01
A comprehensive geriatric assessment systematically collects information on geriatric conditions and is propagated in oncology as a useful tool when assessing older cancer patients. The objectives were: (a) to study the prevalence of geriatric conditions in cancer patients aged ≥ 65 years, acutely admitted to a general medicine ward; (b) to determine functional decline and mortality within 12 months after admission; and (c) to assess which geriatric conditions and cancer-related variables are associated with 12-month mortality. This was an observational cohort study of 292 cancer patients aged ≥ 65 years, acutely admitted to the general medicine and oncology wards of two university hospitals and one secondary teaching hospital. Baseline assessments included patient characteristics, reason for admission, comorbidity, and geriatric conditions. Follow-up at 3 and 12 months was aimed at functional decline (loss of one or more activities of daily living [ADL]) and mortality. The median patient age was 74.9 years, and 95% lived independently; 126 patients (43%) had metastatic disease. A high prevalence of geriatric conditions was found for instrumental ADL impairment (78%), depressive symptoms (65%), pain (65%), impaired mobility (48%), malnutrition (46%), and ADL impairment (38%). Functional decline was observed in 8% and 33% of patients at 3 and 12 months, respectively. Mortality rates were 38% at 3 months and 64% at 12 months. Mortality was associated with cancer-related factors only. In these acutely hospitalized older cancer patients, mortality was only associated with cancer-related factors. The prevalence of geriatric conditions in this population was high. Future research is needed to elucidate if addressing these conditions can improve quality of life.
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Buurman, Bianca M.; van Munster, Barbara C.; Kuper, Ingeborg M.J.A.; Smorenburg, Carolien H.; de Rooij, Sophia E.
2011-01-01
Introduction. A comprehensive geriatric assessment systematically collects information on geriatric conditions and is propagated in oncology as a useful tool when assessing older cancer patients. Objectives. The objectives were: (a) to study the prevalence of geriatric conditions in cancer patients aged ≥65 years, acutely admitted to a general medicine ward; (b) to determine functional decline and mortality within 12 months after admission; and (c) to assess which geriatric conditions and cancer-related variables are associated with 12-month mortality. Methods. This was an observational cohort study of 292 cancer patients aged ≥65 years, acutely admitted to the general medicine and oncology wards of two university hospitals and one secondary teaching hospital. Baseline assessments included patient characteristics, reason for admission, comorbidity, and geriatric conditions. Follow-up at 3 and 12 months was aimed at functional decline (loss of one or more activities of daily living [ADL]) and mortality. Results. The median patient age was 74.9 years, and 95% lived independently; 126 patients (43%) had metastatic disease. A high prevalence of geriatric conditions was found for instrumental ADL impairment (78%), depressive symptoms (65%), pain (65%), impaired mobility (48%), malnutrition (46%), and ADL impairment (38%). Functional decline was observed in 8% and 33% of patients at 3 and 12 months, respectively. Mortality rates were 38% at 3 months and 64% at 12 months. Mortality was associated with cancer-related factors only. Conclusion. In these acutely hospitalized older cancer patients, mortality was only associated with cancer-related factors. The prevalence of geriatric conditions in this population was high. Future research is needed to elucidate if addressing these conditions can improve quality of life. PMID:21914699
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Jansson, Bruce S; Nyamathi, Adeline; Heidemann, Gretchen; Duan, Lei; Kaplan, Charles
2015-01-01
Although literature documents the need for hospital social workers, nurses, and medical residents to engage in patient advocacy, little information exists about what predicts the extent they do so. This study aims to identify predictors of health professionals' patient advocacy engagement with respect to a broad range of patients' problems. A cross-sectional research design was employed with a sample of 94 social workers, 97 nurses, and 104 medical residents recruited from eight hospitals in Los Angeles. Bivariate correlations explored whether seven scales (Patient Advocacy Eagerness, Ethical Commitment, Skills, Tangible Support, Organizational Receptivity, Belief Other Professionals Engage, and Belief the Hospital Empowers Patients) were associated with patient advocacy engagement, measured by the validated Patient Advocacy Engagement Scale. Regression analysis examined whether these scales, when controlling for sociodemographic and setting variables, predicted patient advocacy engagement. While all seven predictor scales were significantly associated with patient advocacy engagement in correlational analyses, only Eagerness, Skills, and Belief the Hospital Empowers Patients predicted patient advocacy engagement in regression analyses. Additionally, younger professionals engaged in higher levels of patient advocacy than older professionals, and social workers engaged in greater patient advocacy than nurses. Limitations and the utility of these findings for acute-care hospitals are discussed.
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Noffsinger, Dana L
2014-01-01
The role of acute care nurse practitioners (ACNPs) in trauma care has evolved over time. A survey was performed with the aim of describing the role across the United States. There were 68 respondents who depicted the typical trauma ACNP as being a 42-year-old woman who works full-time at a level I American College of Surgeons verified trauma center. Trauma ACNPs typically practice with 80% of their time for clinical care and are based on a trauma and acute care surgery service. They are acute care certified and hold several advanced certifications to supplement their nursing license.
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Ma, Chenjuan; Park, Shin Hye; Shang, Jingjing
2018-05-02
Collaboration among healthcare providers has been considered a promising strategy for improving care quality and patient outcomes. Despite mounting evidence demonstrating the impact of collaboration on outcomes of healthcare providers, there is little empirical evidence on the relationship between collaboration and patient safety outcomes, particularly at the patient care unit level. The purpose of this study is to identify the extent to which interdisciplinary collaboration between nurses and physicians and intradisciplinary collaboration among nurses on patient care units are associated with patient safety outcomes. This is a cross-sectional study using nurse survey data and patient safety indicators data from U.S. acute care hospital units. Collaboration at the unit level was measured by two 6-item scales: nurse-nurse interaction scale and nurse-physician interaction scale. Patient outcome measures included hospital-acquired pressure ulcers (HAPUs) and patient falls. The unit of analysis was the patient care unit, and the final sample included 900 units of 5 adult unit types in 160 hospitals in the U.S. Multilevel logistic and Poisson regressions were used to estimate the relationship between collaboration and patient outcomes. All models were controlled for hospital and unit characteristics, and clustering of units within hospitals was considered. On average, units had 26 patients with HAPUs per 1000 patients and 3 patient falls per 1000 patient days. Critical care units had the highest HAPU rate (50/1000 patients) and the lowest fall rate (1/1000 patient days). A one-unit increase in the nurse-nurse interaction scale score led to 31% decrease in the odds of having a HAPU (OR, 0.69; 95% CI, 0.56-0.82) and 8% lower patient fall rate (IRR, 0.92; 95% CI, 0.87-0.98) on a nursing unit. A one-unit increase in the nurse-physician interaction scale score was associated with 19% decrease in the odds of having a HAPU (OR, 0.81; 95% CI, 0.68-0.97) and 13% lower fall rates
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Courtenay, Molly; Carey, Nicola
2008-08-01
To identify, summarise and critically appraise the current evidence regarding the impact and effectiveness of nurse-led care in acute and chronic pain. A diverse range of models of care exist within the services available for the management of acute and chronic pain. Primary studies have been conducted evaluating these models, but, review and synthesis of the findings from these studies has not been undertaken. Literature review. Searches of Pubmed (NLM) Medline, CINAHL, Web of Knowledge (Science Index, Social Science index), British Nursing Index from January 1996-March 2007 were conducted. The searches were supplemented by an extensive hand search of the literature through references identified from retrieved articles and by contact with experts in the field. Twenty-one relevant publications were identified and included findings from both primary and secondary care. The areas, in which nurses, caring for patients in pain are involved, include assessment, monitoring, evaluation of pain, interdisciplinary collaboration and medicines management. Education programmes delivered by specialist nurses can improve the assessment and documentation of acute and chronic pain. Educational interventions and the use of protocols by specialist nurses can improve patients understanding of their condition and improve pain control. Acute pain teams, led by nurses, can reduce pain intensity and are cost effective. Nurses play key roles in the diverse range of models of care that exist in acute and chronic pain. However, there are methodological weaknesses across this body of research evidence and under researched issues that point to a need for further rigorous evaluation. Nurse-led care is an integral element of the pain services offered to patients. This review highlights the effect of this care and the issues that require consideration by those responsible for the development of nurse-led models in acute and chronic pain.
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Supporting ward staff in acute care areas: the past, the present and the future?
Coad, Sharon; Haines, Susan; Lawrence, Barbara
2002-01-01
Clinical education for acute ward staff caring for critically ill patients has continued to be a strong focus for practice development. Adopting a work-based learning approach to empower ward staff has led to the development of a five-day competency-based high dependency skills course. Developing leadership potential and enhancing networking opportunities for nurses from within critical care and ward areas is essential for the realisation of the aims of Comprehensive Critical Care.
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Operational integration in primary health care: patient encounters and workflows.
Sifaki-Pistolla, Dimitra; Chatzea, Vasiliki-Eirini; Markaki, Adelais; Kritikos, Kyriakos; Petelos, Elena; Lionis, Christos
2017-11-29
Despite several countrywide attempts to strengthen and standardise the primary healthcare (PHC) system, Greece is still lacking a sustainable, policy-based model of integrated services. The aim of our study was to identify operational integration levels through existing patient care pathways and to recommend an alternative PHC model for optimum integration. The study was part of a large state-funded project, which included 22 randomly selected PHC units located across two health regions of Greece. Dimensions of operational integration in PHC were selected based on the work of Kringos and colleagues. A five-point Likert-type scale, coupled with an algorithm, was used to capture and transform theoretical framework features into measurable attributes. PHC services were grouped under the main categories of chronic care, urgent/acute care, preventive care, and home care. A web-based platform was used to assess patient pathways, evaluate integration levels and propose improvement actions. Analysis relied on a comparison of actual pathways versus optimal, the latter ones having been identified through literature review. Overall integration varied among units. The majority (57%) of units corresponded to a basic level. Integration by type of PHC service ranged as follows: basic (86%) or poor (14%) for chronic care units, poor (78%) or basic (22%) for urgent/acute care units, basic (50%) for preventive care units, and partial or basic (50%) for home care units. The actual pathways across all four categories of PHC services differed from those captured in the optimum integration model. Certain similarities were observed in the operational flows between chronic care management and urgent/acute care management. Such similarities were present at the highest level of abstraction, but also in common steps along the operational flows. Existing patient care pathways were mapped and analysed, and recommendations for an optimum integration PHC model were made. The developed web
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Hu, Yi-Hsuan; Wang, Chien-Ying; Huang, Mu-Shun; Lee, Chen-Hsen; Wen, Yi-Szu
2016-11-01
This study investigated surgery-related medical disputes and analyzed disease etiologies and the main causes of disputes in order to identify key points for the purpose of improving the quality of surgical patient care in Taiwan. Reports on all surgery-related cases appraised by the Taiwan Witness Examiner Committee of the Department of Health between 2004 and 2008 were reviewed retrospectively by three senior physicians from the emergency department who specialize in both trauma and emergency general surgery. The causes of the various medical disputes were categorized under the following descriptions: operation- or procedure-related complication, anesthesia complication, inappropriate management or decision, delayed diagnosis or misdiagnosis, and unsatisfactory result. A total of 154 cases were reviewed, of which 39 were trauma-related and 115 were disease-related. The two leading causes of disputes in this review were found to be operation- or procedure-related complications (35.7%) and unsatisfactory results (31.8%), followed by delayed diagnoses or misdiagnoses, inappropriate management, and anesthesia complications. Among these, 74 cases (48.1%) required the care of an acute care surgeon and 40 cases (26.0%) required emergency general surgery intervention. Surgery- or procedure-related complications and unsatisfactory treatment results constituted the major causes of medical disputes in Taiwan. The majority of these cases involved acute care surgery; thus, the establishment of an acute care surgery system should be considered to improve patient care. The management of hemorrhagic shock and incarcerated hernia should be reinforced in future medical training. Copyright © 2016. Published by Elsevier Taiwan LLC.
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Thuemmler, Christoph; Morris, Carole
2005-01-01
Recent audits within our hospital suggest that especially during peak phases the patient flow from our acute admission units downstream into hospital beds is not directed in the most efficient way and patients may be placed inappropriately. This inevitably causes time delays and potentially increases the risk of malpractice as patients have to spend an extended period of time in admission areas with a high workload and very busy staff. Using latest information technology, such as wireless local area networks and handheld devices, can improve the efficiency of patient management and can increase the quality of care by helping to avoid unnecessary treatment delays in overcrowded admission areas.
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Sauaia, A; Ralston, D; Schluter, W W; Marciniak, T A; Havranek, E P; Dunn, T R
2000-01-01
The purpose of this study was to evaluate performance feedback delivered by on-site presentations compared to mailed feedback on improving acute myocardial infarction (AMI) care. We used a randomized trial including 18 hospitals nested within the Cooperative Cardiovascular Project. Patients comprised AMI Medicare patients admitted before (n = 929, 1994 and 1995) and after intervention (n = 438, 1996). Control hospitals received written feedback by mail. The experimental intervention group received a presentation led by a cardiologist and a quality improvement specialist. We assessed the proportion of patients receiving appropriate AMI care before and after the intervention. Both univariate and multivariate analyses demonstrated no effect of the intervention in increasing the proportion of patients who received reperfusion, aspirin, beta-blockers, or angiotensin-converting enzyme inhibitors. On-site feedback presentations were not associated with a larger improvement in AMI care compared to the mailed feedback. Other interventions, such as opinion leaders and patient-directed interventions, may be necessary in order to improve the care of AMI patients.
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The effects of massage therapy on pain management in the acute care setting.
Adams, Rose; White, Barb; Beckett, Cynthia
2010-03-17
Pain management remains a critical issue for hospitals and is receiving the attention of hospital accreditation organizations. The acute care setting of the hospital provides an excellent opportunity for the integration of massage therapy for pain management into the team-centered approach of patient care. This preliminary study evaluated the effect of the use of massage therapy on inpatient pain levels in the acute care setting. The study was conducted at Flagstaff Medical Center in Flagstaff, Arizona-a nonprofit community hospital serving a large rural area of northern Arizona. A convenience sample was used to identify research participants. Pain levels before and after massage therapy were recorded using a 0 - 10 visual analog scale. Quantitative and qualitative methods were used for analysis of this descriptive study. Hospital inpatients (n = 53) from medical, surgical, and obstetrics units participated in the current research by each receiving one or more massage therapy sessions averaging 30 minutes each. The number of sessions received depended on the length of the hospital stay. Before massage, the mean pain level recorded by the patients was 5.18 [standard deviation (SD): 2.01]. After massage, the mean pain level was 2.33 (SD: 2.10). The observed reduction in pain was statistically significant: paired samples t(52) = 12.43, r = .67, d = 1.38, p < .001. Qualitative data illustrated improvement in all areas, with the most significant areas of impact reported being overall pain level, emotional well-being, relaxation, and ability to sleep. This study shows that integration of massage therapy into the acute care setting creates overall positive results in the patient's ability to deal with the challenging physical and psychological aspects of their health condition. The study demonstrated not only significant reduction in pain levels, but also the interrelatedness of pain, relaxation, sleep, emotions, recovery, and finally, the healing process.
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Language used by health care professionals to describe dying at an acute care hospital.
Wentlandt, Kirsten; Toupin, Philippe; Novosedlik, Natalia; Le, Lisa W; Zimmermann, Camilla; Kaya, Ebru
2018-05-21
To understand the language used to describe the deterioration and death of patients in an acute academic tertiary care centre, and to identify whether patient diagnoses or palliative care(PC) involvement was associated with clearer descriptions of this process. We conducted a retrospective chart review of the final admission of 150 patients who died on an inpatient internal medicine unit. Conventional and summative content analysis was performed of the language used to describe, either directly or indirectly, that the patient's death was imminent. Of the 150 deaths, the median age was 79.5(range22-101), 58% were male, and 69% spoke English. A total of 45% of deaths were from cancer, and 66% occurred with prior PC team involvement. There was no documentation of the dying process in 18(12%) of charts. In the remainder, clinicians' documentation of imminent death fell into three categories: 1 identification of the current state using specific labels, e.g. 'dying'(24.7%), or 'end of life'(15.3%), or less specific language, 'unwell' or 'doing poorly'(6.0%); 2 predicting the future state using specific or more vague predictions: e.g.'hours to days'(7.3%) or 'poor or guarded prognosis'(26.0%); 3 using care provided to the patient to imply patient status: e.g. palliative care(49.3%) or comfort care(28.7%). PC involvement, but not a malignant diagnosis, was associated with more frequent use of specific language to describe the current(p=0.004) or future state(p=0.02). Death and dying in hospital is inadequately documented and is often described using unclear and vague language. PC involvement is associated with clearer language to describe this process. Copyright © 2018. Published by Elsevier Inc.
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Hospital at home versus in-patient hospital care.
Shepperd, S; Iliffe, S
2005-07-20
Hospital at home is defined as a service that provides active treatment by health care professionals, in the patient's home, of a condition that otherwise would require acute hospital in-patient care, always for a limited period. To assess the effects of hospital at home compared with in-patient hospital care. We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) specialised register (November 2004), MEDLINE (1966 to 1996), EMBASE (1980 to 1995), Social Science Citation Index (1992 to 1995), Cinahl (1982 to 1996), EconLit (1969 to 1996), PsycLit (1987 to 1996), Sigle (1980 to 1995) and the Medical Care supplement on economic literature (1970 to 1990). Randomised trials of hospital at home care compared with acute hospital in-patient care. The participants were patients aged 18 years and over. Two reviewers independently extracted data and assessed study quality. Twenty two trials are included in this update of the review. Among trials evaluating early discharge hospital at home schemes we found an odds ratio (OR) for mortality of 1.79 95% CI 0.85 to 3.76 for elderly medical patients (age 65 years and over) (n = 3 trials); OR 0.58; 95% CI 0.29 to 1.17 for patients with chronic obstructive pulmonary disease (COPD) (n = 5 trials); and OR 0.78; 95%CI 0.52 to 1.19 for patients recovering from a stroke (n = 4 trials). Two trials evaluating the early discharge of patients recovering from surgery reported an OR 0.43 (95% CI 0.02 to 10.89) for patients recovering from a hip replacement and an OR 1.01 (95% CI 0.37 to 2.81) for patients with a mix of conditions at three months follow-up. For readmission to hospital we found an OR 1.76; 95% CI 0.78 to 3.99 at 3 months follow-up for elderly medical patients (n = 2 trials); OR 0.81; 95% CI 0.55 to 1.19 for patients with COPD (n = 5 trials); and OR 0.96; 95% CI 0.63 to 1.45 for patients recovering from a stroke (n = 3 trials). No significant heterogeneity was observed. One trial recruiting patients
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Reducing Acute Kidney Injury Due to Contrast Material: How Nurses Can Improve Patient Safety.
Lambert, Peggy; Chaisson, Kristine; Horton, Susan; Petrin, Carmen; Marshall, Emily; Bowden, Sue; Scott, Lynn; Conley, Sheila; Stender, Janette; Kent, Gertrude; Hopkins, Ellen; Smith, Brian; Nicholson, Anita; Roy, Nancy; Homsted, Brenda; Downs, Cindy; Ross, Cathy S; Brown, Jeremiah
2017-02-01
Acute kidney injury due to contrast material occurs in 3% to 15% of the 2 million cardiac catheterizations done in the United States each year. To reduce acute kidney injury due to contrast material after cardiovascular interventional procedures. Nurse leaders in the Northern New England Cardiovascular Disease Study Group, a 10-center quality improvement consortium in Maine, New Hampshire, and Vermont, formed a nursing task force to reduce acute kidney injury due to contrast material after cardiovascular interventional procedures. Data were prospectively collected January 1, 2007, through June 30, 2012, on consecutive nonemergent patients (n = 20 147) undergoing percutaneous coronary interventions. Compared with baseline rates, adjusted rates of acute kidney injury among the 10 centers were significantly reduced by 21% and by 28% in patients with baseline estimated glomerular filtration rate less than 60 mL/min per 1.73 m 2 . Key qualitative system factors associated with improvement included use of multidisciplinary teams, standardized fluid orders, use of an intravenous fluid bolus, patient education about oral hydration, and limiting the volume of contrast material. Standardization of evidence-based best practices in nursing care may reduce the incidence of acute kidney injury due to contrast material. ©2017 American Association of Critical-Care Nurses.
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Pain care for patients with epidermolysis bullosa: best care practice guidelines.
Goldschneider, Kenneth R; Good, Julie; Harrop, Emily; Liossi, Christina; Lynch-Jordan, Anne; Martinez, Anna E; Maxwell, Lynne G; Stanko-Lopp, Danette
2014-10-09
Inherited epidermolysis bullosa (EB) comprises a group of rare disorders that have multi-system effects and patients present with a number of both acute and chronic pain care needs. Effects on quality of life are substantial. Pain and itching are burdensome daily problems. Experience with, and knowledge of, the best pain and itch care for these patients is minimal. Evidence-based best care practice guidelines are needed to establish a base of knowledge and practice for practitioners of many disciplines to improve the quality of life for both adult and pediatric patients with EB. The process was begun at the request of Dystrophic Epidermolysis Bullosa Research Association International (DEBRA International), an organization dedicated to improvement of care, research and dissemination of knowledge for EB patients worldwide. An international panel of experts in pain and palliative care who have extensive experience caring for patients with EB was assembled. Literature was reviewed and systematically evaluated. For areas of care without direct evidence, clinically relevant literature was assessed, and rounds of consensus building were conducted. The process involved a face-to-face consensus meeting that involved a family representative and methodologist, as well as the panel of clinical experts. During development, EB family input was obtained and the document was reviewed by a wide variety of experts representing several disciplines related to the care of patients with EB. The first evidence-based care guidelines for the care of pain in EB were produced. The guidelines are clinically relevant for care of patients of all subtypes and ages, and apply to practitioners of all disciplines involved in the care of patients with EB. When the evidence suggests that the diagnosis or treatment of painful conditions differs between adults and children, it will be so noted. Evidence-based care guidelines are a means of standardizing optimal care for EB patients, whose disease is
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SARS: caring for patients in Hong Kong.
Chung, Betty Pui Man; Wong, Thomas Kwok Shing; Suen, Esther Suk Bing; Chung, Joanne Wai Yee
2005-04-01
To explore in depth the experiences of nurses' caring for SARS patients in Hong Kong. Severe Acute Respiratory Syndrome (SARS) dramatically demonstrates the global havoc that can be wreaked by a newly emerging infectious disease. The current literature either has a predominantly biomedical focus or deals with the psychological impact on healthcare workers. Published studies on the lived experience of nurses caring for SARS patients are currently lacking. A phenomenological design. Using methods consistent with Husserl's philosophy, eight Registered Nurses working in three regional hospitals in Hong Kong were invited to participate in sharing their lived experience of caring for SARS patients and data were analysed using Colaizzi's approach. The three major themes explicated were: the various emotions experienced in caring for SARS patients, the concept of uncertainty and revisiting the 'taken for granted' features of nursing. These themes, when taken together, describe the essence of the voyage undertaken by nurses who cared for SARS patients during the outbreak. The findings of this study indicate that extensive and ongoing support is needed to prepare and enable nurses to care for SARS patients during a crisis and make it easier for nurses to deal with the various uncertainties. The essence of caring for SARS patients is highlighted in this study. The experience of caring for SARS patients prompts nurses to find meaning in their experience(s), and to develop knowledge and attitudes on how best to care for patients and prepare for a new crisis in the future. This paper considers a more in-depth understanding of the lived experience of nurses during the crisis and the relevance of this perspective for education and support of nurses.
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Prone positioning in the patient who has acute respiratory distress syndrome: the art and science.
Vollman, Kathleen M
2004-09-01
Acute respiratory distress syndrome (ARDS) remains a significant contributor to the morbidity and mortality of patients in the ICU. A variety of treatments are used to support the lung of the patient who has ARDS and improve gas exchange during the acute injury phase. It seems, however, that the simple, safe, and noninvasive act of prone positioning of the critically ill patient who has ARDS may improve gas exchange while preventing potential complications of high positive end-expiratory pressure, volutrauma, and oxygen toxicity. This article provides the critical care nurse with the physiologic rationale for use of the prone position, indications and contraindications for use, safe strategies for prone positioning, and care techniques and monitoring methods of the patient who is in the prone position.
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Andersen, Ingrid Charlotte; Thomsen, Thora Grothe; Bruun, Poul; Bødtger, Uffe; Hounsgaard, Lise
2017-12-01
To explore the experiences of patients with chronic obstructive pulmonary disease and their family members relating both to participation in care during hospitalisation for an acute exacerbation in chronic obstructive pulmonary disease, and to the subsequent day-to-day care at home. When recovering from an exacerbation, the challenges associated with an unpredictable health condition dominate everyday life for patients and can involve their family members. Proper patient and family participation in care during discharge and follow-up can help patients to improve self-management. However, knowledge of the significance of patient and family participation for recovery and subsequent everyday life is still limited. This study adopted a longitudinal design informed by ethnographic fieldwork principles. Participant observations and interviews with 15 patients and 12 family members were conducted on a Danish hospital ward and twice at the participants' homes. A phenomenological-hermeneutic approach inspired by Ricoeur's theory of interpretation guided the data analysis. Participation in care was perceived as valuable, but could be associated with tensions and increased uncertainty. While patients mostly demonstrated a reactive approach to care, family members strived to be more proactive. In hospital, preparing for discharge included an effort to find a balance between powerlessness and influence during interactions with healthcare professionals. At home, managing further recovery and self-management were characterised by navigating between mutual pressure and consideration within the family. Family members play an important role in ensuring that patients are seen, heard and understood, but want to be acknowledged more by healthcare professionals. Appropriate interactions with healthcare professionals are crucial in order to support discharge and daily self-management. Knowledge of the challenges that patients with chronic obstructive pulmonary disease and their family
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Factors contributing to nursing team work in an acute care tertiary hospital.
Polis, Suzanne; Higgs, Megan; Manning, Vicki; Netto, Gayle; Fernandez, Ritin
Effective nursing teamwork is an essential component of quality health care and patient safety. Understanding which factors foster team work ensures teamwork qualities are cultivated and sustained. This study aims to investigate which factors are associated with team work in an Australian acute care tertiary hospital across all inpatient and outpatient settings. All nurses and midwives rostered to inpatient and outpatient wards in an acute care 600 bed hospital in Sydney Australia were invited to participate in a cross sectional survey between September to October 2013. Data were collected, collated, checked and analysed using Statistical Package for the Social Sciences (SPSS) Version 21. Factors reporting a significant correlation with where p < 0.05 were analysed in a multiple regression model. A total of 501 surveys were returned. Nursing teamwork scores ranged between 3.32 and 4.08. Teamwork subscale Shared Mental Model consistently rated the highest. Mean scores for overall communication between nurses and team leadership were 3.6 (S.D. 0.57) and 3.8 (SD 0.6) respectively. Leadership and communication between nurses were significant predictors of team work p < 0.001. Our findings describe factors predictive of teamwork in an acute care tertiary based hospital setting across inpatient and outpatient specialty units. Our findings are of particular relevance in identifying areas of nurse education and workforce planning to improve nursing team work.
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Johnson, Erin E.; Aiello, Riccardo; Kane, Vincent; Pape, Lisa
2016-01-01
Introduction Although the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a “homeless medical home” initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites. Methods We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services. Results More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies. Conclusion Integrating social determinants of health into clinical care can be effective for high
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Overcoming the barriers to patient-centred care: time, tools and training.
West, Elizabeth; Barron, David N; Reeves, Rachel
2005-04-01
To investigate whether nurses experience barriers to delivering high quality care in areas that are of particular concern to patients and to describe which aspects of care are most affected when nurses lack the required resources, such as time, tools and training to do their job. Patient surveys conducted in the National Health Service of the United Kingdom tend to show there is variation in the extent to which they are satisfied with care in a number of important areas, such as physical comfort, emotional support and the coordination of care. A sample of nurses working in 20 acute London hospitals was asked to complete a postal questionnaire based on a prototype employee survey developed in the United States and adapted by the authors for use in the United Kingdom. Staff in the human resources departments of participating hospitals mailed the questionnaires to nurses' home addresses. After two reminders, 2880 (out of 6160) useable responses were returned, giving a response rate of 47%. Nurses are aware that there are deficits in standards of care in areas that are particularly important to patients. The majority feel overworked (64%) and report that they do not have enough time to perform essential nursing tasks, such as addressing patients' anxieties, fears and concerns and giving patients and relatives information. Their work is often made more difficult by the lack of staff, space, equipment and cleanliness. They are often unable to control noise and temperature in clinical areas. Nurses in acute London hospitals are subject to high levels of aggressive behaviour, mainly from patients and their relatives, but also from other members of staff. More positively, high proportions of the nurses in our survey expressed the desire for further training, particularly in social and interpersonal aspects of care. This paper goes beyond reporting problems with the quality and safety of care to try to understand why patients do not always receive optimum care in areas that
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Bell, Derek; Lambourne, Adrian; Percival, Frances; Laverty, Anthony A.; Ward, David K.
2013-01-01
Recent recommendations for physicians in the UK outline key aspects of care that should improve patient outcomes and experience in acute hospital care. Included in these recommendations are Consultant patterns of work to improve timeliness of clinical review and improve continuity of care. This study used a contemporaneous validated survey compared with clinical outcomes derived from Hospital Episode Statistics, between April 2009 and March 2010 from 91 acute hospital sites in England to evaluate systems of consultant cover for acute medical admissions. Clinical outcomes studied included adjusted case fatality rates (aCFR), including the ratio of weekend to weekday mortality, length of stay and readmission rates. Hospitals that had an admitting Consultant presence within the Acute Medicine Unit (AMU, or equivalent) for a minimum of 4 hours per day (65% of study group) had a lower aCFR compared with hospitals that had Consultant presence for less than 4 hours per day (p<0.01) and also had a lower 28 day re-admission rate (p<0.01). An ‘all inclusive’ pattern of Consultant working, incorporating all the guideline recommendations and which included the minimum Consultant presence of 4 hours per day (29%) was associated with reduced excess weekend mortality (p<0.05). Hospitals with >40 acute medical admissions per day had a lower aCFR compared to hospitals with fewer than 40 admissions per day (p<0.03) and had a lower 7 day re-admission rate (p<0.02). This study is the first large study to explore the potential relationships between systems of providing acute medical care and clinical outcomes. The results show an association between well-designed systems of Consultant working practices, which promote increased patient contact, and improved patient outcomes in the acute hospital setting. PMID:23613858
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Bell, Derek; Lambourne, Adrian; Percival, Frances; Laverty, Anthony A; Ward, David K
2013-01-01
Recent recommendations for physicians in the UK outline key aspects of care that should improve patient outcomes and experience in acute hospital care. Included in these recommendations are Consultant patterns of work to improve timeliness of clinical review and improve continuity of care. This study used a contemporaneous validated survey compared with clinical outcomes derived from Hospital Episode Statistics, between April 2009 and March 2010 from 91 acute hospital sites in England to evaluate systems of consultant cover for acute medical admissions. Clinical outcomes studied included adjusted case fatality rates (aCFR), including the ratio of weekend to weekday mortality, length of stay and readmission rates. Hospitals that had an admitting Consultant presence within the Acute Medicine Unit (AMU, or equivalent) for a minimum of 4 hours per day (65% of study group) had a lower aCFR compared with hospitals that had Consultant presence for less than 4 hours per day (p<0.01) and also had a lower 28 day re-admission rate (p<0.01). An 'all inclusive' pattern of Consultant working, incorporating all the guideline recommendations and which included the minimum Consultant presence of 4 hours per day (29%) was associated with reduced excess weekend mortality (p<0.05). Hospitals with >40 acute medical admissions per day had a lower aCFR compared to hospitals with fewer than 40 admissions per day (p<0.03) and had a lower 7 day re-admission rate (p<0.02). This study is the first large study to explore the potential relationships between systems of providing acute medical care and clinical outcomes. The results show an association between well-designed systems of Consultant working practices, which promote increased patient contact, and improved patient outcomes in the acute hospital setting.
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Acute clinical care and care coordination for traumatic brain injury within Department of Defense.
Jaffee, Michael S; Helmick, Kathy M; Girard, Philip D; Meyer, Kim S; Dinegar, Kathy; George, Karyn
2009-01-01
The nature of current combat situations that U.S. military forces encounter and the use of unconventional weaponry have dramatically increased service personnel's risks of sustaining a traumatic brain injury (TBI). Although the true incidence and prevalence of combat-related TBI are unknown, service personnel returning from deployment have reported rates of concussion between 10% and 20%. The Department of Defense has recently released statistics on TBI dating back to before the wars in Iraq and Afghanistan to better elucidate the impact and burden of TBI on America's warriors and veterans. Patients with severe TBI move through a well-established trauma system of care, beginning with triage of initial injury by first-responders in the war zone to acute care to rehabilitation and then returning home and to the community. Mild and moderate TBIs may pose different clinical challenges, especially when initially undetected or if treatment is delayed because more serious injuries are present. To ensure identification and prompt treatment of mild and moderate TBI, the U.S. Congress has mandated that military and Department of Veterans Affairs hospitals screen all service personnel returning from combat. Military health professionals must evaluate them for concussion and then treat the physical, emotional, and cognitive problems that may surface. A new approach to health management and care coordination is needed that will allow medical transitions between networks of care to become more centralized and allow for optimal recovery at all severity levels. This article summarizes the care systems available for the acute management of TBI from point of injury to stateside military treatment facilities. We describe TBI assessment, treatment, and overall coordination of care, including innovative clinical initiatives now used.
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Jang, H; Baek, J G; Yoo, S-J
2015-06-01
Patients with asymptomatic haemorrhoids are known to be less tolerant of radiation doses lower than known tolerance doses. In the present study, the authors sought to identify the risk factors of acute haemorrhoid aggravation after whole pelvic radiotherapy (WPRT). The records of 33 patients with cervical, rectal or prostate cancer with asymptomatic haemorrhoids, which were confirmed by colonoscopy before the start of radiotherapy (RT), were reviewed. Acute anal symptoms, such as anal pain and bleeding, were observed up to 1 month after RT completion. Dosimetric and patient factors were analysed, and subgroup analyses were performed. The median induction dose for acute anal symptoms was 34.1 Gy (range, 28.8-50.4 Gy). Post-operative treatment intent showed more acute anal toxicity of patient factors (p = 0.04). In subgroup analysis, post-operative treatment intent and concurrent chemoradiotherapy were found to be related to acute anal symptoms (p < 0.01). Of the dosimetric factors, V10 tended to be related to acute anal symptoms (p = 0.08). This study indicates that asymptomatic haemorrhoid may deteriorate after low-dose radiation and that patient factors, such as treatment intent and concurrent chemotherapy, probably influence anal toxicity. In patients with asymptomatic haemorrhoids, WPRT requires careful dosimetry and clinical attention. The tolerance of anal canal tends to be ignored in patients with pelvic cancer who are undergoing WPRT. However, patients with asymptomatic haemorrhoids may be troubled by low radiation doses, and further studies are required.
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Durham, Spencer H; Badowski, Melissa E; Liedtke, Michelle D; Rathbun, R Chris; Pecora Fulco, Patricia
2017-05-01
Patients infected with human immunodeficiency virus (HIV) admitted to the hospital have complex antiretroviral therapy (ART) regimens with an increased medication error rate upon admission. This report provides a resource for clinicians managing HIV-infected patients and ART in the inpatient setting. A survey of the authors was conducted to evaluate common issues that arise during an acute hospitalization for HIV-infected patients. After a group consensus, a review of the medical literature was performed to determine the supporting evidence for the following HIV-associated hospital queries: admission/discharge orders, antiretroviral hospital formularies, laboratory monitoring, altered hepatic/renal function, drug-drug interactions (DDIs), enteral administration, and therapeutic drug monitoring. With any hospital admission for an HIV-infected patient, a specific set of procedures should be followed including a thorough admission medication history and communication with the ambulatory HIV provider to avoid omissions or substitutions in the ART regimen. DDIs are common and should be reviewed at all transitions of care during the hospital admission. ART may be continued if enteral nutrition with a feeding tube is deemed necessary, but the entire regimen should be discontinued if no oral access is available for a prolonged period. Therapeutic drug monitoring is not generally recommended but, if available, should be considered in unique clinical scenarios where antiretroviral pharmacokinetics are difficult to predict. ART may need adjustment if hepatic or renal insufficiency ensues. Treatment of hospitalized patients with HIV is highly complex. HIV-infected patients are at high risk for medication errors during various transitions of care. Baseline knowledge of the principles of antiretroviral pharmacotherapy is necessary for clinicians managing acutely ill HIV-infected patients to avoid medication errors, identify DDIs, and correctly dose medications if organ
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Experiences of Patients in Acute and Closed Psychiatric Wards: A Systematic Review.
Nugteren, Willem; van der Zalm, Yvonne; Hafsteinsdóttir, Thóra B; van der Venne, Cokky; Kool, Nienke; van Meijel, Berno
2016-10-01
To obtain insight into the patients' experiences during treatment in an acute, closed psychiatric ward. A systematic literature search was conducted in the databases Medline, Embase, CINAHL, and Cochrane. Ten articles were selected. Four main themes emerged from the literature: (a) the inappropriate use of the ward rules, (b) nurses' lack of time for interacting with patients, (c) the feeling of humiliation, and (d) the involvement of significant others. Nurses can use the findings of this systematic review to improve quality of care in acute psychiatric units. © 2015 Wiley Periodicals, Inc.
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Belenguer-Muncharaz, A; Albert-Rodrigo, L; Ferrandiz-Sellés, A; Cebrián-Graullera, G
2013-10-01
A comparison was made between invasive mechanical ventilation (IMV) and noninvasive positive pressure ventilation (NPPV) in haematological patients with acute respiratory failure. A retrospective observational study was made from 2001 to December 2011. A clinical-surgical intensive care unit (ICU) in a tertiary hospital. Patients with hematological malignancies suffering acute respiratory failure (ARF) and requiring mechanical ventilation in the form of either IMV or NPPV. Analysis of infection and organ failure rates, duration of mechanical ventilation and ICU and hospital stays, as well as ICU, hospital and mortality after 90 days. The same variables were analyzed in the comparison between NPPV success and failure. Forty-one patients were included, of which 35 required IMV and 6 NPPV. ICU mortality was higher in the IMV group (100% vs 37% in NPPV, P=.006). The intubation rate in NPPV was 40%. Compared with successful NPPV, failure in the NPPV group involved more complications, a longer duration of mechanical ventilation and ICU stay, and greater ICU and hospital mortality. Multivariate analysis of mortality in the NPPV group identified NPPV failure (OR 13 [95%CI 1.33-77.96], P=.008) and progression to acute respiratory distress syndrome (OR 10 [95%CI 1.95-89.22], P=.03) as prognostic factors. The use of NPPV reduced mortality compared with IMV. NPPV failure was associated with more complications. Copyright © 2012 Elsevier España, S.L. and SEMICYUC. All rights reserved.
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Kuwabara, Kazuaki; Matsuda, Shinya; Anan, Makoto; Fushimi, Kiyohide; Ishikawa, Koichi B; Horiguchi, Hiromasa; Hayashida, Kenshi; Fujimori, Kenji
2010-06-11
Many studies have reported economic evaluation of evolving agents or therapies for patients with heart failure (HF). However, little is known whether the disease progression category (acute or chronic HF) would be considered as a risk adjustment in health service research. This study profiles the difference in resource use or medical care for acute versus chronic HF. This study analyzed 17,912 HF patients treated in 62 academic hospitals and 351 community hospitals. Study variables included demographic variables, comorbid status, physical activity or disease progression at admission, procedures and laboratory tests, type and dose of heart-related medications, length of stay (LOS), and total charges (TC; 1 US$= 100 yen) for acute and chronic HF. The independent contributions of disease progression categories on LOS and TC were identified using multivariate analysis. We identified 9813 chronic and 8099 acute HF patients. Median LOS was 18 days for both chronic and acute HF, whereas TC was US$5731 and US$6447, respectively. Regression analysis revealed that acute HF was associated with a slightly greater TC, whereas performance of procedures was the most prominent factor. As NYHA class was the next most influential factor, class 3 or 4 resulted in longer LOS or greater TC, than did class 1. This study suggests that acute HF increased resource use slightly, whereas use of some practices indicated in critical care was affected more by the procedures performed. Disease progression category should remain an indicator for appropriateness of medical care. Copyright (c) 2008 Elsevier Ireland Ltd. All rights reserved.
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McCurdy, BR
2012-01-01
Executive Summary In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions. After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses. The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html. Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive
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Manrai, Manish; Kochhar, Rakesh; Gupta, Vikas; Yadav, Thakur Deen; Dhaka, Narendra; Kalra, Naveen; Sinha, Saroj K; Khandelwal, Niranjan
2018-02-01
To study the outcome of acute collections occurring in patients with acute pancreatitis BACKGROUND:: There are limited data on natural history of acute collections arising after acute pancreatitis (AP). Consecutive patients of AP admitted between July 2011 and December 2012 were evaluated by imaging for development of acute collections as defined by revised Atlanta classification. Imaging was repeated at 1 and 3 months. Spontaneous resolution, evolution, and need for intervention were assessed. Of the 189 patients, 151 patients (79.9%) had acute collections with severe disease and delayed hospitalization being predictors of acute collections. Thirty-six patients had acute interstitial edematous pancreatitis, 8 of whom developed acute peripancreatic fluid collections, of which 1 evolved into pseudocyst. Among the 153 patients with acute necrotizing pancreatitis, 143 (93.4%) developed acute necrotic collection (ANC). Twenty-three of 143 ANC patients died, 21 had resolved collections, whereas 84 developed walled-off necrosis (WON), with necrosis >30% (P = 0.010) and Computed Tomographic Severity Index score ≥7 (P = 0.048) predicting development of WON. Of the 84 patients with WON, 8 expired, 53 patients required an intervention, and 23 were managed conservatively. Independent predictors of any intervention among all patients were Computed Tomographic Severity Index score ≥7 (P < 0.001) and interval between onset of pain to hospitalization >7 days (P = 0.04). Patients with severe AP and delayed hospitalization more often develop acute collections. Pancreatic pseudocysts are a rarity in acute interstitial pancreatitis. A majority of patients with necrotising pancreatitis will develop ANC, more than half of whom will develop WON. Delay in hospitalization and higher baseline necrosis score predict need for intervention.
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Patient participation in medication safety during an acute care admission.
McTier, Lauren; Botti, Mari; Duke, Maxine
2015-10-01
Patient participation in medication management during hospitalization is thought to reduce medication errors and, following discharge, improve adherence and therapeutic use of medications. There is, however, limited understanding of how patients participate in their medication management while hospitalized. To explore patient participation in the context of medication management during a hospital admission for a cardiac surgical intervention of patients with cardiovascular disease. Single institution, case study design. The unit of analysis was a cardiothoracic ward of a major metropolitan, tertiary referral hospital in Melbourne, Australia. Multiple methods of data collection were used including pre-admission and pre-discharge patient interviews (n = 98), naturalistic observations (n = 48) and focus group interviews (n = 2). All patients had changes made to their pre-operative cardiovascular medications as a consequence of surgery. More patients were able to list and state the purpose and side-effects of their cardiovascular medications at pre-admission than prior to discharge from hospital. There was very little evidence that nurses used opportunities such as medication administration times to engage patients in medication management during hospital admission. Failure to engage patients in medication management and provide opportunities for patients to learn about changes to their medications has implications for the quality and safety of care patients receive in hospital and when managing their medications once discharged. To increase the opportunity for patients to participate in medication management, a fundamental shift in the way nurses currently provide care is required. © 2013 John Wiley & Sons Ltd.
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Rathert, Cheryl; May, Douglas R
2007-01-01
Experts continue to decry the lack of progress made in decreasing the alarming frequency of medical errors in health care organizations (Leape, L. L., & Berwick, D. M. (2005). Five years after to err is human: What have we learned?. Journal of the American Medical Association, 293(19), 2384-2390). At the same time, other experts are concerned about the lack of job satisfaction and turnover among nurses (. Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press). Research and theory suggest that a work environment that facilitates patient-centered care should increase patient safety and nurse satisfaction. The present study began with a conceptual model that specifies how work environment variables should be related to both nurse and patient outcomes. Specifically, we proposed that health care work units with climates for patient-centered care should have nurses who are more satisfied with their jobs. Such units should also have higher levels of patient safety, with fewer medication errors. We examined perceptions of nurses from three acute care hospitals in the eastern United States. Nurses who perceived their work units as more patient centered were significantly more satisfied with their jobs than were those whose units were perceived as less patient centered. Those whose work units were more patient centered reported that medication errors occurred less frequently in their units and said that they felt more comfortable reporting errors and near-misses than those in less patient-centered units. Patients and quality leaders continue to call for delivery of patient-centered care. If climates that facilitate such care are also related to improved patient safety and nurse satisfaction, proactive, patient-centered management of the work environment could result in improved patient, employee, and organizational outcomes.
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Post-acute care disparities in total joint arthroplasty.
Lan, Roy H; Kamath, Atul F
2017-09-01
Understanding the socioeconomic factors that influence hospitalization and post-discharge metrics after joint replacement is important for identifying key areas of improvement in the delivery of orthopaedic care. An institutional administrative data set of 2869 patients from an academic arthroplasty referral center was analyzed to quantify the relationship between socioeconomic factors and post-acute rehabilitation care received, length of stay, and cost of care. The study used International Classification of Disease, ninth edition coding in order to identify cohorts of patients who received joint arthroplasty of the knee and hip between January 2007 and May 2015. The study found that females (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.74-2.46), minorities (OR, 2.11; 95% CI, 1.78-2.51), and non-private insurance holders (OR, 1.56; 95% CI, 1.26-1.94) were more likely to be assigned to institutional care after discharge. The study also found that minorities (OR, 1.45; 95% CI, 1.24-1.70) and non-private insurance holders (OR, 1.43; 95% CI, 1.16-1.77) are more likely to exhibit longer length of stay. Mean charges were higher for males when compared to females ($80,010 vs $74,855; P < .001), as well as total costs ($19,910 vs $18,613; P = .001). Socioeconomic factors such as gender, race, and insurance status should be further explored with respect to healthcare policies seeking to influence quality of care and health outcomes.
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Association between in-hospital acute hypertensive episodes and outcomes in older trauma patients.
Saliba, Lina; Stawicki, Stanislaw Peter; Thongrong, Cattleya; Bergese, Sergio Daniel; Papadimos, Thomas John; Gerlach, Anthony Thomas
2014-08-01
Although chronic hypertension is associated with long-term complications, few studies directly examine the effects of in-hospital acute hypertensive episodes in trauma patients. The aim was to determine whether there is an association between in-hospital acute hypertension and morbidity. We included trauma patients between 45 and 89 years who presented to a level I trauma center between January and September 2008. Patients were classified as either experiencing or not experiencing acute hypertensive episode(s) as defined by systolic blood pressure ≥180, or diastolic blood pressure ≥110 mmHg, or at least two readings of systolic blood pressure ≥160 or diastolic blood pressure ≥100 mmHg. The primary outcome was a composite endpoint of myocardial infarction, stroke, venous thromboembolism, new-onset atrial fibrillation, or acute kidney injury. At least one acute hypertensive episode occurred in 42.6% (69/162) of patients. A total of 10.5% patients developed the composite endpoint, 17.4% in the acute hypertensive episode group compared to 5.4% in the non-hypertensive group, p = 0.012. Patients in the acute hypertensive group were more likely to require an intensive care unit admission compared to the non-hypertensive group (33.3 versus 14.0%, p = 0.004). Of the 17 patients who developed an acute hypertensive episode and met the primary endpoint, 10 were on home antihypertensive medications. Of those, four were restarted on all medications initially, three on some, two were started on new medications, and one was not resumed on home medications. Development of acute hypertensive episode(s) in older trauma patients was associated with an increase in the composite endpoint. Prospective studies are needed.
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Meeting information needs of families of critical care patients.
Barbret, L C; Westphal, C G; Daly, G A
1997-01-01
Families of patients in critical care experience extreme anxiety and frustration while awaiting their loved ones' recovery or stabilization. To study the hypothesis that meeting families' informational needs can reduce their anxiety and help them cope with the initial crisis, a small task force at a Midwest acute care facility, using a CQI approach, studied possible solutions. Initial findings showed low satisfaction for families of critically ill patients with the present system of imparting information to them. After initiation of a storyboard to present information by the critical care team, families reported increased satisfaction and greater knowledge recall.
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Southard, Kelly; Jarrell, Ashley; Shattell, Mona M; McCoy, Thomas P; Bartlett, Robin; Judge, Christine A
2012-05-01
Specific efforts by hospital accreditation organizations encourage renovation of nursing stations, so nurses can better see, attend, and care for their patients. The purpose of this study was to examine the effect of nursing station design on the therapeutic milieu in an adult acute care psychiatric unit. A repeated cross-sectional, pretest-posttest design was used. Data were collected from a convenience sample of 81 patients and 25 nursing staff members who completed the Ward Atmosphere Scale. Pretest data were collected when the unit had an enclosed nursing station, and posttest data were collected after renovations to the unit created an open nursing station. No statistically significant differences were found in patient or staff perceptions of the therapeutic milieu. No increase in aggression toward staff was found, given patients' ease of access to the nursing station. More research is needed about the impact of unit design in acute care psychiatric settings. Copyright 2012, SLACK Incorporated.
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Integrated Transitions of Care for Patients With Rare Pulmonary Diseases.
Moreo, Kathleen; Lattimer, Cheri; Lett, James E; Heggen-Peay, Cherilyn L; Simone, Laura
Many continuing education (CE) resources are available to support case management professionals in developing competencies in transitions of care (TOC) that apply generally across disease areas. However, CE programs and tools are lacking for advanced TOC competencies in specific disease areas. This article describes 2 projects in which leading TOC, case management, and CE organizations collaborated to develop CE-accredited interdisciplinary pathways for promoting safe and effective TOC for patients with rare pulmonary diseases, including pulmonary arterial hypertension (PAH) and idiopathic pulmonary fibrosis (IPF). The interdisciplinary pathways apply to PAH and IPF case management practice and TOC across settings that include community-based primary care and specialty care, PAH or IPF centers of expertise, acute care and post-acute settings, long-term care, rehabilitation and skilled nursing facilities, and patients' homes. Both PAH and IPF are chronic, progressive respiratory diseases that are associated with severe morbidity and mortality, along with high health care costs. Because they are relatively rare diseases with nonspecific symptoms and many comorbidities, PAH and IPF are difficult to diagnose. Early diagnosis, referral to centers of expertise, and aggressive treatment initiation are essential for slowing disease progression and maintaining quality of life and function. Both the rarity and complexity of PAH and IPF pose unique challenges to ensuring effective and safe TOC. Expert consensus and evidence-based approaches to meeting these challenges, and thereby improving PAH and IPF patient outcomes, are presented in the 2 interdisciplinary TOC pathways that are described in this article. In coordinating care for patients with complex pulmonary diseases such as PAH and IPF, case managers across practice settings can play key roles in improving workflow processes and communication, transition planning, coordinating TOC with centers of expertise
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Sieffert, Michelle R; Fox, Justin P; Abbott, Lindsay E; Johnson, R Michael
2015-05-01
Obesity is associated with greater rates of surgical complications. To address these complications after outpatient plastic surgery, obese patients may seek care in the emergency department and potentially require admission to the hospital, which could result in greater health care charges. The purpose of this study was to determine the relationship of obesity, postdischarge hospital-based acute care, and hospital charges within 30 days of outpatient plastic surgery. From state ambulatory surgery center databases in four states, all discharges for adult patients who underwent liposuction, abdominoplasty, breast reduction, and blepharoplasty were identified. Patients were grouped by the presence or absence of obesity. Multivariable regression models were used to compare the frequency of hospital-based acute care, serious adverse events, and hospital charges within 30 days between groups while controlling for confounding variables. The final sample included 47,741 discharges, with 2052 of these discharges (4.3 percent) being obese. Obese patients more frequently had a hospital-based acute care encounter [7.3 percent versus 3.9 percent; adjusted OR, 1.35 (95% CI,1.13 to 1.61)] or serious adverse event [3.2 percent versus 0.9 percent; adjusted OR, 1.73 (95% CI, 1.30 to 2.29)] within 30 days of surgery. Obese patients had adjusted hospital charges that were, on average, $3917, $7412, and $7059 greater (p < 0.01) than those of nonobese patients after liposuction, abdominoplasty, and breast reduction, respectively. Obese patients who undergo common outpatient plastic surgery procedures incur substantially greater health care charges, in part attributable to more frequent adverse events and hospital-based health care within 30 days of surgery. Risk, II.
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[Acute otitis media in children: the strategy of patient care].
Davydova, A P
2010-01-01
Acute otitis media in children is an emergency ENT pathology encountered not only by otorhinolaryngologists but also in the practical work of general pediatrists, infectionists, allergologists, and representatives of other medical disciplines. Retrospective analysis demonstrates a progressively increasing ENT morbidity rate, especially that of non-purulent forms. Clinical and laboratory characteristics of 130 emergency patients examined in the present study using PCR-testing and bacteriological methods provided data on the activity of Streptococci, Mycoplasmas, Chlamidiae, viruses, and other causative agents of ENT diseases. A strategy for the combined treatment of patients with ENT pathology in an infectious department under control of an otorhinolaryngologist is proposed taking into consideration etiology and pathogenesis of the disease.
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A population-based study of severity in patients with acute on chronic pancreatitis.
Akshintala, Venkata S; Hutfless, Susan M; Yadav, Dhiraj; Khashab, Mouen A; Lennon, Anne Marie; Makary, Martin A; Hirose, Kenzo; Andersen, Dana K; Kalloo, Anthony N; Singh, Vikesh K
2013-11-01
The objectives of this study were to evaluate the severity of patients with acute pancreatitis (AP) on chronic pancreatitis (CP) and compare this to patients with AP without CP. The Maryland Health Services database was queried for all adult inpatient discharges with a primary diagnosis of AP from 1994 to 2010. Acute pancreatitis on CP and AP without CP were defined by the presence of the associated diagnosis code for CP. Severity was defined as organ failure, intensive care unit stay, or mortality. Acute pancreatitis on CP accounted for 13.7% of all AP discharges (9747/70,944). The proportion of AP-on-CP discharges doubled during the study period (8.8% to 17.6%; P < 0.0001). When compared with patients with AP without CP, AP-on-CP patients were younger, were more likely to be male and black, had higher rates of alcohol and drug abuse, and had less severe disease with lower rates of mortality, organ failure, need for mechanical ventilation, and intensive care unit stay. Among AP-on-CP patients, significant predictors of severity included advanced age, weight loss, and 2 or more comorbidities. Patients with AP on CP have less severe disease than do those with AP without CP. Weight loss, advanced age, and comorbidity increase the risk of severity in patients with AP on CP.
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Nursing challenges caring for bone marrow transplantation patients with graft versus host disease.
Neumann, Joyce
2017-12-01
Nursing care of blood and marrow transplantation (BMT) patients is complicated. Nursing considerations of BMT patients with GVHD require an additional set of skills and knowledge that include side effects, both expected and less common, assessment skills, treatment administration, both standard and novel, and acute or intensive care. Nursing care of BMT patients with skin GVHD will be determined by the degree of skin alteration with distinct decisions made about hygiene, both topical and systemic treatment, infection prevention, relief of discomfort, functional ability (ADL) and body image alteration. The nurse needs to have knowledge about assessment criteria for acute and chronic (NIH) assessment with special attention to skin (presence of rash, texture, mobility), joint mobility, mouth care, dressings, and skin care products. Nursing consideration of gastrointestinal GVHD includes importance of accurate intake and output, obtaining culture, fluid and electrolyte imbalance, nutrition, treatment, and skin care. Complication of GVHD treatment, namely effects of steroids require experts from many disciplines to provide comprehensive care. Caring and advocating for GVHD patients may include preparing for outcomes that are undesirable and impact the patient's quality of life and mortality. BMT survivorship programs are a major source of patient education about chronic GVHD for patients after treatment. Caring for BMT patients, especially those experiencing GVHD, takes a knowledgeable, committed, and caring team of healthcare providers. Workshops like this are vital in providing information and networking to keep providers around the region and globe engaged in this critical work. Copyright © 2017. Published by Elsevier B.V.
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Neuroanatomical Predictors of Awakening in Acutely Comatose Patients
Kowalski, Robert G.; Buitrago, Manuel M.; Duckworth, Josh; Chonka, Zachary D.; Puttgen, H. Adrian; Stevens, Robert D.; Geocadin, Romergryko G.
2016-01-01
Objective Lateral brain displacement has been associated with loss of consciousness and poor outcome in a range of acute neurologic disorders. We studied the association between lateral brain displacement and awakening from acute coma. Methods This prospective observational study included all new onset coma patients admitted to the Neurosciences Critical Care Unit (NCCU) over 12 consecutive months. Head computed tomography (CT) scans were analyzed independently at coma onset, after awakening, and at follow-up. Primary outcome measure was awakening, defined as the ability to follow commands before hospital discharge. Secondary outcome measures were discharge Glasgow Coma Scale (GCS), modified Rankin Scale, Glasgow Outcome Scale, and hospital and NCCU lengths of stay. Results Of the 85 patients studied, the mean age was 58 ± 16 years, 51% were female, and 78% had cerebrovascular etiology of coma. Fifty-one percent of patients had midline shift on head CT at coma onset and 43 (51%) patients awakened. In a multivariate analysis, independent predictors of awakening were younger age (odds ratio [OR] = 1.039, 95% confidence interval [CI] = 1.002–1.079, p = 0.040), higher GCS score at coma onset (OR = 1.455, 95% CI = 1.157–1.831, p = 0.001), nontraumatic coma etiology (OR = 4.464, 95% CI = 1.011–19.608, p = 0.048), lesser pineal shift on follow-up CT (OR = 1.316, 95% CI = 1.073–1.615, p = 0.009), and reduction or no increase in pineal shift on follow-up CT (OR = 11.628, 95% CI = 2.207–62.500, p = 0.004). Interpretation Reversal and/or limitation of lateral brain displacement are associated with acute awakening in comatose patients. These findings suggest objective parameters to guide prognosis and treatment in patients with acute onset of coma. PMID:25628166
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Aabenhus, Rune; Thorsen, Hanne; Siersma, Volkert; Brodersen, John
2013-01-01
Patient-reported outcomes are seldom validated measures in clinical trials of acute respiratory tract infections (ARTIs) in primary care. We developed and validated a patient-reported outcome sum-scaling measure to assess the severity and functional impacts of ARTIs. Qualitative interviews and field testing among adults with an ARTI were conducted to ascertain a high degree of face and content validity of the questionnaire. Subsequently, a draft version of the Acute Respiratory Tract Infection Questionnaire (ARTIQ) was statistically validated by using the partial credit Rasch model to test dimensionality, objectivity, and reliability of items. Test of known groups' validity was conducted by comparing participants with and without an ARTI. The final version of the ARTIQ consisted of 38 items covering five dimensions (Physical-upper, Physical-lower, Psychological, Sleep, and Medicine) and five single items. All final dimensions were confirmed to fit the Rasch model, thus enabling sum-scaling of responses. The ARTIQ scores in participants with an ARTI were significantly higher than in those without ARTI (known groups' validity). A self-administered, multidimensional, sum-scaling questionnaire with high face and content validity and adequate psychometric properties for assessing severity and functional impacts from ARTIs in adults is available to clinical trials and audits in primary care. Copyright © 2013, International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc.
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Moumneh, Thomas; Richard-Jourjon, Vanessa; Friou, Emilie; Prunier, Fabrice; Soulie-Chavignon, Caroline; Choukroun, Jacques; Mazet-Guilaumé, Betty; Riou, Jérémie; Penaloza, Andréa; Roy, Pierre-Marie
2018-03-02
In patients consulting in the Emergency Department for chest pain, a HEART score ≤ 3 has been shown to rule out an acute coronary syndrome (ACS) with a low risk of major adverse cardiac event (MACE) occurrence. A negative CARE rule (≤ 1) that stands for the first four elements of the HEART score may have similar rule-out reliability without troponin assay requirement. We aim to prospectively assess the performance of the CARE rule and of the HEART score to predict MACE in a chest pain population. Prospective two-center non-interventional study. Patients admitted to the ED for non-traumatic chest pain were included, and followed-up at 6 weeks. The main study endpoint was the 6-week rate of MACE (myocardial infarction, coronary angioplasty, coronary bypass, and sudden unexplained death). 641 patients were included, of whom 9.5% presented a MACE at 6 weeks. The CARE rule was negative for 31.2% of patients, and none presented a MACE during follow-up [0, 95% confidence interval: (0.0-1.9)]. The HEART score was ≤ 3 for 63.0% of patients, and none presented a MACE during follow-up [0% (0.0-0.9)]. With an incidence below 2% in the negative group, the CARE rule seemed able to safely rule out a MACE without any biological test for one-third of patients with chest pain and the HEART score for another third with a single troponin assay.
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Fundamentals of acute burn care and physical therapy management.
Wright, P C
1984-08-01
The purpose of this paper is to discuss general treatment guidelines for treating patients with acute burns and to review pathophysiology of acute burn injuries. I will discuss skin composition briefly, give a review of acute burn pathophysiology and medical treatment, outline the psychological factors physical therapists should consider when working with these patients, and discuss physical therapy for the patient with acute burns. Physical therapy for patients with burns has become a specialty as knowledge of burn injuries increases. I have attempted to review physical therapy burn knowledge for inexperienced clinicians beginning to treat patients with acute burns.
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Treatment strategies in the acute therapy of migraine: stratified care and early intervention.
D'Amico, D; Moschiano, F; Usai, S; Bussone, G
2006-05-01
Various treatment strategies have been proposed to help clinicians provide the most effective acute treatment for migraine patients. Stratified care is based on the concept that the most appropriate initial treatment can be prescribed after evaluation of each patient's headache characteristics. The results of a large multicentre trial showed that when patients were stratified according to disability grade, clinical outcomes were significantly better than with step-care approaches. Prospective studies have shown that treating migraines with triptans when pain is mild (early intervention) considerably increases success rates for endpoints (pain-free at 2 h, sustained pain-free state) for which triptans had relatively poor efficacy in pivotal trials, and which contribute most to patient satisfaction. Stratified care and early treatment are also cost-effective. However these strategies are not suitable for all patients. Stratified care may be rendered difficult by medication contraindications and changes in attack characteristics over time. Early triptan intervention carries a risk of medication overuse and might not be indicated in patients with lack of pain progression. Successful implementation of both strategies requires that physicians are well informed, and that they elicit an exhaustive headache history from each patient.
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Casemix classification payment for sub-acute and non-acute inpatient care, Thailand.
Khiaocharoen, Orathai; Pannarunothai, Supasit; Zungsontiporn, Chairoj; Riewpaiboon, Wachara
2010-07-01
There is a need to develop other casemix classifications, apart from DRG for sub-acute and non-acute inpatient care payment mechanism in Thailand. To develop a casemix classification for sub-acute and non-acute inpatient service. The study began with developing a classification system, analyzing cost, assigning payment weights, and ended with testing the validity of this new casemix system. Coefficient of variation, reduction in variance, linear regression, and split-half cross-validation were employed. The casemix for sub-acute and non-acute inpatient services contained 98 groups. Two percent of them had a coefficient of variation of the cost of higher than 1.5. The reduction in variance of cost after the classification was 32%. Two classification variables (physical function and the rehabilitation impairment categories) were key determinants of the cost (adjusted R2 = 0.749, p = .001). Validity results of split-half cross-validation of sub-acute and non-acute inpatient service were high. The present study indicated that the casemix for sub-acute and non-acute inpatient services closely predicted the hospital resource use and should be further developed for payment of the inpatients sub-acute and non-acute phase.
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Lin, Shin-Yi; Tang, Sung-Chun; Tsai, Li-Kai; Yeh, Shin-Joe; Shen, Li-Jiuan; Wu, Fe-Lin Lin; Jeng, Jiann-Shing
2015-11-01
Mannitol, an osmotic diuretic, is commonly used to treat patients with acute brain edema, but its use also increases the risk of developing acute kidney injury (AKI). In this study, we investigated the incidence and risk factors of mannitol-related AKI in acute stroke patients.A total of 432 patients (ischemic stroke 62.3%) >20 years of age who were admitted to the neurocritical care center in a tertiary hospital and received mannitol treatment were enrolled in this study. Clinical parameters including the scores of National Institutes of Health Stroke Scale (NIHSS) at admission, vascular risk factors, laboratory data, and concurrent nephrotoxic medications were registered. Acute kidney injury was defined as an absolute elevation in the serum creatinine (Scr) level of ≥0.3 mg/dL from the baseline or a ≥50% increase in Scr.The incidence of mannitol-related AKI was 6.5% (95% confidence interval, 4.5%-9.3%) in acute stroke patients, 6.3% in patients with ischemic stroke, and 6.7% in patients with intracerebral hemorrhage. Multivariate analysis revealed that diabetes, lower estimated glomerular filtration rate at baseline, higher initial NIHSS score, and concurrent use of diuretics increased the risk of mannitol-related AKI. When present, the combination of these elements displayed an area under the receiver operating characteristic curve of 0.839 (95% confidence interval, 0.770-0.909). In conclusion, mannitol-related AKI is not uncommon in the treatment of acute stroke patients, especially in those with vulnerable risk factors.
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Use of a guideline based questionnaire to audit hospital care of acute asthma.
Bell, D; Layton, A J; Gabbay, J
1991-01-01
OBJECTIVES--To design an audit questionnaire and pilot its use by an audit assistant to monitor inpatient management of acute asthma and to compare the care given by chest physicians and general physicians. DESIGN--Retrospective review by a chest physician and audit assistant of a random sample of 76 case records of patients by a criterion based questionnaire developed from hospital guidelines on management of acute asthma. SETTING--One district general hospital. PATIENTS--76 adult patients with acute asthma: 38 admitted with a relevant primary diagnosis between April 1988 and March 1989 and a further 38 admitted through the accident and emergency department between April 1989 and March 1990. MAIN OUTCOME MEASURES--Conformity with recognised standards for assessment and management of acute asthma before and after the audit and by chest physicians and general physicians. RESULTS--Age and sex did not differ significantly between the different groups of patients. Overall, deviations from the guidelines occurred in recording measures of severity of asthma, emergency treatment with beta 2 agonists (60/76, 79%) and steroids (43/76, 57%), and prescription of antibiotics in accordance with at least one criterion of the guidelines (29/45, 64%). Chest physicians were more rigorous than general physicians in recording severity measures, especially serum potassium concentration (chi 2 = 3.6, df = 1, p = 0.06), emergency steroid treatment within the correct period (chi 2 = 3.9, df = 1, p = 0.05), and referral for follow up at an outpatient chest clinic. Recording of arterial blood gas tensions improved significantly between the 1988-9 and 1989-90 samples (chi 2 = 7.0, df = 1, p = 0.08). CONCLUSIONS--The questionnaire proved easy to use for both doctor and audit assistant. The audit improved few standards of care and emphasises the need for further reinforcement and feedback. PMID:2070112
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Hummel, Jana; Weisbrod, Cecilia; Boesch, Leila; Himpler, Katharina; Hauer, Klaus; Hautzinger, Martin; Gaebel, Andrea; Zieschang, Tania; Fickelscherer, Andrea; Diener, Slawomira; Dutzi, Ilona; Krumm, Bertram; Oster, Peter; Kopf, Daniel
2017-04-01
Comorbid depression is highly prevalent in geriatric patients and associated with functional loss, frequent hospital re-admissions, and a higher mortality rate. Cognitive behavioral psychotherapy (CBT) has shown to be effective in older depressive patients living in the community. To date, CBT has not been applied to older patients with acute physical illness and comorbid depression. To evaluate the effectiveness of CBT in depressed geriatric patients, hospitalized for acute somatic illness. Randomized controlled trial with waiting list control group. Postdischarge intervention in a geriatric day clinic; follow-up evaluations at the patients' homes. A total of 155 randomized patients, hospitalized for acute somatic illness, aged 82 ± 6 years and suffering from depression [Hospital Anxiety and Depression Scale (HADS) scores >7]. Exclusion criteria were dementia, delirium, and terminal state of medical illness. Fifteen, weekly group sessions based on a CBT manual. Commencement of psychotherapy immediately after discharge in the intervention group and a 4-month waiting list interval with usual care in the control group. HADS depression total score after 4 months. Secondary endpoints were functional, cognitive, psychosocial and physical status, resource utilization, caregiver burden, and amount of contact with physician. The intervention group improved significantly in depression scores (HADS baseline 18.8; after 4 months 11.4), whereas the control group deteriorated (HADS baseline 18.1; after 4 months 21.6). Significant improvement in the intervention group, but not in the control group, was observed for most secondary outcome parameters such as the Barthel and Karnofsky indexes. Intervention effects were less pronounced in patients with cognitive impairment or acute fractures. CBT is feasible and highly effective in geriatric patients. The benefits extend beyond effective recovery and include improvement in physical and functional parameters. Early diagnosis
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The experience of acute leukaemia in adult patients: a qualitative thematic synthesis.
Papadopoulou, Constantina; Johnston, Bridget; Themessl-Huber, Markus
2013-10-01
The aim of this review was to systematically identify and synthesise all qualitative evidence on how adult patients diagnosed with acute leukaemia experience living with their illness. A systematic search strategy was developed comprising of two search strings: i) acute leukaemia and ii) qualitative methodology. The search strategy was run in seven electronic databases (Medline, CINAHL, PsychINFO, EMBASE, BNI & Archive, SSCI and ASSIA). Nine qualitative studies in adult patients with acute leukaemia, published in peer reviewed journals between 01/1990 and 01/2013 were included in the final sample. The qualitative thematic synthesis resulted in the development of a conceptual model describing a person's path to build a renewed self. Following the initial blow of diagnosis with the range of initial reactions, patients with acute leukaemia are living in a contracting world; they have to deal with the life in hospital, the several losses and the impact of their illness on their emotions and interpersonal relationships. Several factors take up a buffering role at that stage: coping, support, information and hope. Finally, patients accommodate acute leukaemia in their lives through re-evaluating personal values and assigning new meaning to their experience. Results from this thematic synthesis are indicative of the impact of acute leukaemia on patients' lives and the processes they use to make sense and accommodate the illness in their life. Increasing our understanding of these processes is warranted to improve patient care. Copyright © 2013. Published by Elsevier Ltd.
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Hui, David; Elsayem, Ahmed; Palla, Shana; De La Cruz, Maxine; Li, Zhijun; Yennurajalingam, Sriram
2010-01-01
Abstract Background Acute palliative care units (APCUs) are new programs aimed at integrating palliative and oncology care. Few outcome studies from APCUs are available. Objectives We examined the frequency, survival, and predictors associated with home discharge and death in our APCU. Methods All patients discharged from the APCU between September 1, 2003 and August 31, 2008 were included. Demographics, cancer diagnosis, discharge outcomes, and overall survival from discharge were retrieved retrospectively. Results The 2568 patients admitted to APCU had the following characteristics: median age, 59 years (range, 18–101); male, 51%; median hospital stay, 11 days; median APCU stay, 7 days; and median survival 21 days (95% confidence interval [CI] 19–23 days). Five hundred ninety-two (20%), 89 (3%), and 1259 (43%) patients were discharged to home, health care facilities, and hospice, respectively, with a median survival of 60, 29, and 14 days, respectively (p < 0.001). Nine hundred fifty-eight (33%) patients died during admission (median stay, 11 days). Compared to hospice transfers, home discharge (hazard ratio = 0.35, 95% CI 0.30–0.41, p < 0.001) was associated with longer survival in multivariate analysis, with a 6-month survival of 22%. Multivariate logistic regression revealed that male gender, specific cancer primaries, and admissions from oncology units were associated with death in the APCU, while younger age and direct admissions to the APCU were associated with home discharge. Conclusions Our APCU serves patients with advanced cancer with diverse clinical characteristics and survival, and discharged home a significant proportion with survival greater than 6 months. Results from this simultaneous care program suggest a pattern of care different from that of traditional hospice and palliative care services. PMID:19824813
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A volunteer companion-observer intervention reduces falls on an acute aged care ward.
Donoghue, Judith; Graham, Jenny; Mitten-Lewis, Suzanne; Murphy, Moira; Gibbs, Julie
2005-01-01
Falls are the most frequently reported adverse event in hospitalised patients and carry a risk of great harm for the frail elderly. This intervention aimed to prevent high-risk in-patients on an acute aged care ward from falling. Patients assessed at high falls risk were accommodated in a room staffed by volunteer companion-observers. The volunteers engaged them in conversation, played cards, opened meals and used the call bell to summon nurses if patients attempted to move from the bed or chair without assistance. Because of occupational health and safety considerations, the volunteers did not assist patients to ambulate. The falls rate in the acute aged care ward decreased by 44 percent (p < 0.000). No patients fell in the observation room when volunteers were present. Relatives of participating in-patients expressed appreciation of the volunteer role, in terms of increased safety and also companionship. Volunteers exercised initiative in determining their pattern of work and developing resources to support their role. Because volunteers are not present around the clock, other strategies are needed to prevent wandering, frequently confused older in-patients from falling during the night. In a context where frail elderly patients need constant supervision, using volunteers is a reasonable strategy. This intervention used an inexpensive, human resources-based approach to significantly reduce the incidence of falls in the population at highest risk of falling. The additional benefits to patients in terms of cognitive improvement bear further investigation.
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Bakerly, Nawar Diar; Davies, C; Dyer, M; Dhillon, P
2009-01-01
Home treatment models for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) proved to be a safe alternative to hospitalization. These models have the potential to free up resources; however, in the United Kingdom, it remains unclear to whether they provide cost savings compared with hospital treatment. Over a 12-month period from August 2003, 130 patients were selected for the integrated care group (total admissions with AECOPD = 546). These patients were compared with 95 retrospective controls in the hospital treatment group. Controls were selected from admissions during the previous 12 months (total of 662 admissions) to match the integrated care group in age, sex, and postal code. Resource use data were collected for both groups and compared using National Health Service (NHS) perspective for cost minimization analysis. In the integrated care group (130 patients), 107 (82%) patients received home support with average length of stay 3.3 (SD 3.9) days compared with 10.4 (SD 7.7) in the hospital group (95 patients). Average number of visits per patients in the integrated care group was 3.08 (SD = 0.95; 95% CI = 2.9-3.2). Cost per patient in the integrated care group was pound1653 (95% CI, pound1521-1802) compared with pound2256 (95% CI, pound2126- 2407) in the hospital group. The integrated care group resulted in cost saving of approximately pound600 (P < 0.001) per patient. This integrated care model for the management of patients with AECOPD offered cost savings of pound600 per patient over the conventional hospital treatment model using the new NHS tariff from an acute trust provider perspective.
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Dilwali, Prashant K
2013-01-01
The responsibility of hospitals is changing. Those activities that were once confined within the walls of the medical facility have largely shifted outside them, yet the requirements for hospitals have only grown in scope. With the passage of the Patient Protection and Affordable Care Act (ACA) and the development of accountable care organizations, financial incentives are focused on care coordination, and a hospital's responsibility now includes postdischarge outcomes. As a result, hospitals need to adjust their business model to accommodate their increased need to impact post-acute care settings. A home care service line can fulfill this role for hospitals, serving as an effective conduit to the postdischarge realm-serving as both a potential profit center and a risk mitigation offering. An alliance between home care agencies and hospitals can help improve clinical outcomes, provide the necessary care for communities, and establish a potentially profitable product line.
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Acute Q fever in febrile patients in northwestern of Iran.
Esmaeili, Saber; Golzar, Farhad; Ayubi, Erfan; Naghili, Behrooz; Mostafavi, Ehsan
2017-04-01
Q fever is an endemic disease in different parts of Iran. This study aimed to investigate the prevalence of acute Q fever disease among at-risk individuals in northwestern Iran. An etiological study was carried out in 2013 in Tabriz County. A total of 116 individuals who were in contact with livestock and had a nonspecific febrile illness were enrolled in the study. IgG phase II antibodies against Coxiella burnetii were detected using ELISA. The prevalence of acute Q fever was 13.8% (95% confidence interval [CI]: 8.0, 21.0%). Headache (87.5%) and fatigue and weakness (81.3%) were the dominant clinical characteristics among patients whit acute Q fever. Acute lower respiratory tract infection and chills were poorly associated with acute Q fever. Furthermore, 32% (95% CI: 24, 41%) of participants had a history of previous exposure to Q fever agent (past infection). Consumption of unpasteurized dairy products was a weak risk factor for previous exposure to C. burnetii. This study identified patients with acute Q fever in northwestern of Iran. The evidence from this study and previous studies conducted in different regions of Iran support this fact that Q fever is one of the important endemic zoonotic diseases in Iran and needs due attention by clinical physicians and health care system.
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Management, characteristics and outcomes of patients with acute coronary syndrome in Sri Lanka.
Galappatthy, Priyadarshani; Bataduwaarachchi, Vipula R; Ranasinghe, Priyanga; Galappatthy, Gamini K S; Wijayabandara, Maheshi; Warapitiya, Dinuka S; Sivapathasundaram, Mythily; Wickramarathna, Thilini; Senarath, Upul; Sridharan, Sathasivam; Wijeyaratne, Chandrika N; Ekanayaka, Ruvan
2018-02-16
Ischaemic heart disease is the leading cause of in-hospital mortality in Sri Lanka. Acute Coronary Syndrome Sri Lanka Audit Project (ACSSLAP) is the first national clinical-audit project that evaluated patient characteristics, clinical outcomes and care provided by state-sector hospitals. ACSSLAP prospectively evaluated acute care, in-hospital care and discharge plans provided by all state-sector hospitals managing patients with ACS. Data were collected from 30 consecutive patients from each hospital during 2-4 weeks window. Local and international recommendations were used as audit standards. Data from 87/98 (88.7%) hospitals recruited 2177 patients, with 2116 confirmed as having ACS. Mean age was 61.4±11.8 years (range 20-95) and 58.7% (n=1242) were males. There were 813 (38.4%) patients with unstable angina, 695 (32.8%) with non-ST-elevation myocardial infarction (NSTEMI) and 608 (28.7%) with ST-elevation myocardial infarction (STEMI). Both STEMI (69.9%) and NSTEMI (61.4%) were more in males (P<0.001). Aspirin, clopidogrel and statins were given to over 90% in acute setting and on discharge. In STEMI, 407 (66.9%) were reperfused; 384 (63.2%) were given fibrinolytics and only 23 (3.8%) underwent primary percutaneous coronary intervention (PCI). Only 42.3 % had thrombolysis in <30 min and 62.5% had PCI in <90 min. On discharge, beta-blockers and ACE inhibitors/angiotensin II receptor blockers were given to only 50.7% and 69.2%, respectively and only 17.6% had coronary interventions planned. In patients with ACS, aspirin, clopidogrel and statin use met audit standards in acute setting and on discharge. Vast majority of patients with STEMI underwent fibrinolyisis than PCI, due to limited resources. Primary PCI, planned coronary interventions and timely thrombolysis need improvement in Sri Lanka. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless
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Leland, Natalie; Gozalo, Pedro; Christian, TJ; Bynum, Julie; Mor, Vince; Wetle, Terrie Fox; Teno, Joan
2015-01-01
Background Post-acute care (PAC) rehabilitation aims to maximize independence and facilitate a safe community transition. Yet little is known about PAC patients’ success in staying home post-discharge or differences on this outcome across PAC providers. Objectives Examine the percentage of PAC patients who remain in the community at least 30 days after discharge (i.e., successful community discharge) following hip fracture rehabilitation and describe differences among PAC facilities based on this outcome. Research Design Retrospective observational study. Subjects Community-dwelling, Medicare fee-for-service beneficiaries 75 years of age and older who experienced their first hip fracture between 1999–2007 (n=880,779). PAC facilities admitting hip fracture patients in 2006. Measures Successful community discharge, sites of readmission after PAC discharge. Results Between 1999 and 2007, 57% of patients achieved successful community discharge. Black were less likely (adjusted odds ratios=0.84, 95% confidence interval 0.82–0.86) than similar whites to achieve successful community discharge. Among all who re-entered the community (n=581,095), 14% remained in the community fewer than 30 days. Acute hospitals (67.5%) and institutional PAC (16.8%) were the most common sites of re-entry. The median proportion of successful community discharge among facilities was 49% (IQR: 33%–66%). Lowest-quartile facilities admitted older (85.9 vs. 84.1 years of age), sicker patients (e.g., higher rates of hospital complications 6.0% vs. 4.6%), but admitted fewer annually (7.1 vs. 19.3), compared to the highest quartile. Conclusions Re-entry into the healthcare system after PAC community discharge is common. Due to the distinct care needs of the PAC population there is a need for a quality measure that complements the current 30-day hospital readmission outcome and captures the objectives of PAC rehabilitation. PMID:26340664
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Post–Acute Care Use and Hospital Readmission after Sepsis
Jones, Tiffanie K.; Fuchs, Barry D.; Small, Dylan S.; Halpern, Scott D.; Hanish, Asaf; Umscheid, Craig A.; Baillie, Charles A.; Kerlin, Meeta Prasad; Gaieski, David F.
2015-01-01
Rationale: The epidemiology of post–acute care use and hospital readmission after sepsis remains largely unknown. Objectives: To examine the rate of post–acute care use and hospital readmission after sepsis and to examine risk factors and outcomes for hospital readmissions after sepsis. Methods: In an observational cohort study conducted in an academic health care system (2010–2012), we compared post–acute care use at discharge and hospital readmission after 3,620 sepsis hospitalizations with 108,958 nonsepsis hospitalizations. We used three validated, claims-based approaches to identify sepsis and severe sepsis. Measurements and Main Results: Post–acute care use at discharge was more likely after sepsis, driven by skilled care facility placement (35.4% after sepsis vs. 15.8%; P < 0.001), with the highest rate observed after severe sepsis. Readmission rates at 7, 30, and 90 days were higher postsepsis (P < 0.001). Compared with nonsepsis hospitalizations (15.6% readmitted within 30 d), the increased readmission risk was present regardless of sepsis severity (27.3% after sepsis and 26.0–26.2% after severe sepsis). After controlling for presepsis characteristics, the readmission risk was found to be 1.51 times greater (95% CI, 1.38–1.66) than nonsepsis hospitalizations. Readmissions after sepsis were more likely to result in death or transition to hospice care (6.1% vs. 13.3% after sepsis; P < 0.001). Independent risk factors associated with 30-day readmissions after sepsis hospitalizations included age, malignancy diagnosis, hospitalizations in the year prior to the index hospitalization, nonelective index admission type, one or more procedures during the index hospitalization, and low hemoglobin and high red cell distribution width at discharge. Conclusions: Post–acute care use and hospital readmissions were common after sepsis. The increased readmission risk after sepsis was observed regardless of sepsis severity and was associated with
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[Review of the knowledge on acute kidney failure in the critical patient].
Romero García, M; Delgado Hito, P; de la Cueva Ariza, L
2013-01-01
Acute renal failure affects from 1% to 25% of patients admitted to intensive care units. These figures vary depending on the population studied and criteria. The complications of acute renal failure (fluid overload, metabolic acidosis, hyperkalemia, bleeding) are treated. However, mortality remains high despite the technological advances of recent years because acute renal failure is usually associated with sepsis, respiratory failure, serious injury, surgical complications or consumption coagulopathy. Mortality ranges from 30% to 90%. Although there is no universally accepted definition, the RIFLE classification gives us an operational tool to define the degree of acute renal failure and to standardize the initiation of renal replacement techniques as well as to evaluate the results. Therefore, nurses working within the intensive care unit must be familiar with this disease, with its treatment (drug or alternative) and with the prevention of possible complications. Equally, they must be capable of detecting the manifestations of dependency each one of the basic needs and to be able to identify the collaboration problems in order to achieve an individualized care plan. Copyright © 2012 Elsevier España, S.L. y SEEIUC. All rights reserved.
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Dovjak, Peter; Föger-Samwald, Ursula; Konrad, Maarit; Bichler, Bernhard; Pietschmann, Peter
2015-10-01
With respect to the pathogenesis of osteoporosis, primary and secondary forms of the disease can be distinguished. It has been recognized that the incidence of primary and secondary osteoporosis differs in women and men. The aim of the present study was to assess the incidence and gender distribution of factors contributing to osteoporosis in older hip fracture patients. In this cross-sectional study 404 patients with hip fractures and controls referred to an acute geriatric care department over a period of 15 months were included. The medical history was recorded and blood samples were analyzed for routine laboratory parameters. A total of 249 patients with hip fractures and 155 matched controls were studied. The Tinetti test and the Barthel index were found to show highly significant differences in both groups mainly because of the postoperative state of patients with fractures. Vitamin D deficiency was found in 94.1% of male fracture patients and 94.6% of female fracture patients. On average 2.4 secondary contributors of osteoporosis were present in male fracture patients versus 2.9 in male controls and 2.3 in female fracture patients versus 2.3 in female controls. For most parameters no significant gender differences of possible secondary contributors to osteoporosis were found. Secondary osteoporosis was diagnosed in all male fracture patients and in 56.2% of all female fracture patients. Based on the findings of this study it is recommended that hip fracture patients should be assessed for secondary contributors of osteoporosis. Although the overall distribution of secondary contributors was similar in women and men, the prevalence of secondary osteoporosis was higher in men.
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2013-01-01
Background Improving palliative care management in acute hospital settings has been identified as a priority internationally. The aim of this study was to establish the proportion of inpatients within one acute hospital in New Zealand who meet prognostic criteria for palliative care need and explore key aspects of their management. Methods A prospective survey of adult hospital inpatients (n = 501) was undertaken. Case notes were examined for evidence that the patient might be in their last year of life according to Gold Standards Framework (GSF) prognostic indicator criteria. For patients who met GSF criteria, clinical and socio-demographic information were recorded. Results Ninety-nine inpatients met GSF criteria, representing 19.8% of the total census population. The patients’ average age was 70 years; 47% had a primary diagnosis of cancer. Two thirds had died within 6 months of their admission. Seventy-eight of the 99 cases demonstrated evidence that a palliative approach to care had been adopted; however documentation of discussion about goals of care was very limited and only one patient had evidence of an advance care plan. Conclusion One fifth of hospital inpatients met criteria for palliative care need, the majority of whom were aged >70 years. Whilst over three quarters were concluded to be receiving care in line with a palliative care approach, very little documented evidence of discussion with patients and families regarding end of life issues was evident. Future research needs to explore how best to support ‘generalist’ palliative care providers in initiating, and appropriately recording, such discussions. PMID:23537092
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Ben-Josef, Gal; Ott, Lesli S; Spivack, Steven B; Wang, Changqin; Ross, Joseph S; Shah, Sachin J; Curtis, Jeptha P; Kim, Nancy; Krumholz, Harlan M; Bernheim, Susannah M
2014-11-01
It is unknown whether hospitals with percutaneous coronary intervention (PCI) capability provide costlier care than hospitals without PCI capability for patients with acute myocardial infarction. The growing number of PCI hospitals and higher rate of PCI use may result in higher costs for episodes-of-care initiated at PCI hospitals. However, higher rates of transfers and postacute care procedures may result in higher costs for episodes-of-care initiated at non-PCI hospitals. We identified all 2008 acute myocardial infarction admissions among Medicare fee-for-service beneficiaries by principal discharge diagnosis and classified hospitals as PCI- or non-PCI-capable on the basis of hospitals' 2007 PCI performance. We added all payments from admission through 30 days postadmission, including payments to hospitals other than the admitting hospital. We calculated and compared risk-standardized payment for PCI and non-PCI hospitals using 2-level hierarchical generalized linear models, adjusting for patient demographics and clinical characteristics. PCI hospitals had a higher mean 30-day risk-standardized payment than non-PCI hospitals (PCI, $20 340; non-PCI, $19 713; P<0.001). Patients presenting to PCI hospitals had higher PCI rates (39.2% versus 13.2%; P<0.001) and higher coronary artery bypass graft rates (9.5% versus 4.4%; P<0.001) during index admissions, lower transfer rates (2.2% versus 25.4%; P<0.001), and lower revascularization rates within 30 days (0.15% versus 0.27%; P<0.0001) than those presenting to non-PCI hospitals. Despite higher PCI and coronary artery bypass graft rates for Medicare patients initially presenting to PCI hospitals, PCI hospitals were only $627 costlier than non-PCI hospitals for the treatment of patients with acute myocardial infarction in 2008. © 2014 American Heart Association, Inc.
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Routines and rituals: a grounded theory of the pain management of drug users in acute care settings.
McCreaddie, May; Lyons, Imogen; Watt, Debbie; Ewing, Elspeth; Croft, Jeanette; Smith, Marion; Tocher, Jennifer
2010-10-01
This study reviewed the perceptions and strategies of drug users and nurses with regard to pain management in acute care settings. Drug users present unique challenges in acute care settings with pain management noted to be at best suboptimal, at worst non-existent. Little is known about why and specifically how therapeutic effectiveness is compromised. Qualitative: constructivist grounded theory. A constructivist grounded theory approach incorporating a constant comparative method of data collection and analysis was applied. The data corpus comprised interviews with drug users (n = 11) and five focus groups (n = 22) of nurses and recovering drug users. Moral relativism as the core category both represents the phenomenon and explains the basic social process. Nurses and drug users struggle with moral relativism when addressing the issue of pain management in the acute care setting. Drug users lay claim to expectations of compassionate care and moralise via narration. Paradoxically, nurses report that the caring ideal and mutuality of caring are diminished. Drug users' individual sensitivities, anxieties and felt stigma in conjunction with opioid-induced hyperalgesia complicate the processes. Nurses' and hospitals' organisational routines challenge drug user rituals and vice versa leading both protagonists to become disaffected. Consequently, key clinical issues such as preventing withdrawal and managing pain are left unaddressed and therapeutic effectiveness is compromised. This study provides a robust account of nurses' and drug users' struggle with pain management in the acute care setting. Quick technological fixes such as urine screens, checklists or the transient effects of (cognitive-based) education (or training) are not the answer. This study highlights the need for nurses to engage meaningfully with this perceptibly 'difficult' group of patients. The key aspects likely to contribute to problematic interactions with this patient cohort are outlined so that
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Parsons Leigh, Jeanna; Niven, Daniel J; Boyd, Jamie M; Stelfox, Henry T
2017-01-19
Healthcare systems have difficulty incorporating scientific evidence into clinical practice, especially when science suggests that existing clinical practices are of low-value (e.g. ineffective or harmful to patients). While a number of lists outlining low-value practices in acute care medicine currently exist, less is known about how best to initiate and sustain the removal of low-value clinical practices (i.e. de-adoption). This study will develop a comprehensive list of barriers and facilitators to the de-adoption of low-value clinical practices in acute care facilities to inform the development of a framework to guide the de-adoption process. The proposed project is a multi-stage mixed methods study to develop a framework to guide the de-adoption of low-value clinical practices in acute care medicine that will be tested in a representative sample of acute care settings in Alberta, Canada. Specifically, we will: 1) conduct a systematic review of the de-adoption literature to identify published barriers and facilitators to the de-adoption of low-value clinical practices in acute care medicine and any associated interventions proposed (Phase one); 2) conduct focus groups with acute care stakeholders to identify important themes not published in the literature and obtain a comprehensive appreciation of stakeholder perspectives (Phase two); 3) extend the generalizability of focus group findings by conducting individual stakeholder surveys with a representative sample of acute care providers throughout the province to determine which barriers and facilitators identified in Phases one and two are most relevant in their clinical setting (Phase three). Identified barriers and facilitators will be catalogued and integrated with targeted interventions in a framework to guide the process of de-adoption in each of four targeted areas of acute care medicine (Emergency Medicine, Cardiovascular Health and Stroke, Surgery and Critical Care Medicine). Analyses will be
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Use of alcohol hand sanitizer as an infection control strategy in an acute care facility.
Hilburn, Jessica; Hammond, Brian S; Fendler, Eleanor J; Groziak, Patricia A
2003-04-01
Nosocomial infections are a major problem in health care facilities, resulting in extended durations of care, substantial morbidity and mortality, and excess costs. Since alcohol gel hand sanitizers combine high immediate antimicrobial efficacy with ease of use, this study was carried out to determine the effect of the use of an alcohol gel hand sanitizer by caregivers on infection types and rates in an acute care facility. Patients were educated about the study through a poster on the unit, and teachable patients were given portable bottles of the alcohol hand gel for bedside use, along with an educational brochure explaining how and why to practice good hand hygiene. Infection rate and type data were collected in 1 unit of a 498-bed acute care facility for 16 months (February 2000 to May 2001). An alcohol gel hand sanitizer was provided and used by caregivers in the orthopedic surgical unit of the facility during this period. The primary infection types (more than 80%) found were urinary tract (UTI) and surgical site (SSI) infections. Infection types and rates for the unit during the period the alcohol hand sanitizer (intervention) was used were compared with the infection types and rates for the same unit when the alcohol hand sanitizer was not used (baseline); the results demonstrated a 36.1% decrease in infection rates for the 10-month period that the hand sanitizer was used. This study indicates that use of an alcohol gel hand sanitizer can decrease infection rates and provide an additional tool for an effective infection control program in acute care facilities.
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Sharma, Manupriya; Sachdeva, Man Updesh Singh; Bose, Parveen; Varma, Neelam; Varma, Subhash; Marwaha, R.K.; Malhotra, Pankaj
2017-01-01
Background & objectives: Mixed-phenotype acute leukaemia (MPAL) is a rare neoplasm with no definite treatment protocols and a distinctly poor outcome. Advancement in polychromatic flow cytometry has made its identification easier. This prospective study was designed to identify cases of MPAL and study their clinical presentation and haematological profile in a tertiary care hospital in north India. Methods: Ethylenediaminetetraacetic acid (EDTA)-anticoagulated bone marrow aspirate samples of patients diagnosed as acute leukaemia (AL) on the basis of morphology were utilized for immunophenotyping. A comprehensive panel of fluorochrome-labelled monoclonal antibodies targeting myeloid, B-cell, T-cell and immaturity markers was utilized. The patients diagnosed to have MPAL, on the basis of the World Health Organization 2008 classification, were selected for further analyses. Results: There were 15 (2.99%) patients with MPAL of the total 501 cases of AL. Seven were children, all males and mean age of 5.08±3.88 yr. Eight were adults, male:female=6:2 and mean age of 21.43±5.74 yr. Eight were diagnosed as B/myeloid and seven were T/myeloid. No association was observed between age and immunophenotype of MPAL. On morphology, 11 were diagnosed as AML and four as ALL, and no specific morphology of blasts was predictive of a MPAL. Interpretation & conclusions: MPAL appeared to be a rare neoplasm (2.99% of AL cases). A comprehensive primary panel of monoclonal antibodies should be used to identify this neoplasm known to have a poor outcome. PMID:28639598
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Acute pain management efficiency improves with point-of-care handheld electronic billing system.
Fahy, Brenda G
2009-02-01
Technology advances continue to impact patient care and physician workflow. To enable more efficient performance of billing activities, a point-of-care (POC) handheld computer technology replaced a paper-based system on an acute pain management service. Using a handheld personal digital assistant (PDA) and software from MDeverywhere (MDe, MDeverywhere, Long Island, NY), we performed a 1-yr prospective observational study of an anesthesiology acute pain management service billings and collections. Seventeen anesthesiologists providing billable acute pain services were trained and entered their charges on a PDA. Twelve months of data, just before electronic implementation (pre-elec), were compared to a 12-m period after implementation (post-elec). The total charges were 4883 for 890 patients pre-elec and 5368 for 1128 patients post-elec. With adoption of handheld billing, the charge lag days decreased from 29.3 to 7.0 (P < 0.001). The days in accounts receivable trended downward from 59.9 to 51.1 (P = 0.031). The average number of charge lag days decreased significantly with month (P = 0.0002). The net collection rate increased from 37.4% pre-elec to 40.3% post-elec (P < 0.001). The return on investment was 1.18 fold (118%). Implementation of POC electronic billing using PDAs to replace a paper-based billing system improved the collection rate and decreased the number of charge lag days with a positive return on investment. The handheld PDA billing system provided POC support for physicians during their daily clinical (e.g., patient locations, rounding lists) and billing activities, improving workflow.
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Bray, Benjamin D; Cloud, Geoffrey C; James, Martin A; Hemingway, Harry; Paley, Lizz; Stewart, Kevin; Tyrrell, Pippa J; Wolfe, Charles D A; Rudd, Anthony G
2016-07-09
Studies in many health systems have shown evidence of poorer quality health care for patients admitted on weekends or overnight than for those admitted during the week (the so-called weekend effect). We postulated that variation in quality was dependent on not only day, but also time, of admission, and aimed to describe the pattern and magnitude of variation in the quality of acute stroke care across the entire week. We did this nationwide, registry-based, prospective cohort study using data from the Sentinel Stroke National Audit Programme. We included all adult patients (aged >16 years) admitted to hospital with acute stroke (ischaemic or primary intracerebral haemorrhage) in England and Wales between April 1, 2013, and March 31, 2014. Our outcome measure was 30 day post-admission survival. We estimated adjusted odds ratios for 13 indicators of acute stroke-care quality by fitting multilevel multivariable regression models across 42 4-h time periods per week. The study cohort comprised 74,307 patients with acute stroke admitted to 199 hospitals. Care quality varied across the entire week, not only between weekends and weekdays, with different quality measures showing different patterns and magnitudes of temporal variation. We identified four patterns of variation: a diurnal pattern (thrombolysis, brain scan within 12 h, brain scan within 1 h, dysphagia screening), a day of the week pattern (stroke physician assessment, nurse assessment, physiotherapy, occupational therapy, and assessment of communication and swallowing by a speech and language therapist), an off-hours pattern (door-to-needle time for thrombolysis), and a flow pattern whereby quality changed sequentially across days (stroke-unit admission within 4 h). The largest magnitude of variation was for door-to-needle time within 60 min (range in quality 35-66% [16/46-232/350]; coefficient of variation 18·2). There was no difference in 30 day survival between weekends and weekdays (adjusted odds ratio 1
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Pine, Alexander B; Lee, Eun-Ju; Sekeres, Mikkael; Steensma, David P; Zelterman, Daniel; Prebet, Thomas; DeZern, Amy; Komrokji, Rami; Litzow, Mark; Luger, Selina; Stone, Richard; Erba, Harry P; Garcia-Manero, Guillermo; Lee, Alfred I; Podoltsev, Nikolai A; Barbarotta, Lisa; Kasberg, Stephanie; Hendrickson, Jeanne E; Gore, Steven D; Zeidan, Amer M
2017-02-01
Transfusion of blood products is a key component of the supportive management in patients with acute leukemia (AL). However high-quality trial evidence and clinical outcome data to support specific transfusion goals for blood products for patients with AL remain limited leading to diverse transfusion practices. The primary objective of this study was to determine the spectrum of transfusion patterns in a variety of care settings among providers who treat AL patients. A 31-question survey queried providers caring for AL patients about the existence of institutional guidelines for transfusion of blood products, transfusion triggers for hemoglobin (Hb), platelets (PLTs), and fibrinogen in various settings including inpatient and outpatient and before procedures. We analyzed 130 responses and identified divergent transfusion Hb goals in hospitalized and ambulatory patients, fibrinogen goals for cryoprecipitate transfusions, and variation in practice for use of certain PLTs and red blood cell products. The least variable transfusion patterns were reported for PLT goals in thrombocytopenia and in the setting of invasive procedures such as bone marrow biopsy and lumbar punctures. This survey confirmed wide variations in blood product transfusion practices across several clinical scenarios in patients with AL. The findings emphasized the need for large prospective randomized trials to develop standardized evidence-based guidelines for blood product transfusions in patients with AL with the goal of limiting unnecessary transfusions without compromising outcomes. © 2016 AABB.
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Tan, Emma Su Zan; Mackenzie, Lynette; Travasssaros, Katrina; Yeo, Megan
2016-08-01
Acute hospitals are facing more complex admissions with older people at increased risk of functional decline. This study aimed to create and trial the feasibility of a new screening tool designed to identify patients at risk of functional decline who need an occupational therapy referral within acute care. Ten screening tools were reviewed and the Modified Blaylock Tool for Occupational Therapy Referral (MBTOTR) was developed. The MBTOTR was applied in a retrospective chart review of 50 patients over the age of 65 years who were admitted to five acute wards. Data on patients identified at risk of functional decline were compared to patients who were referred to occupational therapy. Occupational therapy referrals were made by ward staff for 14 out of the 50 patients reviewed (32.5%). Only 14% (n = 7) of patients did not require a referral. The MBTOTR identified no irrelevant occupational therapy referrals. However, 66.5% of patients identified as needing an occupational therapy referral did not get one. The MBTOTR identified high risk acute patients requiring an occupational therapy referral who were not referred to occupational therapy. Use of the MBTOTR would facilitate early occupational therapy referrals for complex patients, and potentially better discharge outcomes. Implications for rehabilitation The MBTOTR can be used in acute care settings to facilitate relevant occupational therapy referrals. Without a screening tool, many older people who should have an occupational therapy assessment may not receive a referral for occupational therapy. Nursing and medical staff need to use this tool to identify older people in their care who may benefit from occupational therapy assessment and intervention. If occupational therapy referrals can be made early, this may contribute to reducing delays to discharge plans for complex patients.
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Ho, Chester H; Cheung, Amanda; Southern, Danielle; Ocampo, Wrechelle; Kaufman, Jaime; Hogan, David B; Baylis, Barry; Conly, John M; Stelfox, Henry T; Ghali, William A
2016-12-01
Research regarding the reliability of the Braden Scale and nurses' perspectives on the instrument for predicting pressure ulcer (PU) risk in acute care settings is limited. A mixed-methods study was conducted in a tertiary acute care facility to examine interrater reliability (IRR) of the Braden Scale and its subscales, and a qualitative survey using semi-structured interviews was conducted among nurses caring for patients in acute care units to gain nurse perspective regarding scale usability. Data were extracted from a previous retrospective, randomized, controlled trial involving adult patients with compromised mobility receiving care in a tertiary acute care hospital in Canada. One-way, intraclass correlation coefficients (ICCs) were calculated on item and total scores, and kappa statistics were used to determine reliability of categorizing patients on their risk. Interview results were categorized by common themes. Reliability was assessed on 64 patients, where nurses and research staff independently assessed enrolled participants at baseline and after 72 hours using the Braden Scale as it appeared on an electronic medical record. IRR for the total score was high (ICC = 0.807). The friction and shear item had the lowest reliability (ICC = 0.266). Reliability of categorizing patients' level of risk had moderate agreement (κ = 0.408). Three (3) major and 12 subthemes emerged from the 14 nurse interviews; nurses were aware of the scale's purpose but were uncertain of its effectiveness, some items were difficult to rate, and questions were raised as to whether using the scale enhanced patient care. Aspects identified by nurses to enhance usability included: 1) changes to the electronic version (incorporating the scale into daily assessment documents with readily available item descriptions), 2) additional training, and 3) easily available resource material to improve reliability and usability of scale. These findings need to be considered when using the Braden
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Thumfart, Julia; Reindl, Tobias; Rheinlaender, Cornelia; Müller, Dominik
2018-03-01
Paediatric palliative care is no longer restricted to patients with cancer and has been extended to patients with other chronic conditions, such as cystic fibrosis or neuromuscular disorders. This review focused on the current state of palliative care for children and adolescents with chronic kidney disease (CKD). We assessed the literature on CKD published up to August 2017. All the papers, except one from 1996, were published this century. This review discusses the role that palliative care plays in the process of decision-making and explores the possibilities of implementing palliative care into the routine therapy of affected patients and providing support for their families. Offering early palliative care as an integral part of the kidney, supportive care provided by the nephrology care team is both necessary and feasible for patients with CKD. As a minimum, a specialised palliative care team should be involved in patients with multiple comorbidities, in conservative treatment scenarios and in acute life-threatening complications. Further studies and guidelines are required to improve the care of patients with CKD and their families. Supportive palliative care should be implemented into the routine care of patients with life-limiting kidney disease. ©2017 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.
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George, Jim; Long, Susannah; Vincent, Charles
2013-01-01
Maintaining patient safety in acute hospitals is a global health challenge. Traditionally, patient safety measures have been concentrated on critical care and surgical patients. In this review the medical literature was reviewed over the last ten years on aspects of patient safety specifically related to patients with dementia. Patients with dementia do badly in hospital with frequent adverse events resulting in the geriatric syndromes of falls, delirium and loss of function with increased length of stay and increased mortality. Contributory factors include inadequate assessment and treatment, inappropriate intervention, discrimination, low staff levels and lack of staff training. Unfortunately there is no one simple solution to this problem, but what is needed is a multifactorial, multilevel approach at the seven levels of care – patient, task, staff, team, environment, organisation and institution. Improving safety and quality of care for patients with dementia in acute hospitals will benefit all patients and is an urgent priority for the NHS. PMID:23759885
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Koifman, Edward; Beigel, Roy; Iakobishvili, Zaza; Shlomo, Nir; Biton, Yitschak; Sabbag, Avi; Asher, Elad; Atar, Shaul; Gottlieb, Shmuel; Alcalai, Ronny; Zahger, Doron; Segev, Amit; Goldenberg, Ilan; Strugo, Rafael; Matetzky, Shlomi
2017-01-01
Ischemic time has prognostic importance in ST-elevation myocardial infarction patients. Mobile intensive care unit use can reduce components of total ischemic time by appropriate triage of ST-elevation myocardial infarction patients. Data from the Acute Coronary Survey in Israel registry 2000-2010 were analyzed to evaluate factors associated with mobile intensive care unit use and its impact on total ischemic time and patient outcomes. The study comprised 5474 ST-elevation myocardial infarction patients enrolled in the Acute Coronary Survey in Israel registry, of whom 46% ( n=2538) arrived via mobile intensive care units. There was a significant increase in rates of mobile intensive care unit utilization from 36% in 2000 to over 50% in 2010 ( p<0.001). Independent predictors of mobile intensive care unit use were Killip>1 (odds ratio=1.32, p<0.001), the presence of cardiac arrest (odds ratio=1.44, p=0.02), and a systolic blood pressure <100 mm Hg (odds ratio=2.01, p<0.001) at presentation. Patients arriving via mobile intensive care units benefitted from increased rates of primary reperfusion therapy (odds ratio=1.58, p<0.001). Among ST-elevation myocardial infarction patients undergoing primary reperfusion, those arriving by mobile intensive care unit benefitted from shorter median total ischemic time compared with non-mobile intensive care unit patients (175 (interquartile range 120-262) vs 195 (interquartile range 130-333) min, respectively ( p<0.001)). Upon a multivariate analysis, mobile intensive care unit use was the most important predictor in achieving door-to-balloon time <90 min (odds ratio=2.56, p<0.001) and door-to-needle time <30 min (odds ratio=2.96, p<0.001). One-year mortality rates were 10.7% in both groups (log-rank p-value=0.98), however inverse propensity weight model, adjusted for significant differences between both groups, revealed a significant reduction in one-year mortality in favor of the mobile intensive care unit group (odds ratio=0
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Urban, Ann-Marie; Wagner, Joan I
2013-12-01
Hospitals are situated within historical and socio-political contexts; these influence the provision of patient care and the work of registered nurses (RNs). Since the early 1990s, restructuring and the increasing pressure to save money and improve efficiency have plagued acute care hospitals. These changes have affected both the work environment and the work of nurses. After recognizing this impact, healthcare leaders have dedicated many efforts to improving the work environment in hospitals. Admirable in their intent, these initiatives have made little change for RNs and their work environment, and thus, an opportunity exists for other efforts. Research indicates that spirit at work (SAW) not only improves the work environment but also strengthens the nurse's power to improve patient outcomes and contribute to a high-quality workplace. In this paper, we present findings from our research that suggest SAW be considered an important component in improving the work environment in acute care hospitals.
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Sedation and Analgesia in Transportation of Acutely and Critically Ill Patients.
Johnston, Dawn; Franklin, Kevin; Rigby, Paul; Bergman, Karen; Davidson, Scott B
2016-06-01
Transportation of acutely or critically ill patients is a challenge for health care providers. Among the difficulties that providers face is the balance between adequate sedation and analgesia for the transportation event and maintaining acceptable respiratory and physiologic parameters of the patient. This article describes common challenges in providing sedation and analgesia during various phases of transport. Copyright © 2016 Elsevier Inc. All rights reserved.
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Collins, Sarah A.; Gazarian, Priscilla; Stade, Diana; McNally, Kelly; Morrison, Conny; Ohashi, Kumiko; Lehmann, Lisa; Dalal, Anuj; Bates, David W.; Dykes, Patricia C.
2014-01-01
Patient- and Family-Centered Care (PFCC) is essential for high quality care in the critical and acute-specialty care hospital setting. Effective PFCC requires clinicians to form an integrated interprofessional team to collaboratively engage with the patient/family and contribute to a shared patient-centered plan of care. We conducted observations on a critical care and specialty unit to understand the plan of care activities and workflow documentation requirements for nurses and physicians to inform the development of a shared patient-centered plan of care to support patient engagement. We identified siloed plan of care documentation, with workflow opportunities to converge the nurses plan of care with the physician planned To-do lists and quality and safety checklists. Integration of nurses and physicians plan of care activities into a shared plan of care is a feasible and valuable step toward interprofessional teams that effectively engage patients in plan of care activities. PMID:25954345
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Kang, Shih-Chao; Lin, Ming-Hwai; Hwang, I-Hsuan; Lin, Ming-Hsien; Chang, Hsiao-Ting; Hwang, Shinn-Jang
2012-05-01
This study investigated the impact of hospice care on end-of-life elderly patients with lung cancer in Taiwan. Data were collected from deceased inpatients with lung cancer who were at least 65 years old, using the National Health Insurance Research Database of 2004. A total of 1282 patients were enrolled, of whom 277 (21.6%) received hospice care (hospice-care group) and the other 1005 (78.4%) received general acute ward care (control group). The patients' age, gender, and institution of hospitalization did not differ significantly between the two groups, and most of the patients had chosen medical centers and their affiliated hospices for terminal care. The hospice-care group had a significantly shorter hospital stay and lower costs of hospitalization than the control group, with patients cared for primarily by family physicians and radiation oncologists (all p<0.05). The hospice-care group had an elevated incidence of co-morbid diabetes mellitus, higher scores on the Charlson Comorbidity Index, fewer acute lower respiratory conditions, and fewer invasive procedures than the control group (all p<0.05). Natural opium alkaloids were the most commonly prescribed drugs in the hospice-care group, whereas parenteral solutions were most frequently requested in the control group. Hospice care has provided a humane and cost-efficient pathway for end-of-life elderly patients with lung cancer. Parenteral nutrition/hydration should be limited for terminal care patients. Opioids should be promoted for the relief of pain and dyspnea in acute ward care. Family physicians and radiation oncologists play important roles in hospice care. Compared with the prevalence of hospice care in the United Kingdom and other developed countries, hospice care in Taiwan is in the position to be expanded. Copyright © 2012. Published by Elsevier B.V.
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Soares-Oliveira, Miguel; Araújo, Fernando
2014-06-01
Implementing integrated systems for emergency care of patients with acute ischemic stroke helps reduce morbidity and mortality. We describe the process of organizing and implementing a regional system to cover around 3.7 million people and its main initial results. We performed a descriptive analysis of the implementation process and a retrospective analysis of the following parameters: number of patients prenotified by the pre-hospital system; number of times thrombolysis was performed; door-to-needle time; and functional assessment three months after stroke. The implementation process started in November 2005 and ended in December 2009, and included 11 health centers. There were 3574 prenotifications from the prehospital system. Thrombolysis was performed in 1142 patients. The percentage of patients receiving thrombolysis rose during the study period, with a maximum of 16%. Median door-to-needle time was 62 min in 2009. Functional recovery three months after stroke was total or near total in 50% of patients. The regional system implemented for emergency care of patients with acute ischemic stroke has led to health gains, with progressive improvements in patients' access to thrombolysis, and to greater equity in the health care system, thus helping to reduce mortality from cerebrovascular disease in Portugal. Our results, which are comparable with those of international studies, support the strategy adopted for implementation of this system. Copyright © 2013 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.
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Nontechnical skills performance and care processes in the management of the acute trauma patient.
Pucher, Philip H; Aggarwal, Rajesh; Batrick, Nicola; Jenkins, Michael; Darzi, Ara
2014-05-01
Acute trauma management is a complex process, with the effective cooperation among multiple clinicians critical to success. Despite this, the effect of nontechnical skills on performance on outcomes has not been investigated previously in trauma. Trauma calls in an urban, level 1 trauma center were observed directly. Nontechnical performance was measured using T-NOTECHS. Times to disposition and completion of assessment care processes were recorded, as well as any delays or errors. Statistical analysis assessed the effect of T-NOTECHS on performance and outcomes, accounting for Injury Severity Scores (ISS) and time of day as potential confounding factors. Meta-analysis was performed for incidence of delays. Fifty trauma calls were observed, with an ISS of 13 (interquartile range [IQR], 5-25); duration of stay 1 (IQR, 1-8) days; T-NOTECHS, 20.5 (IQR, 18-23); time to disposition, 24 minutes (IQR, 18-42). Trauma calls with low T-NOTECHS scores had a greater time to disposition: 35 minutes (IQR, 23-53) versus 20 (IQR, 16-25; P = .046). ISS showed a significant correlation to duration of stay (r = 0.736; P < .001), but not to T-NOTECHS (r = 0.201; P = .219) or time to disposition (r = 0.113; P = .494). There was no difference between "in-hours" and "out-of-hours" trauma calls for T-NOTECHS scores (21 [IQR, 18-22] vs 20 [IQR, 20-23]; P = .361), or time to disposition (34 minutes [IQR, 24-52] vs 17 [IQR, 15-27]; P = .419). Regression analysis revealed T-NOTECHS as the only factor associated with delays (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.06-0.95). Better teamwork and nontechnical performance are associated with significant decreases in disposition time, an important marker of quality in acute trauma care. Addressing team and nontechnical skills has the potential to improve patient assessment, treatment, and outcomes. Copyright © 2014 Mosby, Inc. All rights reserved.
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Torregrosa, Isidro; Montoliu, Carmina; Urios, Amparo; Elmlili, Nisrin; Puchades, María Jesús; Solís, Miguel Angel; Sanjuán, Rafael; Blasco, Maria Luisa; Ramos, Carmen; Tomás, Patricia; Ribes, José; Carratalá, Arturo; Juan, Isabel; Miguel, Alfonso
2012-01-01
Acute kidney injury (AKI) is a common complication in cardiac surgery and coronary angiography, which worsens patients' prognosis. The diagnosis is based on the increase in serum creatinine, which is delayed. It is necessary to identify and validate new biomarkers that allow for early and effective interventions. To assess the sensitivity and specificity of neutrophil gelatinase-associated lipocalin in urine (uNGAL), interleukin-18 (IL-18) in urine and cystatin C in serum for the early detection of AKI in patients with acute coronary syndrome or heart failure, and who underwent cardiac surgery or catheterization. The study included 135 patients admitted to the intensive care unit for acute coronary syndrome or heart failure due to coronary or valvular pathology and who underwent coronary angiography or cardiac bypass surgery or valvular replacement. The biomarkers were determined 12 hours after surgery and serum creatinine was monitored during the next six days for the diagnosis of AKI. The area under the ROC curve (AUC) for NGAL was 0.983, and for cystatin C and IL-18 the AUCs were 0.869 and 0.727, respectively. At a cut-off of 31.9 ng/ml for uNGAL the sensitivity was 100% and the specificity was 91%. uNGAL is an early marker of AKI in patients with acute coronary syndrome or heart failure and undergoing cardiac surgery and coronary angiography, with a higher predictive value than cystatin C or IL-18.
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Sifri, Costi D; Burke, Gene H; Enfield, Kyle B
2016-12-01
The purpose of this study was to determine the effectiveness of copper-impregnated composite hard surfaces and linens in an acute care hospital to reduce health care-associated infections (HAIs). We performed a quasiexperimental study with a control group, assessing development of HAIs due to multidrug resistant organisms (MDROs) and Clostridium difficile in the acute care units of a community hospital following the replacement of a 1970s-era clinical wing with a new wing outfitted with copper-impregnated composite hard surfaces and linens. The study was conducted over a 25.5-month time period that included a 3.5-month washout period. HAI rates obtained from the copper-containing new hospital wing (14,479 patient-days; 72 beds) and the unmodified hospital wing (19,177 patient-days) were compared with those from the baseline period (46,391 patient-days). The new wing had 78% (P = .023) fewer HAIs due to MDROs or C difficile, 83% (P = .048) fewer cases of C difficile infection, and 68% (P = .252) fewer infections due to MDROs relative to the baseline period. No changes in rates of HAI were observed in the unmodified hospital wing. Copper-impregnated composite hard surfaces and linens may be useful technologies to prevent HAIs in acute care hospital settings. Additional studies are needed to determine whether reduced HAIs can be attributed to the use of copper-containing antimicrobial hard and soft surfaces. Copyright © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
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Subacute and non-acute casemix in Australia.
Lee, L A; Eagar, K M; Smith, M C
1998-10-19
The costs of subacute care (palliative care, rehabilitation medicine, psychogeriatrics, and geriatric evaluation and management) and non-acute care (nursing home, convalescent and planned respite care) are not adequately described by existing casemix classifications. The predominant treatment goals in subacute care are enhancement of quality of life and/or improvement in functional status and, in non-acute care, maintenance of current health and functional status. A national classification system for this area has now been developed--the Australian National Sub-Acute and Non-Acute Patient Classification System (AN-SNAP). The AN-SNAP system, based on analysis of over 30,000 episodes of care, defines four case types of subacute care (palliative care, rehabilitation, psychogeriatric care, and geriatric evaluation and management and one case type of non-acute care (maintenance care), and classifies both overnight and ambulatory care. The AN-SNAP system reflects the goal of management--a change in functional status or improvement in quality of life--rather than the patient's diagnosis. It will complement the existing AN-DRG classification.
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Bell, Jack J; Bauer, Judith D; Capra, Sandra; Pulle, Ranjeev Chrys
2014-12-01
Malnutrition is highly prevalent and resistant to intervention following hip fracture. This study investigated the impact of individualised versus multidisciplinary nutritional care on nutrition intake and outcomes in patients admitted to a metropolitan hospital acute hip fracture unit. A prospective, controlled before and after comparative interventional study aligning to the CONSORT guidelines for pragmatic clinical trials. Randomly selected patients receiving individualised nutritional care (baseline) were compared with post-interventional patients receiving a new model of nutritional care promoting nutrition as a medicine, multidisciplinary nutritional care, foodservice enhancements, and improved nutrition knowledge and awareness. Malnutrition was diagnosed using the Academy of Nutrition and Dietetics criteria. Fifty-eight weighed food records were available for each group across a total of 82 patients (n = 44, n = 38). Group demographics were not significantly different with predominantly community dwelling (72%), elderly (82.2 years), female (70%), malnourished (51.0%) patients prone to co-morbidities (median 5) receiving early surgical intervention (median D1). Multidisciplinary nutritional care reduced intake barriers and increased total 24-h energy (6224 vs. 2957 kJ; p < 0.001) and protein (69.0 vs. 33.8 g; p < 0.001) intakes, reduced nutritional deterioration over admission (5.4 vs. 20.5%; p = 0.049), and increased discharge directly back to the community setting (48.0 vs. 17.6%; p = 0.012). Trends suggested a reduction in median length of stay (D13 vs. D14). Inpatient mortality remained low across groups (5.2%, 2.3%). Multidisciplinary nutritional care improves nutrition intake and outcomes in acute hip fracture inpatients. Similar pragmatic study designs should be considered in other elderly inpatient populations perceived resistant to nutritional intervention. Copyright © 2013 Elsevier Ltd and European Society for Clinical Nutrition and
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Interprofessional communication failures in acute care chains: How can we identify the causes?
van Leijen-Zeelenberg, Janneke E; van Raak, Arno J A; Duimel-Peeters, Inge G P; Kroese, Mariëlle E A L; Brink, Peter R G; Vrijhoef, Hubertus J M
2015-01-01
Although communication failures between professionals in acute care delivery occur, explanations for these failures remain unclear. We aim to gain a deeper understanding of interprofessional communication failures by assessing two different explanations for them. A multiple case study containing six cases (i.e. acute care chains) was carried out in which semi-structured interviews, physical artifacts and archival records were used for data collection. Data were entered into matrices and the pattern-matching technique was used to examine the two complementary propositions. Based on the level of standardization and integration present in the acute care chains, the six acute care chains could be divided into two categories of care processes, with the care chains equally distributed among the categories. Failures in communication occurred in both groups. Communication routines were embedded within organizations and descriptions of communication routines in the entire acute care chain could not be found. Based on the results, failures in communication could not exclusively be explained by literature on process typology. Literature on organizational routines was useful to explain the occurrence of communication failures in the acute care chains. Organizational routines can be seen as repetitive action patterns and play an important role in organizations, as most processes are carried out by means of routines. The results of this study imply that it is useful to further explore the role of organizational routines on interprofessional communication in acute care chains to develop a solution for failures in handover practices.
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Self-transcendence and work engagement in acute care staff registered nurses.
Palmer, Beth; Quinn Griffin, Mary T; Reed, Pamela; Fitzpatrick, Joyce J
2010-01-01
The ability of human beings to find meaning by being directed toward something, or someone, other than themselves is termed "self-transcendence." Previous research indicated that the ability of nurses to self-transcend and thus derive positive meaning from patient-caring experiences increased work commitment and fostered work engagement. However, the relationship between self-transcendence and work engagement had not been investigated. The purpose of this study was to explore the levels and relationships of self-transcendence and work engagement in acute care staff registered nurses (ACSRNs). This was a descriptive correlational study using Reed's theory of self-transcendence. The Self-transcendence Scale, the Utrecht Work Engagement Scale, and a demographic questionnaire were completed by a convenience sample of 84 ACSRNs who attended an annual acute care nursing conference in northern Illinois. ACSRNs level of self-transcendence was high, similar to that of other nurses, but higher than that of nonnurses. ACSRNs level of work engagement was at the high end of the "average" range. There was a significant positive correlation between self-transcendence and work engagement. Nurses with higher levels of self-transcendence had more energy toward and were more dedicated and absorbed in their work.
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Kellens, Sebastiaan; Verbrugge, Frederik H; Vanmechelen, Maxime; Grieten, Lars; Van Lierde, Johan; Dens, Joseph; Vrolix, Mathias; Vandervoort, Pieter
2016-04-01
High-sensitivity cardiac troponin testing is used to detect myocardial damage in patients with acute chest pain. Heart-type fatty acid binding protein (H-FABP) may be an alternative, available as point-of-care test. Patients (n=203) referred by general practitioners for suspected acute coronary syndrome or presenting with typical chest pain and one major cardiovascular risk factor at the emergency department were prospectively included in a single-centre cohort study. High-sensitivity cardiac troponin T (hs-TnT) and point-of-care H-FABP testing were concomitantly performed at admission and after 6h. Maximal hs-TnT levels above the 99th percentile were observed in 152 patients (75%) with 127 (63%) fulfilling criteria for myocardial infarction. Upon admission, hs-TnT and H-FABP were associated with an area under the curve (95% CI) of 0.83 (0.77-0.89) and 0.79 (0.73-0.85), respectively, to predict myocardial infarction, which increased to 0.93 (0.90-0.97) and 0.88 (0.84-0.93), respectively, after 6h. The diagnostic accuracy for non-ST-segment elevation myocardial infarction was somewhat lower with an area under the curve (95% CI) of 0.80 (0.72-0.87), 0.90 (0.84-0.96), 0.73 (0.64-0.81) and 0.77 (0.67-0.86), respectively. When assessment was performed within 3h of chest pain onset, diagnostic accuracy of H-FABP versus hs-TnT was similar. Each standard deviation increase in admission H-FABP was associated with a 68% relative risk increase of all-cause mortality (p-value=0.027) during 666 ± 155 days of follow-up. Point-of-care H-FABP testing has lower diagnostic accuracy compared with hs-TnT assessment in patients with high pre-test acute coronary syndrome probability, but might be of interest when assessment is possible early after chest pain onset. © The European Society of Cardiology 2015.
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ERIC Educational Resources Information Center
Auslander, Gail K.; Soskolne, Varda; Stanger, Varda; Ben-Shahar, Ilana; Kaplan, Giora
2008-01-01
This study aimed to examine the implementation, adequacy, and outcomes of discharge planning. The authors carried out a prospective study of 1,426 adult patients discharged from 11 acute care hospitals in Israel. Social workers provided detailed discharge plans on each patient. Telephone interviews were conducted two weeks post-discharge. Findings…