Posttraumatic stress disorder in children and their parents following admission to the pediatric intensive care unit: a review.

PubMed

Nelson, Lara P; Gold, Jeffrey I

2012-05-01

To evaluate posttraumatic stress disorder in children who have been admitted to the pediatric intensive care unit and their families. Studies were identified through PubMed, MEDLINE, and Ovid. All descriptive, observational, and controlled studies with a focus on posttraumatic stress disorder and the pediatric intensive care unit were included. Posttraumatic stress disorder rates in children following admission to the pediatric intensive care unit were between 5% and 28%, while rates of posttraumatic stress disorder symptoms were significantly higher, 35% to 62%. There have been inconsistencies noted across risk factors. Objective and subjective measurements of disease severity were intermittently positively associated with development of posttraumatic stress disorder. There was a positive relationship identified between the child's symptoms of posttraumatic stress disorder and their parents' symptoms.The biological mechanisms associated with the development of posttraumatic stress disorder in children admitted to the pediatric intensive care unit have yet to be explored. Studies in children following burn or other unintentional injury demonstrate potential relationships between adrenergic hormone levels and a diagnosis of posttraumatic stress disorder. Likewise genetic studies suggest the importance of the adrenergic system in this pathway.The rates of posttraumatic stress disorder in parents following their child's admission to the pediatric intensive care unit ranged between 10.5% and 21%, with symptom rates approaching 84%. It has been suggested that mothers are at increased risk for the development of posttraumatic stress disorder compared to fathers. Objective and subjective measures of disease severity yielded mixed findings with regard to the development of posttraumatic stress disorder. Protective parental factors may include education or the opportunity to discuss the parents' feelings during the admission. Following admission to the pediatric intensive care unit, both children and their parents have high rates of trauma exposure, both personally and secondary exposure via other children and their families, and subsequently are reporting significant rates of posttraumatic stress disorder. To effectively treat our patients, we must recognize the signs of posttraumatic stress disorder and strive to mitigate the negative effects.

Predictors of intensive care unit admission and mortality in patients with ischemic stroke: investigating the effects of a pulmonary rehabilitation program.

PubMed

Güngen, Belma Doğan; Tunç, Abdulkadir; Aras, Yeşim Güzey; Gündoğdu, Aslı Aksoy; Güngen, Adil Can; Bal, Serdar

2017-07-11

The aim of this study was to investigate the predictors of intensive care unit (ICU) admission and mortality among stroke patients and the effects of a pulmonary rehabilitation program on stroke patients. This prospective study enrolled 181 acute ischemic stroke patients aged between 40 and 90 years. Demographical characteristics, laboratory tests, diffusion-weighed magnetic resonance imaging (DWI-MRI) time, nutritional status, vascular risk factors, National Institute of Health Stroke Scale (NIHSS) scores and modified Rankin scale (MRS) scores were recorded for all patients. One-hundred patients participated in the pulmonary rehabilitation program, 81 of whom served as a control group. Statistically, one- and three-month mortality was associated with NIHSS and MRS scores at admission and three months (p<0.001; r=0.440, r=0.432, r=0.339 and r=0.410, respectively). One and three months mortality- ICU admission had a statistically significant relationship with parenteral nutrition (p<0.001; r=0.346, r=0.300, respectively; r=0.294 and r=0.294, respectively). Similarly, there was also a statistically significant relationship between pneumonia onset and one- and three-month mortality- ICU admission (p<0.05; r=0.217, r=0.127, r=0.185 and r=0.185, respectively). A regression analysis showed that parenteral nutrition (odds ratio [OR] =13.434, 95% confidence interval [CI] =1.148-157.265, p=0.038) was a significant predictor of ICU admission. The relationship between pulmonary physiotherapy (PPT) and ICU admission- pneumonia onset at the end of three months was statistically significant (p=0.04 and p=0.043, respectively). This study showed that PPT improved the prognosis of ischemic stroke patients. We believe that a pulmonary rehabilitation program, in addition to general stroke rehabilitation programs, can play a critical role in improving survival and functional outcomes. NCT03195907 . Trial registration date: 21.06.2017 'Retrospectively registered'.

Role of Admission Troponin-T and Serial Troponin-T Testing in Predicting Outcomes in Severe Sepsis and Septic Shock.

PubMed

Vallabhajosyula, Saraschandra; Sakhuja, Ankit; Geske, Jeffrey B; Kumar, Mukesh; Poterucha, Joseph T; Kashyap, Rahul; Kashani, Kianoush; Jaffe, Allan S; Jentzer, Jacob C

2017-09-09

Troponin-T elevation is seen commonly in sepsis and septic shock patients admitted to the intensive care unit. We sought to evaluate the role of admission and serial troponin-T testing in the prognostication of these patients. This was a retrospective cohort study from 2007 to 2014 on patients admitted to the intensive care units at the Mayo Clinic with severe sepsis and septic shock. Elevated admission troponin-T and significant delta troponin-T were defined as ≥0.01 ng/mL and ≥0.03 ng/mL in 3 hours, respectively. The primary outcome was in-hospital mortality. Secondary outcomes included 1-year mortality and lengths of stay. During this 8-year period, 944 patients met the inclusion criteria with 845 (90%) having an admission troponin-T ≥0.01 ng/mL. Serial troponin-T values were available in 732 (78%) patients. Elevated admission troponin-T was associated with older age, higher baseline comorbidity, and severity of illness, whereas significant delta troponin-T was associated with higher severity of illness. Admission log 10 troponin-T was associated with unadjusted in-hospital (odds ratio 1.6; P =0.003) and 1-year mortality (odds ratio 1.3; P =0.04), but did not correlate with length of stay. Elevated delta troponin-T and log 10 delta troponin-T were not significantly associated with any of the primary or secondary outcomes. Admission log 10 troponin-T remained an independent predictor of in-hospital mortality (odds ratio 1.4; P =0.04) and 1-year survival (hazard ratio 1.3; P =0.008). In patients with sepsis and septic shock, elevated admission troponin-T was associated with higher short- and long-term mortality. Routine serial troponin-T testing did not add incremental prognostic value in these patients. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Clinical characteristics and mental health outcomes for women admitted to an Australian Mother-Baby Unit: a focus on borderline personality disorder and emotional dysregulation?

PubMed

Yelland, Chris; Girke, Teresa; Tottman, Charlotte; Williams, Anne Sved

2015-12-01

To describe the clinical population of women admitted to a Mother-Baby Unit in Adelaide, South Australia and to evaluate changes during admission in both Axes I and II diagnoses of maternal mental health, and in mother-infant relationships. Both clinical and self-report assessments of maternal mental health were made at admission and discharge, and self-report comparisons of the mother-infant relationship. Depressive illnesses (46.2%) were found to be the most prevalent conditions leading to admission, with rates of psychosis (10.3%) and bipolar disorder (3.4%) being lower. A high incidence of borderline personality disorder (23.1%) was found clinically, with almost half the admitted women showing features of borderline personality disorder on a self-report measure at admission. Significant improvements in maternal mental health and the mother-infant relationship were found at the time of discharge. Admission to this Mother-Baby Unit on mothers' self-report scales showed improvement in mothers' mental health and the relationship that they have with their infant. Given the high prevalence of borderline personality disorder and emotional dysregulation identified within the population, treatment implications and possible consequences for the infant are discussed for this client group. © The Royal Australian and New Zealand College of Psychiatrists 2015.

Prevalence of vitamin deficiencies on admission: relationship to hospital mortality in critically ill patients.

PubMed

Corcoran, T B; O'Neill, M A; Webb, S A R; Ho, K M

2009-03-01

Vitamin deficiency is believed to be common in critical illness. Water soluble and antioxidant vitamins are those most frequently used for supplementation in these patients. There are no data to confirm the prevalence of vitamin deficiencies in high-risk emergently admitted intensive care patients, nor their association with hospital mortality. One hundred and twenty-nine consecutive, critically ill patients who were emergently admitted to intensive care were enrolled in this prospective observational cohort study. Patient data including diagnosis, source of admission and severity of illness scores were prospectively collected. Within the first 48 hours of admission, concentrations of C-reactive protein, Vitamins A, E, B1, B12 and folate were measured on arterial blood. Multivariate stepwise logistic regression modelling was performed to examine the association of vitamin concentrations with hospital mortality. Fifty-five patients (43%) had a biochemical deficiency of one of the five vitamins on admission to the intensive care unit. A total of 18 patients died (14%) during their hospital stay (15 of those in the intensive care unit). Moderate correlations with C-reactive protein concentrations were demonstrated for Vitamins B12, A and E (Spearman's r = 0.309, -0.541 and -0.299, P = 0.001, 0.001 and 0.007 respectively). Hospital mortality was significantly associated with age, APACHE II score, admission and maximum Sequential Organ Failure Assessment scores and admission source in the univariate analyses. Multivariate analysis did not demonstrate an association between biochemical deficiency and mortality. Biochemical deficiencies of water-soluble and antioxidant vitamins are common on admission in unplanned or emergency admissions to the intensive care unit, but we could not demonstrate an independent association with hospital mortality.

Inappropriate prescribing for older people admitted to an intermediate-care nursing home unit and hospital wards.

PubMed

Bakken, Marit Stordal; Ranhoff, Anette Hylen; Engeland, Anders; Ruths, Sabine

2012-09-01

To identify inappropriate prescribing among older patients on admission to and discharge from an intermediate-care nursing home unit and hospital wards, and to compare changes during stay within and between these groups. Observational study. Altogether 400 community-dwelling people aged ≥ 70 years, on consecutive emergency admittance to hospital wards of internal medicine and orthopaedic surgery, were randomized to an intermediate-care nursing home unit or hospital wards; 290 (157 at the intermediate-care nursing home unit and 133 in hospital wards) were eligible for this sub-study. Prevalence on admission and discharge of potentially inappropriate medications (Norwegian general practice [NORGEP] criteria) and drug-drug interactions; changes during stay. The mean (SD) age was 84.7 (6.2) years; 71% were women. From admission to discharge, the mean numbers of drugs prescribed per person increased from 6.0 (3.3) to 9.3 (3.8), p < 0.01. The prevalence of potentially inappropriate medications increased from 24% to 35%, p < 0.01; concomitant use of ≥ 3 psychotropic/opioid drugs and drug combinations including non-steroid anti-inflammatory drugs (NSAIDs) increased significantly. Serious drug-drug interactions were scarce both on admission and discharge (0.7%). Inappropriate prescribing was prevalent among older people acutely admitted to hospital, and the prevalence was not reduced during stay at an intermediate-care nursing home unit specially designed for these patients.

Early initiated feeding versus early reached target enteral nutrition in critically ill children: An observational study in paediatric intensive care units in Turkey.

PubMed

Baǧci, Soyhan; Keleş, Elif; Girgin, Feyza; Yıldızdaş, Dinçer R; Horoz, Özden Ö; Yalındağ, Nilüfer; Tanyıldız, Murat; Bayrakçi, Benan; Kalkan, Gökhan; Akyıldız, Başak N; Köker, Alper; Köroğlu, Tolga; Anıl, Ayşe B; Zengin, Neslihan; Dinleyici, Ener Ç; Kıral, Eylem; Dursun, Oğuz; Yavuz, Süleyman Tolga; Bartmann, Peter; Müller, Andreas

2018-05-01

Although early enteral nutrition (EN) is strongly associated with lower mortality in critically ill children, there is no consensus on the definition of early EN. The aim of this study was to evaluate our current practice supplying EN and to identify factors that affect both the initiation of feeding within 24 h after paediatric intensive care unit (PICU) admission and the adequate supply of EN in the first 48 h after PICU admission in critically ill children. We conducted a prospective, multicentre, observational study in nine PICUs in Turkey. Any kind of tube feeding commenced within 24 h of PICU admission was considered early initiated feeding (EIF). Patients who received more than 25% of the estimated energy requirement via enteral feeding within 48 h of PICU admission were considered to have early reached target EN (ERTEN). Feeding was initiated in 47.4% of patients within 24 h after PICU admission. In many patients, initiation of feeding seems to have been delayed without an evidence-based reason. ERTEN was achieved in 43 (45.3%) of 95 patients. Patients with EIF were significantly more likely to reach ERTEN. ERTEN was an independent significant predictor of mortality (P < 0.001), along with reached target enteral caloric intake on day 2 associated with decreased mortality. There is a substantial variability among clinicians' perceptions regarding indications for delay to initiate enteral feeding in critically ill children, especially after the first 6 h of PICU admission. ERTEN, but not EIF, is associated with a significantly lower mortality rate in critically ill children. © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

Admission interview scores are associated with clinical performance in an undergraduate physiotherapy course: an observational study.

PubMed

Edgar, Susan; Mercer, Annette; Hamer, Peter

2014-12-01

The purpose of this study was to determine if there is an association between admission interview score and subsequent academic and clinical performance, in a four-year undergraduate physiotherapy course. Retrospective observational study. 141 physiotherapy students enrolled in two entry year groups. Individual student performance in all course units, practical examinations, clinical placements as well as year level and overall Grade Point Average. Predictor variables included admission interview scores, admission academic scores and demographic data (gender, age and entry level). Interview score demonstrated a significant association with performance in three of six clinical placements through the course. This association was stronger than for any other admission criterion although effect sizes were small to moderate. Further, it was the only admission score to have a significant association with overall Clinical Grade Point Average for the two year groups analysed (r=0.322). By contrast, academic scores on entry showed significant associations with all year level Grade Point Averages except Year 4, the clinical year. This is the first study to review the predictive validity of an admission interview for entry into a physiotherapy course in Australia. The results show that performance in this admission interview is associated with overall performance in clinical placements through the course, while academic admission scoring is not. These findings suggest that there is a role for both academic and non-academic selection processes for entry into physiotherapy. Copyright © 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Inequalities in Specialist Hand Surgeon Distribution across the United States.

PubMed

Rios-Diaz, Arturo J; Metcalfe, David; Singh, Mansher; Zogg, Cheryl K; Olufajo, Olubode A; Ramos, Margarita S; Caterson, Edward J; Talbot, Simon G

2016-05-01

Unequal access to hospital specialists for emergency care is an issue in the United States. The authors sought to describe the geographic distribution of specialist hand surgeons and associated factors in the United States. Geographic distributions of surgeons holding a Subspecialty Certificate in Surgery of the Hand and hand surgery fellowship positions were identified from the American Board of Medical Specialties Database and the literature (2013), respectively. State-level population and per capita income were ascertained using U.S. Census data. Variations in hand trauma admissions were determined using Healthcare Cost and Utilization Project national/state inpatient databases. Risk-adjusted generalized linear models were used to assess independent association between hand surgeon density and hand trauma admission density, fellowship position density, and per capita income. Among 2019 specialist hand surgeons identified, 72.1 percent were orthopedic surgeons, 18.3 percent were plastic surgeons, and 9.6 percent were general surgeons. There were 157 hand surgery fellowship positions nationwide. There were 149,295 annual hand trauma admissions. The national density of specialist hand surgeons and density of trauma admission were 0.6 and 47.6, respectively. The density of specialist hand surgeons varied significantly between states. State-level variations in density of surgeons were independent and significantly associated with median per capita income (p < 0.001) and with density of fellowships (p = 0.014). Specialist hand surgeons are distributed unevenly across the United States. State-level analyses suggest that states with lower per capita incomes may be particularly underserved, which may contribute to regional disparities in access to emergency hand trauma care.

Admission to dedicated pediatric cardiac intensive care units is associated with decreased resource use in neonatal cardiac surgery.

PubMed

Johnson, Joyce T; Wilkes, Jacob F; Menon, Shaji C; Tani, Lloyd Y; Weng, Hsin-Yi; Marino, Bradley S; Pinto, Nelangi M

2018-06-01

Neonates undergoing congenital heart surgery require highly specialized, resource-intensive care. Location of care and degree of specialization can vary between and within institutions. Using a multi-institutional cohort, we sought to determine whether location of admission is associated with an increase in health care costs, resource use and mortality. We retrospectively analyzed admission for neonates (<30 days) undergoing congenital heart surgery between 2004 and 2013 by using the Pediatric Health Information Systems database (44 children's hospitals). Multivariate generalized estimating equations adjusted for center- and patient-specific risk factors and stratified by age at admission were performed to examine the association of admission intensive care unit (ICU) with total hospital costs, mortality, and length of stay. Of 19,984 neonates (60% male) identified, 39% were initially admitted to a cardiac ICU (CICU), 48% to a neonatal ICU (NICU), and 13% to a pediatric ICU. In adjusted models, admission to a CICU versus NICU was associated with a $20,440 reduction in total hospital cost for infants aged 2 to 7 days at admission (P = .007) and a $23,700 reduction in total cost for infants aged 8 to 14 days at admission (P = .01). Initial admission to a CICU or pediatric ICU versus NICU at <15 days of age was associated with shorter hospital and ICU length of stay and fewer days of mechanical ventilation. There was no difference in adjusted mortality by admission location. Admission to an ICU specializing in cardiac care is associated with significantly decreased hospital costs and more efficient resource use for neonates requiring cardiac surgery. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation.

PubMed

Lecuyer, Lucien; Chevret, Sylvie; Thiery, Guillaume; Darmon, Michael; Schlemmer, Benoît; Azoulay, Elie

2007-03-01

Cancer patients requiring mechanical ventilation are widely viewed as poor candidates for intensive care unit (ICU) admission. We designed a prospective study evaluating a new admission policy titled The ICU Trial. Prospective study. Intensive care unit. One hundred eighty-eight patients requiring mechanical ventilation and having at least one other organ failure. Over a 3-yr period, all patients with hematologic malignancies or solid tumors proposed for ICU admission underwent a triage procedure. Bedridden patients and patients in whom palliative care was the only cancer treatment option were not admitted to the ICU. Patients at earliest phase of the malignancy (diagnosis < 30 days) were admitted without any restriction. All other patients were prospectively included in The ICU Trial, consisting of a full-code ICU admission followed by reappraisal of the level of care on day 5. Among the 188 patients, 103 survived the first 4 ICU days and 85 died from the acute illness. Hospital survival was 21.8% overall. Among the 103 survivors on day 5, none of the characteristics of the malignancy were significantly different between the 62 patients who died and the 41 who survived. Time course of organ dysfunction over the first 6 ICU days differed significantly between survivors and nonsurvivors. Organ failure scores were more accurate on day 6 than at admission or on day 3 for predicting survival. All patients who required initiation of mechanical ventilation, vasopressors, or dialysis after 3 days in the ICU died. Survival was 40% in mechanically ventilated cancer patients who survived to day 5 and 21.8% overall. If these results are confirmed in future interventional studies, we recommend ICU admission with full-code management followed by reappraisal on day 6 in all nonbedridden cancer patients for whom lifespan-extending cancer treatment is available.

Using Lean principles to manage throughput on an inpatient rehabilitation unit.

PubMed

Chiodo, Anthony; Wilke, Ruste; Bakshi, Rishi; Craig, Anita; Duwe, Doug; Hurvitz, Edward

2012-11-01

Performance improvement is a mainstay of operations management and maintenance of certification. In this study at a University Hospital inpatient rehabilitation unit, Lean management techniques were used to manage throughput of patients into and out of the inpatient rehabilitation unit. At the start of this process, the average admission time to the rehabilitation unit was 5:00 p.m., with a median time of 3:30 p.m., and no patients received therapy on the day of admission. Within 8 mos, the mean admission time was 1:22 p.m., 50% of the patients were on the rehabilitation unit by 1:00 p.m., and more than 70% of all patients received therapy on the day of admission. Negative variance from this performance was evaluated, the identification of inefficient discharges holding up admissions as a problem was identified, and a Lean workshop was initiated. Once this problem was tackled, the prime objective of 70% of patients receiving therapy on the date of admission was consistently met. Lean management tools are effective in improving throughput on an inpatient rehabilitation unit.

Should We Pay Attention to the Delay Before Admission to a Pediatric Intensive Care Unit for Children With Cancer? Impact on 1-Month Mortality. A Report From the French Children's Oncology Study Group, GOCE.

PubMed

Fausser, Jeanne-L; Tavenard, Aude; Rialland, Fanny; Le Moine, Philippe; Minckes, Odile; Jourdain, Anne; Tirel, Olivier; Pellier, Isabelle; Gandemer, Virginie

2017-07-01

Acute complications requiring admission to pediatric intensive care unit (PICU) are frequent for children with cancer. Our objective was to determine early prognostic factors of mortality in a cohort of children with cancer hospitalized in PICU for acute complications and particularly to assess whether the delay before admission to a PICU is an early predictor of mortality. We conduct a retrospective multicenter analysis. All patients transferred in PICU for acute complications between January 2002 and December 2012 were included. One-month mortality of the 224 patients analyzed was 24.5%. Delay before PICU admission was a significant prognostic factor of 1-month mortality with nonsurvivors experiencing a longer median delay than survivors (24 vs. 12 h, respectively, P<0.05). Time from diagnosis to PICU admission (P<0.001), hematopoietic stem cell transplant (P<0.05), the duration of neutropenia (P<0.01), infection type (P<0.001), number of organ dysfunctions (P<0.001), and reaching any grade 4 toxicity before PICU admission (P<0.001) also affected mortality rate at 1-month post-PICU discharge. In the multivariate analysis, only reaching any grade 4 toxicity before PICU admission influenced 1-month mortality (odds ratio, 2.30; 95% confidence interval, 1.07-4.96; P<0.05). These results suggest that PICU admission before severe impairment leads to a better outcome for children with cancer.

Adherence Barriers to Chronic Dialysis in the United States

PubMed Central

Thadhani, Ravi I.; Maddux, Franklin W.

2014-01-01

Hemodialysis patients often do not attend their scheduled treatment session. We investigated factors associated with missed appointments and whether such nonadherence poses significant harm to patients and increases overall health care utilization in an observational analysis of 44 million hemodialysis treatments for 182,536 patients with ESRD in the United States. We assessed the risk of hospitalization, emergency room visit, or intensive-coronary care unit (ICU-CCU) admission in the 2 days after a missed treatment relative to the risk for patients who received hemodialysis. Over the 5-year study period, the average missed treatment rate was 7.1 days per patient-year. In covariate adjusted logistic regression, the risk of hospitalization (odds ratio [OR], 3.98; 95% confidence interval [95% CI], 3.93 to 4.04), emergency room visit (OR, 2.00; 95% CI, 1.87 to 2.14), or ICU-CCU admission (OR, 3.89; 95% CI, 3.81 to 3.96) increased significantly after a missed treatment. Overall, 0.9 missed treatment days per year associated with suboptimal transportation to dialysis, inclement weather, holidays, psychiatric illness, pain, and gastrointestinal upset. These barriers also associated with excess hospitalization (5.6 more events per patient-year), emergency room visits (1.1 more visits), and ICU-CCU admissions (0.8 more admissions). In conclusion, poor adherence to hemodialysis treatments may be a substantial roadblock to achieving better patient outcomes. Addressing systemic and patient barriers that impede access to hemodialysis care may decrease missed appointments and reduce patient morbidity. PMID:24762400

Turning Over Patient Turnover: An Ethnographic Study of Admissions, Discharges, and Transfers

PubMed Central

Mowinski Jennings, Bonnie; Sandelowski, Margarete; Boshamer, Cary C.; Higgins, Melinda K.

2014-01-01

The impact on nursing work of patient turnover (admissions, discharges, and transfers) became evident in an ethnographic study of turbulence. The patient turnover data were generated from extensive observations, 21 formal interviews, and a year of admission and discharge records on one medical and one surgical unit. Timing of turnover events on the two units differed, but on both units admissions typically interrupted workflow more than did discharges, clustered admissions were more disruptive than staggered admissions, and patient turnover during change of shift was more disruptive than during medication administration. Understanding the complexity of patient turnover will elucidate the work involved and improve the evidence base for nurse staffing, a key determinant of quality and safety of care. PMID:24242196

Physician Variability in Management of Emergency Department Patients with Chest Pain.

PubMed

Smulowitz, Peter B; Barrett, Orit; Hall, Matthew M; Grossman, Shamai A; Ullman, Edward A; Novack, Victor

2017-06-01

Chest pain is a common emergency department (ED) presentation accounting for 8-10 million visits per year in the United States. Physician-level factors such as risk tolerance are predictive of admission rates. The recent advent of accelerated diagnostic pathways and ED observation units may have an impact in reducing variation in admission rates on the individual physician level. We conducted a single-institution retrospective observational study of ED patients with a diagnosis of chest pain as determined by diagnostic code from our hospital administrative database. We included ED visits from 2012 and 2013. Patients with an elevated troponin or an electrocardiogram (ECG) demonstrating an ST elevation myocardial infarction were excluded. Patients were divided into two groups: "admission" (this included observation and inpatients) and "discharged." We stratified physicians by age, gender, residency location, and years since medical school. We controlled for patient- and hospital-related factors including age, gender, race, insurance status, daily ED volume, and lab values. Of 4,577 patients with documented dispositions, 3,252 (70.9%) were either admitted to the hospital or into observation (in an ED observation unit or in the hospital), while 1,333 (29.1%) were discharged. Median number of patients per physician was 132 (interquartile range 89-172). Average admission rate was 73.7±9.5% ranging from 54% to 96%. Of the 3,252 admissions, 2,638 (81.1%) were to observation. There was significant variation in the admission rate at the individual physician level with adjusted odds ratio ranging from 0.42 to 5.8 as compared to the average admission. Among physicians' characteristics, years elapsed since finishing medical school demonstrated a trend towards association with a higher admission probability. There is substantial variation among physicians in the management of patients presenting with chest pain, with physician experience playing a role.

Hypogonadism on admission to acute rehabilitation is correlated with lower functional status at admission and discharge.

PubMed

Carlson, N E; Brenner, L A; Wierman, M E; Harrison-Felix, C; Morey, C; Gallagher, S; Ripley, D

2009-04-01

To investigate the association between hormone levels and functional status during acute TBI rehabilitation. Retrospective cohort study of 43 men with moderate-to-severe TBI admitted to an acute rehabilitation unit during a 1 year period. Labs were drawn on admission, including total and free testosterone (T), prolactin, adrenocorticotropin hormone (ACTH), cortisol, thyroid stimulating hormone (TSH), free thyroxine (fT4) and insulin-like growth factor (IGF-1). Functional Independence Measure (FIM) scores were obtained at admission and discharge. Associations between admission hormone levels and the main outcomes, admission and discharge FIM scores, were assessed using linear regression. Lower total and free T-levels at admission were associated with lower total FIM scores at admission (p < 0.038) and discharge (p < 0.046). Higher cortisol levels at admission were significantly associated with lower admission (p = 0.012) and discharge (p = 0.036) scores on the cognitive-FIM. Prolactin, TSH, fT4 and IGF-1 were not correlated with functional status. In men, lower total and free T-levels at admission to acute rehabilitation correlate with lower admission and discharge FIM scores. These data support the need for studies to investigate the impact of physiological testosterone therapy on outcomes during and post-rehabilitation.

Effect of advanced age and vital signs on admission from an ED observation unit.

PubMed

Caterino, Jeffrey M; Hoover, Emily M; Moseley, Mark G

2013-01-01

The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission. We conducted a prospective, observational cohort study of ED patients placed in an ED-based observation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at a cutoff of 65 years or more. Vital signs were examined continuously and at commonly accepted cutoffs.We additionally controlled for demographics, comorbid conditions, laboratory values, and observation protocol. Three hundred patients were enrolled, 12% (n = 35) were 65 years or older, and 11% (n = 33) required admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07%-14.9%) in older adults and 12.1% (95% CI, 8.4%-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR], 0.30; 95% CI, 0.05-1.67). Predictors of admission included systolic pressure 180 mm Hg or greater (OR, 4.19; 95% CI, 1.08-16.30), log Charlson comorbidity score (OR, 2.93; 95% CI, 1.57-5.46), and white blood cell count 14,000/mm(3) or greater (OR, 11.35; 95% CI, 3.42-37.72). Among patients placed in an ED observation unit, age 65 years or more is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure 180 mm Hg or greater was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion. Copyright © 2013 Elsevier Inc. All rights reserved.

Effect of advanced age and vital signs on admission from an emergency department observation unit

PubMed Central

Caterino, Jeffrey M.; Hoover, Emily; Moseley, Mark G.

2012-01-01

Objectives The primary objective was to determine the relationship between advanced age and need for admission from an emergency department (ED) observation unit. The secondary objective was to determine the relationship between initial ED vital signs and admission. Methods We conducted a prospective, observational cohort study of ED patients placed in an ED-based observation unit. Multivariable penalized maximum likelihood logistic regression was used to identify independent predictors of need for hospital admission. Age was examined continuously and at a cutoff of ≥65 years. Vital signs were examined continuously and at commonly accepted cutoffs. We additionally controlled for demographics, co-morbid conditions, laboratory values, and observation protocol. Results Three hundred patients were enrolled, 12% (n=35) ≥65 years old and 11% (n=33) requiring admission. Admission rates were 2.9% (95% confidence interval [CI], 0.07-14.9%) in older adults and 12.1% (95% CI, 8.4-16.6%) in younger adults. In multivariable analysis, age was not associated with admission (odds ratio [OR] 0.30, 95% CI 0.05-1.67). Predictors of admission included: systolic pressure ≥180 mmHg (OR 4.19, 95% CI 1.08-16.30), log Charlson co-morbidity score (OR 2.93, 95% CI 1.57-5.46), and white blood cell count ≥14,000/mm3 (OR11.35, 95% CI 3.42-37.72). Conclusions Among patients placed in an ED observation unit, age ≥65 years is not associated with need for admission. Older adults can successfully be discharged from these units. Systolic pressure≥180 mmHg was the only predictive vital sign. In determining appropriateness of patients selected for an ED observation unit, advanced age should not be an automatic disqualifying criterion. PMID:22386358

What impact did a Paediatric Early Warning system have on emergency admissions to the paediatric intensive care unit? An observational cohort study.

PubMed

Sefton, G; McGrath, C; Tume, L; Lane, S; Lisboa, P J G; Carrol, E D

2015-04-01

The ideology underpinning Paediatric Early Warning systems (PEWs) is that earlier recognition of deteriorating in-patients would improve clinical outcomes. To explore how the introduction of PEWs at a tertiary children's hospital affects emergency admissions to the Paediatric Intensive Care Unit (PICU) and the impact on service delivery. To compare 'in-house' emergency admissions to PICU with 'external' admissions transferred from District General Hospitals (without PEWs). A before-and-after observational study August 2005-July 2006 (pre), August 2006-July 2007 (post) implementation of PEWs at the tertiary children's hospital. The median Paediatric Index of Mortality (PIM2) reduced; 0.44 vs 0.60 (p<0.001). Fewer admissions required invasive ventilation 62.7% vs 75.2% (p=0.015) for a shorter median duration; four to two days. The median length of PICU stay reduced; five to three days (p=0.002). There was a non-significant reduction in mortality (p=0.47). There was no comparable improvement in outcome seen in external emergency admissions to PICU. A 39% reduction in emergency admission total beds days reduced cancellation of major elective surgical cases and refusal of external PICU referrals. Following introduction of PEWs at a tertiary children's hospital PIM2 was reduced, patients required less PICU interventions and had a shorter length of stay. PICU service delivery improved. Copyright © 2014 Elsevier Ltd. All rights reserved.

Influenza in hospitalized children in Ireland in the pandemic period and the 2010/2011 season: risk factors for paediatric intensive-care-unit admission.

PubMed

Rebolledo, J; Igoe, D; O'Donnell, J; Domegan, L; Boland, M; Freyne, B; McNAMARA, A; Molloy, E; Callaghan, M; Ryan, A; O'Flanagan, D

2014-09-01

Influenza causes significant morbidity and mortality in children. This study's objectives were to describe influenza A(H1N1)pdm09 during the pandemic, to compare it with circulating influenza in 2010/2011, and to identify risk factors for severe influenza defined as requiring admission to a paediatric intensive care unit (PICU). Children hospitalized with influenza during the pandemic were older, and more likely to have received antiviral therapy than children hospitalized during the 2010/2011 season. In 2010/2011, only one child admitted to a PICU with underlying medical conditions had been vaccinated. The risk of severe illness in the pandemic was higher in females and those with underlying conditions. In 2010/2011, infection with influenza A(H1N1)pdm09 compared to other influenza viruses was a significant risk factor for severe disease. An incremental relationship was found between the number of underlying conditions and PICU admission. These findings highlight the importance of improving low vaccination uptake and increasing the use of antivirals in vulnerable children.

Rainfall-Associated Bronchospasm Epidemics: The Epidemiological Effects of Air Pollutants and Weather Variables

PubMed Central

Haddadzadeh Shoushtari, Maryam; Asgari Darian, Ali; Dastoorpoor, Maryam; Ebrahimzadeh, Pegah

2017-01-01

Background This study compares different risk factors in patients visiting a hospital during five rainfall-associated bronchospasm epidemics in Ahvaz and those visiting on other occasions. Methods This case-control study was conducted on 5307 patients with bronchospasm admitted to the Emergency Department of Imam Khomeini Hospital in Ahvaz (Iran) from late October to December (as the epidemic) and 916 patients admitted from late January to March (as the nonepidemic) in 2011 to 2015. Results A total of the 41.7% of the cases and 48.8% of the controls had episodes of bronchospasm, suggesting a significant difference between the two groups (P < 0.001). The mean concentrations of PM10, NO, NO2, and NOx pollutants (except O3) were significantly higher in the nonepidemic periods (P < 0.05). The adjusted analysis showed a direct significant relationship between emergency respiratory admissions and each unit of increase in NO and SO2 concentration during the epidemic periods and NO2 concentration during the nonepidemic periods. During the epidemic periods, a direct and significant relationship was also observed between respiratory admissions and each unit of increase in relative humidity and evaporation. Conclusion The results suggest that certain pollutants and weather variables are associated with the risk of emergency respiratory admissions during epidemic periods. PMID:29089817

Use of the Suicide Status Form-II to investigate correlates of suicide risk factors in psychiatrically hospitalized children and adolescents

PubMed Central

Romanowicz, Magdalena; O’Connor, Stephen S.; Schak, Kathryn M.; Swintak, Cosima C.; Lineberry, Timothy W.

2013-01-01

Background Suicide is the third leading cause of death in the United States for youth 12–17 years or age. Acute psychiatric hospitalization represents a clear worst point clinically and acute suicide risk is the most common reason for psychiatric admission. We sought to determine factors associated with differences in individual suicide risk assessment for children and adolescents during acute psychiatric admission. Methods Study participants were 1,153 youth consecutively admitted to an inpatient psychiatry unit who completed a self-administered Suicide Status Form (SSF) within 24 hours of admission. Additional information on suicide risk factors was obtained through medical chart abstraction. Results Females reported significantly greater psychological pain, stress, hopelessness, and self-hate on the SSF and were significantly more likely to have made a suicide attempt just prior to the index hospital admission (OR = 1.59, SE = .29; CI = 1.12–2.26), report a family history of suicide (OR = 2.02, SE = .33; CI = 1.47–2.78), and had experienced a greater number of inpatient psychiatry admissions related to suicidal ideation (RR = 1.33, SE = .13; CI = 1.10–1.61). High school aged youth and those with a primary diagnosis of depression displayed consistently elevated SSF scores and risk factors for suicide compared to comparison groups. Limitations Diagnosis was determined through chart abstraction. Responses to access to firearm question had missing data for 46% of the total sample. Conclusions Systematic administration of a suicide-specific measure at admission may help clinicians improve identification of suicide risk factors in youth in inpatient psychiatry settings. PMID:23856283

Use of the Suicide Status Form-II to investigate correlates of suicide risk factors in psychiatrically hospitalized children and adolescents.

PubMed

Romanowicz, Magdalena; O'Connor, Stephen S; Schak, Kathryn M; Swintak, Cosima C; Lineberry, Timothy W

2013-11-01

Suicide is the third leading cause of death in the United States for youth 12-17 years or age. Acute psychiatric hospitalization represents a clear worst point clinically and acute suicide risk is the most common reason for psychiatric admission. We sought to determine factors associated with differences in individual suicide risk assessment for children and adolescents during acute psychiatric admission. Study participants were 1153 youth consecutively admitted to an inpatient psychiatry unit who completed a self-administered Suicide Status Form (SSF) within 24h of admission. Additional information on suicide risk factors was obtained through medical chart abstraction. Females reported significantly greater psychological pain, stress, hopelessness, and self-hate on the SSF and were significantly more likely to have made a suicide attempt just prior to the index hospital admission (OR=1.59, SE=0.29; CI=1.12-2.26), report a family history of suicide (OR=2.02, SE=0.33; CI=1.47-2.78), and had experienced a greater number of inpatient psychiatry admissions related to suicidal ideation (RR=1.33, SE=0.13; CI=1.10-1.61). High school aged youth and those with a primary diagnosis of depression displayed consistently elevated SSF scores and risk factors for suicide compared to comparison groups. Diagnosis was determined through chart abstraction. Responses to access to firearm question had missing data for 46% of the total sample. Systematic administration of a suicide-specific measure at admission may help clinicians improve identification of suicide risk factors in youth in inpatient psychiatry settings. © 2013 Elsevier B.V. All rights reserved.

Adherence barriers to chronic dialysis in the United States.

PubMed

Chan, Kevin E; Thadhani, Ravi I; Maddux, Franklin W

2014-11-01

Hemodialysis patients often do not attend their scheduled treatment session. We investigated factors associated with missed appointments and whether such nonadherence poses significant harm to patients and increases overall health care utilization in an observational analysis of 44 million hemodialysis treatments for 182,536 patients with ESRD in the United States. We assessed the risk of hospitalization, emergency room visit, or intensive-coronary care unit (ICU-CCU) admission in the 2 days after a missed treatment relative to the risk for patients who received hemodialysis. Over the 5-year study period, the average missed treatment rate was 7.1 days per patient-year. In covariate adjusted logistic regression, the risk of hospitalization (odds ratio [OR], 3.98; 95% confidence interval [95% CI], 3.93 to 4.04), emergency room visit (OR, 2.00; 95% CI, 1.87 to 2.14), or ICU-CCU admission (OR, 3.89; 95% CI, 3.81 to 3.96) increased significantly after a missed treatment. Overall, 0.9 missed treatment days per year associated with suboptimal transportation to dialysis, inclement weather, holidays, psychiatric illness, pain, and gastrointestinal upset. These barriers also associated with excess hospitalization (5.6 more events per patient-year), emergency room visits (1.1 more visits), and ICU-CCU admissions (0.8 more admissions). In conclusion, poor adherence to hemodialysis treatments may be a substantial roadblock to achieving better patient outcomes. Addressing systemic and patient barriers that impede access to hemodialysis care may decrease missed appointments and reduce patient morbidity. Copyright © 2014 by the American Society of Nephrology.

Association of methamphetamine use and restrictive interventions in an acute adult inpatient mental health unit: A retrospective cohort study.

PubMed

McKenna, Brian; McEvedy, Samantha; Kelly, Kathleen; Long, Bec; Anderson, Jess; Dalzell, Elaine; Maguire, Tessa; Tacey, Mark; Furness, Trentham

2017-02-01

The aim of the present study was to describe incidences of restrictive interventions and the association of methamphetamine use at an acute adult inpatient mental health unit in metropolitan Melbourne, Victoria, Australia. A total of 232 consecutive consumer admissions to the inpatient unit across a 3-month period were described for illicit substance use and the use of restrictive interventions (seclusion, mechanical restraint, and physical restraint) prior to and during admission. Of all admissions, 25 (10.8%) involved consumers subjected to a restrictive intervention. Methamphetamine use was either self-reported or detected by saliva test for 71 (30.6%) consumers. Following multivariate analyses, methamphetamine use (odds ratio (OR): 7.83, 95% confidence interval (CI): 2.33-26.31) and restrictive intervention in the emergency department prior to admission (OR: 8.85, 95% CI: 2.83-27.70) were significant independent predictors of the use of restrictive interventions after inpatient admission. Anecdotal observations provided by clinical mental health staff that consumers intoxicated with methamphetamine appear to require restrictive intervention more frequently than other consumers was confirmed with the results of the current study. As the state of Victoria in Australia is on a pathway to the elimination of the use of restrictive interventions in mental health services, clinicians need to develop management strategies that provide specialist mental health care using the least-restrictive interventions. Although 26.8% of methamphetamine users were secluded after admission, restrictive interventions should not be the default management strategy for consumers who present with self-report or positive screen for methamphetamine use. © 2016 Australian College of Mental Health Nurses Inc.

Epidemiology, clinical characteristics, and risk factors for mortality of early- and late-onset invasive candidiasis in intensive care units in China

PubMed Central

Yang, Yi; Guo, Fengmei; Kang, Yan; Zang, Bin; Cui, Wei; Qin, Bingyu; Qin, Yingzhi; Fang, Qiang; Qin, Tiehe; Jiang, Dongpo; Cai, Bojing; Li, Ruoyu; Qiu, Haibo

2017-01-01

Abstract To identify the epidemiology, treatments, outcomes, and risk factors for patients with early- or late-onset invasive candidiasis (EOIC or LOIC) in intensive care units in China. Patients were classified as EOIC (≤10 days) or LOIC (>10 days) according to the time from hospital admission to IC onset to identify distinct clinical characteristics. There were 105 EOIC cases and 201 LOIC cases in this study. EOIC was related to more severe clinical conditions at ICU admission or prior to IC. Significantly, more cases of Candida parapsilosis infection were found in patients with LOIC than in those with EOIC. The mortality of EOIC was significantly lower than that for LOIC. Sequential Organ Failure Assessment (SOFA) score at ICI diagnosis in the EOIC group and the interval from ICU admission to ICI occurrence in the LOIC group were identified as risk factors for mortality. Susceptibility to the first-line agent was associated with a lower risk of mortality in the LOIC group. The mortality rate was significantly lower in the EOIC group, and there were more cases of non-albicans infection in the LOIC group. Susceptibility to the first-line agent was an important predictor of mortality in the LOIC group. SOFA score at ICI diagnosis in the EOIC group and interval from ICU admission to ICI occurrence in the LOIC group were identified as risk factors for mortality. PMID:29049184

Successful outcomes following neurorehabilitation in military traumatic brain injury patients in the United Kingdom.

PubMed

Dharm-Datta, Shreshth; Gough, Michael R C; Porter, Patrick J; Duncan-Anderson, Jennifer; Olivier, Elizabeth; McGilloway, Emer; Etherington, John

2015-10-01

The Defence Medical Rehabilitation Centre Headley Court is the UK military rehabilitation unit. A pilot study identified the Mayo-Portland Adaptability Inventory-4 (MPAI-4) as the most appropriate rehabilitation outcome measure in young military patients with acquired brain injury. MPAI-4 scores were prospectively recorded for patients on admission and discharge. At 4 months, independent living and employment status were recorded. Inclusion criteria were all new admissions with traumatic brain injury (TBI). Before injury, all patients were fully employed and lived independently. In a 3-year period from April 2011, there were 91 TBI patients with complete admission-discharge episodes: by US Department of Defense criteria, 21 were mild, 35 were moderate, and 35 were severe. There was a significant positive relationship between TBI severity and MPAI-4 score on admission (χ = 12.77, df = 2, p = 0.0017).Median age was 27 years, and median duration of admission was 63 days. Employment and independent living status were available for 79 patients at 4 months. Seventy-three patients (92%) were in community-based employment, with 64 (81%) employed in a competitive or transitional work; 6 (8%) were unemployed or in sheltered work. Sixty-nine (87%) were living independently, and 10 (13%) were living with support in their own home, with no one requiring institutional care.Complete MPAI-4 scores were available for 79 patients. There were statistically and clinically significant improvements in MPAI-4 scores between admission and discharge for the overall group: median admission T score was 40.0 (95% confidence interval, 36.0-42.0) and on discharge was 31.0 (95% confidence interval, 27.0-36.0), a nine-point change (Z = 6.53, p < 0.0001). These improvements with rehabilitation were sustained when patients were subdivided by TBI severity or MPAI-4 limitations. This study demonstrates significant functional improvements in military TBI patients following intensive inpatient multidisciplinary rehabilitation, which includes substantial vocational rehabilitation. At 4 months, 92% were employed, and 87% were living independently. Therapeutic study, level V; prognostic/epidemiologic study, level IV.

Chronic obstructive pulmonary disease exacerbation in the intensive care unit: clinical, functional and quality of life at discharge and 3 months of follow up.

PubMed

Viana, Renata Cristina Teixeira Pinto; Pincelli, Mariangela Pimentel; Pizzichini, Emílio; Silva, André Pacheco; Manes, Joice; Marconi, Tatiana Dias; Steidle, Leila John Marques

2017-01-01

The purpose of this study was to evaluate the clinical/functional aspects and quality of life of chronic obstructive pulmonary disease patients who were discharged after an intensive care unit admission for acute respiratory failure. This prospective study included chronic obstructive pulmonary disease patients who were admitted to two intensive care units between December of 2010 and August of 2011 and evaluated over three visits after discharge. Thirty patients were included, and 20 patients completed the three-month follow up. There was a significant improvement in the following: forced expiratory flow in one second (L) (1.1/1.4/1.4; p = 0.019), six-minute walk test (m) (- /232.8 /272.6; p = 0.04), BODE score (7.5/5.0/3.8; p = 0.001), cognition measured by the Mini Mental State Examination (21/23.5/23.5; p = 0.008) and quality of life measured by the total Saint George Respiratory Questionnaire score (63.3/56.8/51, p = 0.02). The mean difference in the total score was 12.3 (between visits 1 and three). Important clinical differences were observed for the symptom score (18.8), activities score (5.2) and impact score (14.3). The majority of participants (80%) reported they would be willing to undergo a new intensive care unit admission. Despite the disease severity, there was a significant clinical, functional and quality of life improvement at the end of the third month. Most patients would be willing to undergo a new intensive care unit admission.

Nursing workload in public and private intensive care units

PubMed Central

Nogueira, Lilia de Souza; Koike, Karina Mitie; Sardinha, Débora Souza; Padilha, Katia Grillo; de Sousa, Regina Marcia Cardoso

2013-01-01

Objective This study sought to compare patients at public and private intensive care units according to the nursing workload and interventions provided. Methods This retrospective, comparative cohort study included 600 patients admitted to 4 intensive care units in São Paulo. The nursing workload and interventions were assessed using the Nursing Activities Score during the first and last 24 hours of the patient's stay at the intensive care unit. Pearson's chi-square test, Fisher's exact test, the Mann-Whitney test, and Student's t test were used to compare the patient groups. Results The average Nursing Activities Score upon admission to the intensive care unit was 61.9, with a score of 52.8 upon discharge. Significant differences were found among the patients at public and private intensive care units relative to the average Nursing Activities Score upon admission, as well as for 12 out of 23 nursing interventions performed during the first 24 hours of stay at the intensive care units. The patients at the public intensive care units exhibited a higher average score and overall more frequent nursing interventions, with the exception of those involved in the "care of drains", "mobilization and positioning", and "intravenous hyperalimentation". The groups also differed with regard to the evolution of the Nursing Activities Score among the total case series as well as the groups of survivors from the time of admission to discharge from the intensive care unit. Conclusion Patients admitted to public and private intensive care units exhibit differences in their nursing care demands, which may help managers with nursing manpower planning. PMID:24213086

Impact of a crisis assessment and treatment service on admissions into an acute psychiatric unit.

PubMed

Adesanya, Adesina

2005-06-01

To assess the impact of a regional/rural crisis assessment and treatment service (CAT) on admissions into an acute adult inpatient psychiatric facility. Relevant data for admissions into an acute adult inpatient psychiatric facility in the 18 month periods before and after the establishment of a CAT were compared. Data extracted from available clinical records were transferred into an appropriately structured pro forma for statistical analysis. There were 69 and 53 index inpatient unit admissions in the two time periods. The majority of these were for single, unemployed men aged in their 30s. Although statistically non-significant, the results appear to suggest that there were proportionately fewer readmissions and that admissions were likely to be influenced by illness severity and diagnostic considerations in the period following the establishment of the CAT. The establishment of CAT did not appear to have had much impact on the duration of psychiatric hospitalization. Crisis assessment and treatment services operating within a regional/rural integrated mental health setting appear to have only limited impact on hospitalization for psychiatric crisis presentations. There is a need for further studies looking at a broader range of outcome variables in the assessment of the impact of CAT on psychiatric hospitalization in such settings.

Spinal cord injury rehabilitation in Riyadh, Saudi Arabia: Time to rehabilitation admission, length of stay and functional independence

PubMed Central

Mahmoud, Husam; Qannam, Hazem; Mortenson, Ben

2017-01-01

Objectives 1) To describe functional status, length of stay (LOS), and time to rehabilitation admission trends. 2) To identify independent predictors of motor function following rehabilitation for traumatic and nontraumatic spinal cord injury (SCI). Participants Adult patients with SCI discharged from inpatient rehabilitation between 2009–2014. Design Retrospective cohort study. Setting Spinal injury rehabilitation unit at the King Fahad Medical City, Riyadh, Saudi Arabia. Methods From retrospective chart reviews of 312 traumatic and 106 nontraumatic SCI, we extracted information on time from injury to rehabilitation admission, rehabilitation LOS, and Functional Independence Measure (FIM) score (admission and discharge). Additionally we collected information on SCI patients’ demographics and injury characteristics. Hierarchical regression was employed to investigate variables associated with FIM motor score at discharge for traumatic SCI and nontraumatic SCI. Outcome measures FIM motor score measured at discharge. Results Mean and median days from injury to rehabilitation admission were not significantly different for traumatic SCI (377±855, 150) and nontraumatic SCI (288±403, 176). Mean and median days for rehabilitation LOS were significantly longer for traumatic SCI (85±60, 70) compared to nontraumatic SCI (64±59, 49) (p=…..). FIM scores improved significantly from admission to discharge in both groups. For individuals with traumatic SCI, after accounting for admission FIM motor score, tetraplegia and time from injury to rehabilitation, admission had a significant but small negative association with discharge FIM motor score. For individuals with nontraumatic SCI, increasing age and AIS score of A or B had a significant negative association with discharge FIM motor score. LOS in rehabilitation was not a significant contributor for either model. Conclusions Decreasing the time from injury to rehabilitation admission may improve outcomes for those with traumatic SCI. Since time spent in rehabilitation was shorter than most other countries, a change in practice in this area may be warranted. Developing new strategies to improve outcomes for older patients with nontraumatic SCI would also be beneficial. PMID:28139661

Japanese Bereaved Family Members' Perspectives of Palliative Care Units and Palliative Care: J-HOPE Study Results.

PubMed

Kinoshita, Satomi; Miyashita, Mitsunori; Morita, Tatsuya; Sato, Kazuki; Shoji, Ayaka; Chiba, Yurika; Miyazaki, Tamana; Tsuneto, Satoru; Shima, Yasuo

2016-06-01

The study purpose was to understand the perspectives of bereaved family members regarding palliative care unit (PCU) and palliative care and to compare perceptions of PCU before admission and after bereavement. A cross-sectional questionnaire survey was conducted, and the perceptions of 454 and 424 bereaved family members were obtained regarding PCU and palliative care, respectively. Family members were significantly more likely to have positive perceptions after bereavement (ranging from 73% to 80%) compared to before admission (ranging from 62% to 71%). Bereaved family members who were satisfied with medical care in the PCU had a positive perception of the PCU and palliative care after bereavement. Respondents younger than 65 years of age were significantly more likely to have negative perceptions of PCU and palliative care. © The Author(s) 2015.

Determining delayed admission to intensive care unit for mechanically ventilated patients in the emergency department.

PubMed

Hung, Shih-Chiang; Kung, Chia-Te; Hung, Chih-Wei; Liu, Ber-Ming; Liu, Jien-Wei; Chew, Ghee; Chuang, Hung-Yi; Lee, Wen-Huei; Lee, Tzu-Chi

2014-08-23

The adverse effects of delayed admission to the intensive care unit (ICU) have been recognized in previous studies. However, the definitions of delayed admission varies across studies. This study proposed a model to define "delayed admission", and explored the effect of ICU-waiting time on patients' outcome. This retrospective cohort study included non-traumatic adult patients on mechanical ventilation in the emergency department (ED), from July 2009 to June 2010. The primary outcomes measures were 21-ventilator-day mortality and prolonged hospital stays (over 30 days). Models of Cox regression and logistic regression were used for multivariate analysis. The non-delayed ICU-waiting was defined as a period in which the time effect on mortality was not statistically significant in a Cox regression model. To identify a suitable cut-off point between "delayed" and "non-delayed", subsets from the overall data were made based on ICU-waiting time and the hazard ratio of ICU-waiting hour in each subset was iteratively calculated. The cut-off time was then used to evaluate the impact of delayed ICU admission on mortality and prolonged length of hospital stay. The final analysis included 1,242 patients. The time effect on mortality emerged after 4 hours, thus we deduced ICU-waiting time in ED > 4 hours as delayed. By logistic regression analysis, delayed ICU admission affected the outcomes of 21 ventilator-days mortality and prolonged hospital stay, with odds ratio of 1.41 (95% confidence interval, 1.05 to 1.89) and 1.56 (95% confidence interval, 1.07 to 2.27) respectively. For patients on mechanical ventilation at the ED, delayed ICU admission is associated with higher probability of mortality and additional resource expenditure. A benchmark waiting time of no more than 4 hours for ICU admission is recommended.

Pediatric inpatient humanitarian care in combat: Iraq and Afghanistan 2002 to 2012.

PubMed

Edwards, Mary J; Lustik, Michael; Burnett, Mark W; Eichelberger, Martin

2014-05-01

The purpose of this study was to define the scope of combat- and noncombat-related inpatient pediatric humanitarian care provided from 2002 to 2012 by the United States (US) Military in Iraq and Afghanistan. A review of the Patient Administration Systems and Biostatistics Activity (PASBA) database for all admissions from 2002 to 2012 by US military hospitals in Afghanistan and Iraq for children 14 years of age and younger provided data to analyze the use of medical care. North Atlantic Treaty Organization Standardization Agreement (STANAG) injury codes provided injury cause and the ICD-codes provided diagnosis. In-hospital mortality, blood usage, number of invasive procedures, and hospital stay were analyzed by country and injury category. There were 6,273 admissions that met inclusion criteria. In Afghanistan, there were more than twice as many pediatric noncombat-related admissions (2,197) as pediatric combat-related admissions (1,095). In Iraq, the difference was minimal (1,391 noncombat vs 1,590 combat). The most common cause of noncombat-related admission in both countries was injury: primarily motor vehicle related and burns, which varied significantly by age. Older patients (older than 8 years in Afghanistan and older than 4 years in Iraq) were more likely combat victims. Mortality was highest for combat trauma in Iraq (11%) and noncombat trauma in Afghanistan (8%). The in-hospital mortality in both countries was 5% for admissions unrelated to trauma. Resource use was highest for combat trauma in both countries. Noncombat-related medical care was the primary reason for pediatric humanitarian admissions to United States military combat hospitals in Iraq and Afghanistan from 2002 to 2012. Combat-related injuries have a higher mortality than noncombat injuries or other admissions. Published by Elsevier Inc.

Association of hospitalizations for asthma with seasonal and pandemic influenza.

PubMed

Gerke, Alicia K; Yang, Ming; Tang, Fan; Foster, Eric D; Cavanaugh, Joseph E; Polgreen, Philip M

2014-01-01

Although influenza has been associated with asthma exacerbations, it is not clear the extent to which this association affects health care use in the United States. The first goal of this project was to determine whether, and to what extent, the incidence of asthma hospitalizations is associated with seasonal variation in influenza. Second, we used influenza trends (2000-2008) to help predict asthma admissions during the 2009 H1N1 influenza pandemic. We identified all hospitalizations between 1998 and 2008 in the Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project during which a primary diagnosis of asthma was recorded. Separately, we identified all hospitalizations during which a diagnosis of influenza was recorded. We performed time series regression analyses to investigate the association of monthly asthma admissions with influenza incidence. Finally, we applied these time series regression models using 1998-2008 data, to forecast monthly asthma admissions during the 2009 influenza pandemic. Based on time series regression models, a strong, significant association exists between concurrent influenza activity and incidence of asthma hospitalizations (P-value < 0.0001). Use of influenza data to predict asthma admissions during the 2009 H1N1 pandemic improved the mean squared prediction error by 60.2%. Influenza activity in the population is significantly associated with asthma hospitalizations in the United States, and this association can be exploited to more accurately forecast asthma admissions. Our results suggest that improvements in influenza surveillance, prevention and treatment may decrease hospitalizations of asthma patients. © 2013 The Authors. Respirology © 2013 Asian Pacific Society of Respirology.

Short- and long-term outcomes of AL amyloidosis patients admitted into intensive care units.

PubMed

Guinault, Damien; Canet, Emmanuel; Huart, Antoine; Jaccard, Arnaud; Ribes, David; Lavayssiere, Laurence; Venot, Marion; Cointault, Olivier; Roussel, Murielle; Nogier, Marie-Béatrice; Pichereau, Claire; Lemiale, Virginie; Arnulf, Bertrand; Attal, Michel; Chauveau, Dominique; Azoulay, Elie; Faguer, Stanislas

2016-09-01

Amyloidosis is a rare and threatening condition that may require intensive care because of amyloid deposit-related organ dysfunction or therapy-related adverse events. Although new multiple myeloma drugs have dramatically improved outcomes in AL amyloidosis, the outcomes of AL patients admitted into intensive care units (ICUs) remain largely unknown. Admission has been often restricted to patients with low Mayo Clinic staging and/or with a complete or very good immunological response at admission. In a retrospective multicentre cohort of 66 adult AL (n = 52) or AA (n = 14) amyloidosis patients, with similar causes of admission to an ICU, the 28-d and 6-month survival rates of AA patients were significantly higher compared to AL patients (93% vs. 60%, P = 0·03; 71% vs. 45%, P = 0·02, respectively). In AL patients, the simplified Index of Gravity Score (IGS2) was the only independent predictive factor for death by day 28, whereas the Mayo-Clinic classification stage had no influence. In Cox's multivariate regression model, only cardiac arrest and on-going chemotherapy at ICU admission significantly predicted death at 6 months. Short-term outcomes of AL patients admitted into an ICU were mainly related to the severity of the acute medical condition, whereas on-going chemotherapy for active amyloidosis impacted on long-term outcomes. © 2016 John Wiley & Sons Ltd.

Time-series analysis of the barriers for admission into a spinal rehabilitation unit.

PubMed

New, P W; Akram, M

2016-02-01

This is a prospective open-cohort case series. The objective of this study was to assess changes over time in the duration of key acute hospital process barriers for patients with spinal cord damage (SCD) from admission until transfer into spinal rehabilitation unit (SRU) or other destinations. The study was conducted in Acute hospitals, Victoria, Australia (2006-2013). Duration of the following discrete sequential processes was measured: acute hospital admission until referral to SRU, referral until SRU assessment, SRU assessment until ready for SRU transfer and ready for transfer until SRU admission. Time-series analysis was performed using a generalised additive model (GAM). Seasonality of non-traumatic spinal cord dysfunction (SCDys) was examined. GAM analysis shows that the waiting time for admission into SRU was significantly (P<0.001) longer for patients who were female, who had tetraplegia, who were motor complete, had a pelvic pressure ulcer and who were referred from another health network. Age had a non-linear effect on the duration of waiting for transfer from acute hospital to SRU and both the acute hospital and SRU length of stay (LOS). The duration patients spent waiting for SRU admission increased over the study period. There was an increase in the number of referrals over the study period and an increase in the number of patients accepted but not admitted into the SRU. There was no notable seasonal influence on the referral of patients with SCDys. Time-series analysis provides additional insights into changes in the waiting times for SRU admission and the LOS in hospital for patients with SCD.

White paper of Italian Gastroenterology: delivery of services for digestive diseases in Italy: weaknesses and strengths.

PubMed

Buscarini, Elisabetta; Conte, Dario; Cannizzaro, Renato; Bazzoli, Franco; De Boni, Michele; Delle Fave, Gianfranco; Farinati, Fabio; Ravelli, Paolo; Testoni, Pier Alberto; Lisiero, Manola; Spolaore, Paolo

2014-07-01

In 2011 the three major Italian gastroenterological scientific societies (AIGO, the Italian Society of Hospital Gastroenterologists and Endoscopists; SIED, the Italian Society of Endoscopy; SIGE, the Italian Society of Gastroenterology) prepared their official document aimed at analysing medical care for digestive diseases in Italy, on the basis of national and regional data (Health Ministry and Lombardia, Veneto, Emilia-Romagna databases) and to make proposals for planning of care. Digestive diseases were the first or second cause of hospitalizations in Italy in 1999-2009, with more than 1,500,000 admissions/year; however only 5-9% of these admissions was in specialized Gastroenterology units. Reported data show a better outcome in Gastroenterology Units than in non-specialized units: shorter average length of stay, in particular for admissions with ICD-9-CM codes proxying for emergency conditions (6.7 days versus 8.4 days); better case mix (higher average diagnosis-related groups weight in Gastroenterology Units: 1 vs 0.97 in Internal Medicine units and 0.76 in Surgery units); lower inappropriateness of admissions (16-25% versus 29-87%); lower in-hospital mortality in urgent admissions (2.2% versus 5.1%); for patients with urgent admissions due to gastrointestinnal haemorrhage, in-hospital mortality was 2.3% in Gastroenterology units versus 4.0% in others. The present document summarizes the scientific societies' official report, which constitutes the "White paper of Italian Gastroenterology". Copyright © 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Precipitating factors, outcomes, and recurrence of diabetic ketoacidosis at a university hospital in Damascus

PubMed Central

Alourfi, Zaynab; Homsi, Hakam

2015-01-01

Aims: To study precipitating factors, outcomes, and recurrence of diabetic ketoacidosis (DKA) at a University hospital at Damascus, the capital of Syria. Patients and Methods: Medical records between 2006 and 2012 were reviewed. One hundred and fifteen admissions for 100 patients with DKA were included. All fulfilled the American Diabetic Association DKA diagnostic criteria. Results: Of 115 admissions of DKA, there were 92 single admission and 23 recurrent admissions (eight patients). The order of precipitating factors of recurrent DKA or single admissions were the same with different percentage. The first and second factors were infection (74% and 48%) and treatment problems (17% and 24%), respectively. Complications rate was significantly higher in the intensive care unit (41.6%), compared to the ward admissions (14.2%). Overall in-hospital mortality rate was 11.3%. The severity of medical conditions that provoke DKA with aging, not the metabolic complications of hyperglycemia or ketoacidosis, were behind this high mortality rate. Patients who died were significantly (P = 0.004) older than patients who were discharged alive. Conclusion: Results concerning precipitating factor were similar to the results of many other studies. However, mortality rate was higher which might be explained by the severity of underlying precipitating illness. PMID:25625084

The ecological relationship between deprivation, social isolation and rates of hospital admission for acute psychiatric care: a comparison of London and New York City.

PubMed

Curtis, Sarah; Copeland, Alison; Fagg, James; Congdon, Peter; Almog, Michael; Fitzpatrick, Justine

2006-03-01

We report on comparative analyses of small area variation in rates of acute hospital admissions for psychiatric conditions in Greater London around the year 1998 and in New York City (NYC) in 2000. Based on a theoretical model of the factors likely to influence psychiatric admission rates, and using data from the most recent population censuses and other sources, we examine the association with area indicators designed to measure access to hospital beds, socio-economic deprivation, social fragmentation and ethnic/racial composition. We report results on admissions for men and women aged 15-64 for all psychiatric conditions (excluding self-harm), drug-related substance abuse/addiction, schizophrenia and affective disorders. The units of analysis in NYC were 165 five-digit Zip Code Areas and, in London, 760 electoral wards as defined in 1998. The analysis controls for age and sex composition and, as a proxy for access to care, spatial proximity to hospitals with psychiatric beds. Poisson regression modeling incorporating random effects was used to control for both overdispersion in the counts of admissions and for the effects of spatial autocorrelation. The results for NYC and London showed that local admission rates for all types of condition were positively and significantly associated with deprivation and the association is independent of demographic composition or 'access' to beds. In NYC, social fragmentation showed a significant association with admissions due to affective disorders and schizophrenia, and for drug dependency among females. Racial minority concentration was significantly and positively associated with admissions for schizophrenia. In London, social fragmentation was associated positively with admissions for men and women due to schizophrenia and affective disorders. The variable measuring racial/ethnic minority concentration for London wards showed a negative association with admission rates for drug dependency and for affective disorders. We discuss the interpretation of these results and the issues they raise in terms of the potential and limitations of international comparison.

A Service Evaluation of a 1-Year Dialectical Behaviour Therapy Programme for Women with Borderline Personality Disorder in a Low Secure Unit.

PubMed

Fox, Emily; Krawczyk, Kirsten; Staniford, Jessica; Dickens, Geoffrey L

2015-11-01

Previous studies about the effectiveness of Dialectical Behaviour Therapy for the treatment of Borderline Personality Disorder have had promising results. However, no previous studies have examined its effectiveness when delivered in low secure inpatient services for women. To evaluate clinical outcomes during and after a 1-year period of admission within a low secure unit for women offering a Dialectical Behaviour Therapy programme. A naturalistic, within subjects study of clinical data collected as part of routine practice was conducted. Participants were 18 consecutively admitted women who met the diagnostic criteria for Borderline Personality Disorder and had completed at least 1 year of treatment. Measures covered: risk behaviours; self-reported symptoms of Borderline Personality Disorder, and current mood and symptom experience; staff reports of clinical problems, needs and social functioning. Scores were compared between admission and at 6 months and 1 year. There was a statistically significant improvement on all 13 measures over the year's treatment. Most improvement was demonstrated between admission and 6 months. Engagement in1-year's treatment was associated with significant reduction in risk behaviours and both staff-rated and self-rated outcome measures. Some significant questions remain about which elements of the programme are most effective but the results are encouraging.

National Characteristics of Lymphatic Malformations in Children: Inpatient Estimates and Trends in the United States, 2000 to 2009.

PubMed

Cheng, Jeffrey; Liu, Beiyu; Farjat, Alfredo E; Routh, Jonathan

2018-04-01

With ever increasing demands to manage finite resources for health care utilization, we performed an investigation to identify inpatient clinical characteristics and trends in children with lymphatic malformations using the Kids' Inpatient Database, years 2000 to 2009, to help identify populations best suited for resource deployment. Subjects included children 18 years and below with International Classification of Diseases (ICD), ninth revision code: 228.1-lymphangioma, any site. In the United States, between 2000 and 2009, inpatient pediatric patients with lymphatic malformations most commonly affected children aged 3 years and younger, urban hospital locations, and the South and West regions. There was no significant change in age of children with lymphatic malformations or the distribution of their age from year to year, P=0.948 and 0.4223, respectively. No significant evidence for seasonal variation or effect on inpatient admission was identified, P=0.7071. A great majority of admissions (>96%) were in urban locations across each year. There was also no significant change in breakdown of admissions by geographic location, P=0.7133. Further investigation may help to elucidate how to improve access to multidisciplinary vascular anomalies teams to optimize care for these children with unique and complex lymphatic malformations.

"Skimming the Cream"? Admissions to Charter Schools in the United States and to Autonomous Schools in England

ERIC Educational Resources Information Center

West, Anne; Ingram, Dabney; Hind, Audrey

2006-01-01

This article focuses on student admissions to charter schools in the United States and to autonomous (foundation and voluntary-aided) secondary schools in England. Analyses of the admissions criteria used by autonomous and nonautonomous secondary schools in England revealed that more autonomous than nonautonomous schools reported using potentially…

Comparing the Incidence of Febrile Neutropenia Resulting in Hospital Admission Between the Branded Docetaxel and the Generic Formulations.

PubMed

Faqeer, Nour Al; Mashni, Ola; Dawoud, Rawan; Rumman, Asma; Hanoun, Esraa; Nazer, Lama

2017-02-01

Studies have raised concern about the safety of generic compared with branded drugs. Febrile neutropenia (FN) resulting in hospital admission was compared between the branded docetaxel (Taxotere®, Sanofi) and 2 generic formulations (docetaxel Ebewe and docetaxel Hospira) in patients with breast cancer. This was a retrospective study that included patients with breast cancer who received docetaxel between January 2012 and December 2014. Patients who had an admission diagnosis of FN and had received docetaxel within 14 days prior to admission were evaluated. The docetaxel brand and dose, patient characteristics, hospital length of stay, admission to the intensive care unit (ICU), and mortality were recorded. During the study period, 2904 cycles of docetaxel were given for 876 patients (1519 cycles of docetaxel Sanofi, 811 cycles of docetaxel Hospira, and 574 cycles of docetaxel Ebewe). Among the cycles given, 130 cycles were associated with FN that required hospital admission. The overall incidence of FN resulting in hospital admission was significantly higher in patients who had received docetaxel Hospira, compared with patients who had received docetaxel Sanofi (47[5.8%] cycles vs 53 [3.5%] cycles, P = .009), but there was no significant difference between docetaxel Ebewe and docetaxel Sanofi (30[5.2%] cycles vs 53 [3.5%] cycles, P = .069). All cases of FN resolved except for 1 patient who died in the ICU after receiving docetaxel Ebewe. There was a significant difference in the incidence of FN between docetaxel Sanofi and docetaxel Hospira, but all cases in both groups resolved completely. © 2016, The American College of Clinical Pharmacology.

The influence of the full moon on the number of admissions related to gastrointestinal bleeding.

PubMed

Román, Eva María; Soriano, Germán; Fuentes, Mercedes; Gálvez, María Luz; Fernández, Clotilde

2004-12-01

The objective of this study was to analyse whether the number of admissions for gastrointestinal bleeding to our bleeding unit increases during the full moon. In a prospective study, we included 447 consecutive patients with gastrointestinal haemorrhage admitted to our bleeding unit during a period of two years. The number of admissions was allocated to the corresponding day of the lunar cycle, and full moon and non-full moon days were compared. A wide variation in the number of admissions throughout the lunar cycle was observed. There were 26 admissions on the 25 days of full moon and 421 admissions in the remaining 713 days of non-full moon. This difference was mainly related to a higher incidence of haemorrhage in men and variceal haemorrhage at full moon. The results of this study suggest an increase in the number of admissions related to gastrointestinal haemorrhage in our bleeding unit during the full moon, especially in men and in patients experiencing variceal haemorrhage. However, the wide variation in the number of admissions throughout the lunar cycle could limit interpretation of the results. Therefore, further studies are needed to clarify the possible influence of the moon on gastrointestinal haemorrhage.

Early labour services: changes, triggers, monitoring and evaluation.

PubMed

Spiby, Helen; Green, Josephine M; Richardson-Foster, Helen; Hucknall, Clare

2013-04-01

to identify the changes to early labour services, their triggers and monitoring. a mixed methods approach in two stages, firstly a postal questionnaire survey of Heads of Midwifery (HoM) services in NHS Trusts in England (cover sheet to each HoM and questionnaire for each unit in their jurisdiction) and, secondly, semi-structured telephone interviews with a purposive sample of senior midwives. The interviews sought further information about reasons for change; the impact of changes and explored the unit's particular innovations. PARTICIPANTS AND RESPONSE RATE: 145 (89%) NHS Trusts provided data (cover sheet and/or questionnaire); responses were received from all areas and types of unit. Seventeen HoMs or designated senior midwives were interviewed. 83 of 170 units (49%) had made changes to early labour service provision during the past 5 years, including home assessment; the introduction of triage units and telephone assessment tools. Changes were more likely in high volume units and in consultant units with midwifery-led care areas. Further changes were planned by 93/178 (25%) units. Triggers for changes to early labour services comprised local or unit-based factors, including Category X (non-labour) admissions, response to service users and research evidence. The impact of Category X admissions on workload contributed to the triggers for change. Fifty-six (31%) could provide a confirmed figure or estimate for category X admissions. Experiences of introducing change included issues related to engagement of the workforce and the contribution of clinical leadership. Thirty-eight (48%) units did not routinely monitor use of early labour services. Overall monitoring of services was not significantly more likely in units that had made changes. Audit activity was reported more frequently in units that had made changes to their early labour services. early labour services had undergone significant changes following a range of triggers but the extent of change was not reflected in monitoring and evaluation activity. Changes to service provision should be accompanied by monitoring and evaluation. Changes to services require utilisation of appropriate change management strategies. Copyright © 2012 Elsevier Ltd. All rights reserved.

Improving Staff Communication and Transitions of Care Between Obstetric Triage and Labor and Delivery.

PubMed

O'Rourke, Kathleen; Teel, Joseph; Nicholls, Erika; Lee, Daniel D; Colwill, Alyssa Covelli; Srinivas, Sindhu K

2018-03-01

To improve staff perception of the quality of the patient admission process from obstetric triage to the labor and delivery unit through standardization. Preassessment and postassessment online surveys. A 13-bed labor and delivery unit in a quaternary care, Magnet Recognition Program, academic medical center in Pennsylvania. Preintervention (n = 100), postintervention (n = 52), and 6-month follow-up survey respondents (n = 75) represented secretaries, registered nurses, surgical technicians, certified nurse-midwives, nurse practitioners, maternal-fetal medicine fellows, anesthesiologists, and obstetric and family medicine attending and resident physicians from triage and labor and delivery units. We educated staff and implemented interventions, an admission huddle and safety time-out whiteboard, to standardize the admission process. Participants were evaluated with the use of preintervention, postintervention, and 6-month follow-up surveys about their perceptions regarding the admission process. Data tracked through the electronic medical record were used to determine compliance with the admission huddle and whiteboards. A 77% reduction (decrease of 49%) occurred in the perception of incomplete patient admission processes from baseline to 6-month follow-up after the intervention. Postintervention and 6-month follow-up survey results indicated that 100% of respondents responded strongly agree/agree/neutral that the new admission process improved communication surrounding care for patients. Data in the electronic medical record indicated that compliance with use of admission huddles and whiteboards increased from 50% to 80% by 6 months. The new patient admission process, including a huddle and safety time-out board, improved staff perception of the quality of admission from obstetric triage to the labor and delivery unit. Copyright © 2018 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.

Relationship between glycated hemoglobin, Intensive Care Unit admission blood sugar and glucose control with ICU mortality in critically ill patients

PubMed Central

Mahmoodpoor, Ata; Hamishehkar, Hadi; Shadvar, Kamran; Beigmohammadi, Mohammadtaghi; Iranpour, Afshin; Sanaie, Sarvin

2016-01-01

Background and Aims: The association between hyperglycemia and mortality is believed to be influenced by the presence of diabetes mellitus (DM). In this study, we evaluated the effect of preexisting hyperglycemia on the association between acute blood glucose management and mortality in critically ill patients. The primary objective of the study was the relationship between HbA1c and mortality in critically ill patients. Secondary objectives of the study were relationship between Intensive Care Unit (ICU) admission blood glucose and glucose control during ICU stay with mortality in critically ill patients. Materials and Methods: Five hundred patients admitted to two ICUs were enrolled. Blood sugar and hemoglobin A1c (HbA1c) concentrations on ICU admission were measured. Age, sex, history of DM, comorbidities, Acute Physiology and Chronic Health Evaluation II score, sequential organ failure assessment score, hypoglycemic episodes, drug history, mortality, and development of acute kidney injury and liver failure were noted for all patients. Results: Without considering the history of diabetes, nonsurvivors had significantly higher HbA1c values compared to survivors (7.25 ± 1.87 vs. 6.05 ± 1.22, respectively, P < 0.001). Blood glucose levels in ICU admission showed a significant correlation with risk of death (P < 0.006, confidence interval [CI]: 1.004–1.02, relative risk [RR]: 1.01). Logistic regression analysis revealed that HbA1c increased the risk of death; with each increase in HbA1c level, the risk of death doubled. However, this relationship was not statistically significant (P: 0.161, CI: 0.933–1.58, RR: 1.2). Conclusions: Acute hyperglycemia significantly affects mortality in the critically ill patients; this relation is also influenced by chronic hyperglycemia. PMID:27076705

[The department budget, in the context of the hospital global budget. Initial results in general medicine].

PubMed

Besançon, F

1984-02-23

In a general hospital (Hôtel-Dieu, in the center of Paris), run with a global budget, budgets determined for each unit were introduced as an experiment in 1980. Physicians were in charge of certain expenses, mainly: linen, drugs, transportation of patients to and from other hospitals within Paris, and blood fractions. The whole does not exceed 4% of the turnover (FF 20 millions in 1980) of a 67 bed internal medicine unit. Other accounts deal with the stays, admissions, prescriptions of technical acts, laboratory analyses, and X-rays. In 1980, expenses were 11% more than budgeted, but the increase in stays and particularly in admissions was significantly greater. The resulting savings were 8.8% and 18.7% for stays and admissions respectively. Psychic reactions were variable. The subsequent budgets followed the fluctuations of recorded expenses, which were fairly important in both directions. The unit budget may be an advance or a regression, in a restrictive and past-perpetuating context. The coherence between the unit budget and the global hospital budget is questionable. Physicians were willing to take part in accounting and saving. They have good reason for not enlarging their financial responsibilities. Conversely, they may give more attention to diseases of public opinion.

Veno-arterial extracorporeal membrane oxygenation for Streptococcus pyogenes toxic shock syndrome in pregnancy.

PubMed

Imaeda, Taro; Nakada, Taka-Aki; Abe, Ryuzo; Tateishi, Yoshihisa; Oda, Shigeto

2016-06-01

Streptococcal toxic shock syndrome (STSS), an invasive Streptococcus pyogenes (Group A streptococcus) infection with hypotension and multiple organ failure, is quite rare in pregnancy but is characterized by rapid disease progression and high fatality rates. We present a case of STSS with infection-induced cardiac dysfunction in a pregnant woman who was treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). A 24-year-old multiparous woman in the third trimester had early symptoms of high fever and diarrhea 1 day prior to admission to the hospital emergency department. On admission, she had multiple organ failure including circulatory failure. Due to fetal distress, emergency Cesarean section was carried out and transferred to intensive care units. She had refractory circulatory failure with depressed myocardial contractility with progressive multiple organ failure, despite receiving significant hemodynamic supports including high-dose catecholamine. Thus, VA-ECMO was initiated 18 h after intensive care unit admission. Consequently, ECMO provided extra time to recover from infection and myocardial depression. She was successfully weaned from VA-ECMO on day 7 and was discharged home on day 53. VA-ECMO can be a therapeutic option for refractory circulatory failure with significant myocardial depression in STSS.

The impact of 24-hr, in-hospital pediatric critical care attending physician presence on process of care and patient outcomes*.

PubMed

Nishisaki, Akira; Pines, Jesse M; Lin, Richard; Helfaer, Mark A; Berg, Robert A; Tenhave, Thomas; Nadkarni, Vinay M

2012-07-01

Attending physicians are only required to provide in-hospital coverage during daytime hours in many pediatric intensive care units. An in-hospital 24-hr pediatric intensive care unit attending coverage model has been increasingly popular, but the impact of 24-hr, in-hospital attending coverage on care processes and outcomes has not been reported. We compared processes of care and outcomes before and after the implementation of a 24-hr in-hospital pediatric intensive care unit attending physician model. Retrospective comparison of before and after cohorts. A single large, academic tertiary medical/surgical pediatric intensive care unit. : Pediatric intensive care unit admissions in 2000-2006. Transition to 24-hr from 12-hr in-hospital pediatric critical care attending physician coverage model in January 2004. A total of 18,702 patients were admitted to intensive care unit: 8,520 in 24 hrs; 10,182 in 12 hrs. Duration of mechanical ventilation was lower (median 33 hrs [interquartile range 12-88] vs. 48 hrs [interquartile range 16-133], adjusted reduction of 35% [95% confidence interval 25%-44%], p < .001) and intensive care unit length of stay was shorter (median 2 days [interquartile range 1-4] vs. 2 days [interquartile range 1-5], adjusted p < .001) for 24 hr vs. 12 hr coverage. The reduction in mechanical ventilation hours was similar when noninvasive, mechanical ventilation was included in ventilation hours (median 42 hrs vs. 56 hrs, adjusted reduction in ventilation hours: 33% [95% confidence interval 20-45], p < .001). Intensive care unit mortality was not significantly different (2.2% vs. 2.5%, adjusted p =.23). These associations were consistent across daytime and nighttime admissions, weekend and weekday admissions, and among subgroups with higher Pediatric Risk of Mortality III scores, postsurgical patients, and histories of previous intensive care unit admission. Implementation of 24-hr in-hospital pediatric critical care attending coverage was associated with shorter duration of mechanical ventilation and shorter length of intensive care unit stay. After accounting for potential confounders, this finding was consistent across a broad spectrum of critically ill children.

Chronic obstructive pulmonary disease exacerbation in the intensive care unit: clinical, functional and quality of life at discharge and 3 months of follow up

PubMed Central

Viana, Renata Cristina Teixeira Pinto; Pincelli, Mariangela Pimentel; Pizzichini, Emílio; Silva, André Pacheco; Manes, Joice; Marconi, Tatiana Dias; Steidle, Leila John Marques

2017-01-01

Objective The purpose of this study was to evaluate the clinical/functional aspects and quality of life of chronic obstructive pulmonary disease patients who were discharged after an intensive care unit admission for acute respiratory failure. Methods This prospective study included chronic obstructive pulmonary disease patients who were admitted to two intensive care units between December of 2010 and August of 2011 and evaluated over three visits after discharge. Thirty patients were included, and 20 patients completed the three-month follow up. Results There was a significant improvement in the following: forced expiratory flow in one second (L) (1.1/1.4/1.4; p = 0.019), six-minute walk test (m) (- /232.8 /272.6; p = 0.04), BODE score (7.5/5.0/3.8; p = 0.001), cognition measured by the Mini Mental State Examination (21/23.5/23.5; p = 0.008) and quality of life measured by the total Saint George Respiratory Questionnaire score (63.3/56.8/51, p = 0.02). The mean difference in the total score was 12.3 (between visits 1 and three). Important clinical differences were observed for the symptom score (18.8), activities score (5.2) and impact score (14.3). The majority of participants (80%) reported they would be willing to undergo a new intensive care unit admission. Conclusion Despite the disease severity, there was a significant clinical, functional and quality of life improvement at the end of the third month. Most patients would be willing to undergo a new intensive care unit admission. PMID:28444072

Patients with cancer in the intensive monitoring unit. New perspectives.

PubMed

Prieto Del Portillo, I; Polo Zarzuela, M; Pujol Varela, I

2014-10-01

In recent years, there has been a significant improvement in the survival of patients with cancer in intensive care units (ICUs). Advances in medical and surgical treatments and better selection of patients has helped improve the life expectancy of this type of patient. An appropriate and early resuscitation in the ICU, without initial limitations on the life support techniques, has been shown to also decrease the mortality of patients with cancer. At present, we should not deny admission to the ICU based only on the underlying neoplastic disease. However, the mortality rate for patients with cancer in the ICU, especially those with hematologic disease, remains high. In some cases, an ICU admission test (ICU test) is required for at least 3 days to identify patients who can benefit from intensive treatment. We would like to propose a decision algorithm for ICU admission that will help in making decisions in an often complex situation. Copyright © 2013 Elsevier España, S.L.U. All rights reserved.

Development and validation of the new ICNARC model for prediction of acute hospital mortality in adult critical care.

PubMed

Ferrando-Vivas, Paloma; Jones, Andrew; Rowan, Kathryn M; Harrison, David A

2017-04-01

To develop and validate an improved risk model to predict acute hospital mortality for admissions to adult critical care units in the UK. 155,239 admissions to 232 adult critical care units in England, Wales and Northern Ireland between January and December 2012 were used to develop a risk model from a set of 38 candidate predictors. The model was validated using 90,017 admissions between January and September 2013. The final model incorporated 15 physiological predictors (modelled with continuous nonlinear models), age, dependency prior to hospital admission, chronic liver disease, metastatic disease, haematological malignancy, CPR prior to admission, location prior to admission/urgency of admission, primary reason for admission and interaction terms. The model was well calibrated and outperformed the current ICNARC model on measures of discrimination (area under the receiver operating characteristic curve 0.885 versus 0.869) and model fit (Brier's score 0.108 versus 0.115). On average, the new model reclassified patients into more appropriate risk categories (net reclassification improvement 19.9; P<0.0001). The model performed well across patient subgroups and in specialist critical care units. The risk model developed in this study showed excellent discrimination and calibration and when validated on a different period of time and across different types of critical care unit. This in turn allows improved accuracy of comparisons between UK critical care providers. Copyright © 2016. Published by Elsevier Inc.

Unplanned admissions in day-case surgery as a clinical indicator for quality assurance.

PubMed

Margovsky, A

2000-03-01

Day surgery is a modern, effective and economical way to treat patients while maintaining the same level of quality of patient care. Quality improvement in day surgery units, however, continues to be an issue due to high rates of unplanned admissions. The aim of the present retrospective study was to investigate reasons for and methods of preventing unplanned postoperative admissions in a day surgical unit over a 12-month period in respect to different surgical specialties. The study was based on an audit from the Endoscopy and Day Surgery Unit (EDSU) at Launceston General Hospital, which provides health care to a population of more than 120000. For the accounted period 920 outpatients had elective day surgical procedures. Overall the unplanned admission rate was 4.7%, and surgical, anaesthetic and social reasons accounted for 58.2, 37.2 and 4.6% of the unplanned admissions, respectively. The highest rate of unplanned admissions was for plastic and reconstructive surgery (12.8%) and orthopaedic surgery (7.5%) despite the relatively small number of patients who underwent such procedures in the day surgery unit. The results also showed a correlation between age group, pre-operative medical status of the patients found suitable for the day surgical procedure and unplanned admissions. Strategies to reduce the unplanned admission rate which include patient selection and pre-operative assessment, patient waiting time and education, pre-operative anaesthesia, follow-up with nursing care and postoperative analgesia are discussed.

Birth outcomes for women using free-standing birth centers in South Auckland, New Zealand.

PubMed

Bailey, David John

2017-09-01

This study investigates maternal and perinatal outcomes for women with low-risk pregnancies laboring in free-standing birth centers compared with laboring in a hospital maternity unit in a large New Zealand health district. The study used observational data from 47 381 births to women with low-risk pregnancies in South Auckland maternity facilities 2003-2010. Adjusted odds ratios with 95% confidence intervals were calculated for instrumental delivery, cesarean section, blood transfusion, neonatal unit admission, and perinatal mortality. Labor in birth centers was associated with significantly lower rates of instrumental delivery, cesarean section and blood transfusion compared with labor in hospital. Neonatal unit admission rates were lower for infants of nulliparous women laboring in birth centers. Intrapartum and neonatal mortality rates for birth centers were low and were not significantly different from the hospital population. Transfers to hospital for labor and postnatal complications occurred in 39% of nulliparous and 9% of multiparous labors. Risk factors identified for transfer were nulliparity, advanced maternal age, and prolonged pregnancy ≥41 weeks' gestation. Labor in South Auckland free-standing birth centers was associated with significantly lower maternal intervention and complication rates than labor in the hospital maternity unit and was not associated with increased perinatal morbidity. © 2017 Wiley Periodicals, Inc.

Applying to University with Criminal Convictions: A Comparative Study of Admissions Policies in the United States and United Kingdom

ERIC Educational Resources Information Center

Custer, Bradley D.

2018-01-01

Higher education institutions in the United States and the United Kingdom increasingly require prospective students to disclose past criminal history on admissions applications. However, a social movement aimed at improving opportunities for people with criminal records may force higher education to reconsider this practice. This paper offers a…

Risk, Predictors, and Outcomes of Acute Kidney Injury in Patients Admitted to Intensive Care Units in Egypt.

PubMed

Abd ElHafeez, Samar; Tripepi, Giovanni; Quinn, Robert; Naga, Yasmine; Abdelmonem, Sherif; AbdelHady, Mohamed; Liu, Ping; James, Matthew; Zoccali, Carmine; Ravani, Pietro

2017-12-07

Epidemiology of acute kidney injury (AKI) in developing countries is under-studied. We evaluated the risk and prognosis of AKI in patients admitted to intensive care units (ICUs) in Egypt. We recruited consecutive adults admitted to ICUs in Alexandria Teaching Hospitals over six months. We used the KDIGO criteria for AKI. We followed participants until the earliest of ICU discharge, death, day 30 from entry or study end. Of the 532 participants (median age 45 (Interquartile range [IQR]: 30-62) years, 41.7% male, 23.7% diabetics), 39.6% had AKI at ICU admission and 37.4% developed AKI after 24 hours of ICU admission. Previous need of diuretics, sepsis and low education were associated with AKI at ICU admission; APACHE II score independently predicted AKI after ICU admission. A total of 120 (22.6%) patients died during 30-day follow-up. Compared to patients who remained AKI-free, mortality was significantly higher in patients who had AKI at study entry (Hazard Ratio [HR] 2.14; 95% Confidence Interval [CI] 1.02-4.48) or developed AKI in ICU (HR 2.74; 95% CI 1.45-5.17). The risk of AKI is high in critically ill people and predicts poor outcomes. Further studies are needed to estimate the burden of AKI among patients before ICU admission.

Hospital costs estimation and prediction as a function of patient and admission characteristics.

PubMed

Ramiarina, Robert; Almeida, Renan Mvr; Pereira, Wagner Ca

2008-01-01

The present work analyzed the association between hospital costs and patient admission characteristics in a general public hospital in the city of Rio de Janeiro, Brazil. The unit costs method was used to estimate inpatient day costs associated to specific hospital clinics. With this aim, three "cost centers" were defined in order to group direct and indirect expenses pertaining to the clinics. After the costs were estimated, a standard linear regression model was developed for correlating cost units and their putative predictors (the patients gender and age, the admission type (urgency/elective), ICU admission (yes/no), blood transfusion (yes/no), the admission outcome (death/no death), the complexity of the medical procedures performed, and a risk-adjustment index). Data were collected for 3100 patients, January 2001-January 2003. Average inpatient costs across clinics ranged from (US$) 1135 [Orthopedics] to 3101 [Cardiology]. Costs increased according to increases in the risk-adjustment index in all clinics, and the index was statistically significant in all clinics except Urology, General surgery, and Clinical medicine. The occupation rate was inversely correlated to costs, and age had no association with costs. The (adjusted) per cent of explained variance varied between 36.3% [Clinical medicine] and 55.1% [Thoracic surgery clinic]. The estimates are an important step towards the standardization of hospital costs calculation, especially for countries that lack formal hospital accounting systems.

Acute respiratory distress syndrome in blunt trauma: identification of independent risk factors.

PubMed

Miller, Preston R; Croce, Martin A; Kilgo, Patrick D; Scott, John; Fabian, Timothy C

2002-10-01

Acute respiratory distress syndrome (ARDS) is a major contributor to morbidity and mortality in trauma patients. Although many injuries and conditions are believed to be associated with ARDS independent risk factors in trauma patients and their relative importance in development of the syndrome are undefined. The aim of this project is to identify independent risk factors for the development of ARDS in blunt trauma patients and to examine the contributions of each factor to ARDS development. Patients with ARDS were identified from the registry of a Level I trauma center over a 4.5-year period. Records were reviewed for demographics, injury characteristics, transfusion requirements, and hospital course. Variables examined included age >65 years, Injury Severity Score (ISS) >25, hypotension on admission (systolic blood pressure <90), significant metabolic acidosis (base deficit <-5.0), severe brain injury as shown by a Glasgow Coma Scale score (GCS) <8 on admission, 24-hour transfusion requirement >10 units packed red blood cells, pulmonary contusion (PC), femur fracture, and major infection (pneumonia, empyema, or intra-abdominal abscess). Both univariate and stepwise logistic regression were used to identify independent risk factors, and receiver operating characteristic curve (ROC) analysis was used to determine the relative contribution of each risk factor. A total of 4397 patients having sustained blunt trauma were admitted to the intensive care unit and survived >24 hours between October 1995 and May 2000. Of these patients 200 (4.5%) developed ARDS. All studied variables were significantly associated with ARDS in univariate analyses. Stepwise logistic regression, however, demonstrated age >65 years, ISS >25, hypotension on admission, 24-hour transfusion requirement >10 units, and pulmonary contusion as independent risk factors, whereas admission metabolic acidosis, femur fracture, infection, and severe brain injury were not. Using a model based on the logistic regression equation derived yields better than 80 per cent discrimination in ARDS patients. The risk factors providing the greatest contribution to ARDS development were ISS >25 (ROC area 0.72) and PC (ROC area 0.68) followed by large transfusion requirement (ROC area 0.56), admission hypotension (ROC area 0.57), and age >65 (ROC area 0.54). Independent risk factors for ARDS in blunt trauma include ISS >25, PC, age >65 years, hypotension on admission, and 24-hour transfusion requirement >10 units but not admission metabolic acidosis, femur fracture, infection, or severe brain injury. Assessment of these variables allows accurate estimate of risk in the majority of cases, and the most potent contributors to the predictive value of the model are ISS >25 and PC. Improvement in understanding of which patients are actually at risk may allow for advances in treatment as well as prevention in the future.

Blood use in patients receiving intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation: the impact of a health system-wide patient blood management program.

PubMed

Leahy, Michael F; Trentino, Kevin M; May, Colleen; Swain, Stuart G; Chuah, Hun; Farmer, Shannon L

2017-09-01

Little is published on patient blood management (PBM) programs in hematology. In 2008 Western Australia announced a health system-wide PBM program with PBM staff appointments commencing in November 2009. Our aim was to assess the impact this program had on blood utilization and patient outcomes in intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation. A retrospective study of 695 admissions at two tertiary hospitals receiving intensive chemotherapy for acute leukemia or undergoing hematopoietic stem cell transplantation between July 2010 and December 2014 was conducted. Main outcomes included pre-red blood cell (RBC) transfusion hemoglobin (Hb) levels, single-unit RBC transfusions, number of RBC and platelet (PLT) units transfused per admission, subsequent day case transfusions, length of stay, serious bleeding, and in-hospital mortality. Over the study period, the mean RBC units transfused per admission decreased 39% from 6.1 to 3.7 (p < 0.001), and the mean PLT units transfused decreased 35% from 6.3 to 4.1 (p < 0.001), with mean RBC and PLT units transfused for follow-up day cases decreasing from 0.6 to 0.4 units (p < 0.001). Mean pre-RBC transfusion Hb level decreased from 8.0 to 6.8 g/dL (p < 0.001), and single-unit RBC transfusions increased 39% to 67% (p < 0.001). This reduction represents blood product cost savings of AU$694,886 (US$654,007). There were no significant changes in unadjusted or adjusted length of stay, serious bleeding events, or in-hospital mortality over the study. The health system-wide PBM program had a significant impact, reducing blood product use and costs without increased morbidity or mortality in patients receiving intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation. © 2017 AABB.

Risk score for pediatric intensive care unit admission in children undergoing hematopoietic stem cell transplantation and analysis of predictive factors for survival.

PubMed

González-Vicent, Marta; Marín, Catalina; Madero, Luis; Sevilla, Julián; Díaz, Miguel Angel

2005-10-01

The authors retrospectively analyzed postransplantation events in 198 children who underwent hematopoietic stem cell transplantation (HSCT) between 1998 and 2002 to obtain a risk score for pediatric intensive care unit (PICU) admission and to ascertain variables predicting a poor outcome. Thirty-six patients (18%) were admitted to the PICU. Median age was 9 years (range 1-18). On univariate analysis, variables significantly associated with PICU admission were male gender (P = 0.01), more than first complete remission (P = 0.003), allogeneic transplantation (P = 0.001), engraftment syndrome (P = 0.03), and acute graft-versus-host disease grade of at least two (P = 0.05). According to this, patients were divided in two levels of risk (low and high), with a respective probability of PICU admission of 8.8 +/- 2.2% and 63.8 +/- 8.8% (P < 0.0001). Seventeen (47%) patients were discharged from the PICU. The probability of event-free survival after PICU admission at 3 years was 24.2 +/- 7%. On univariate analysis, variables with a negative impact on event-free survival were type of transplantation, inotropic support, a C-reactive protein level of at least 10 mg/dL, and a high O-PRISM score. On multivariate analysis, the only variable that influenced event-free survival was the O-PRISM score (< or =10 points, 54.6 +/- 15.3%; >10 points, 8.6 +/- 5.8%; P = 0.007). In conclusion, the risk of PICU admission may be easily estimated using simple variables. A high O-PRISM score at the time of PICU admission predicts a dismal outcome.

The Syrian civil war: The experience of the Surgical Intensive Care Units

PubMed Central

Ozdogan, Hatice Kaya; Karateke, Faruk; Ozdogan, Mehmet; Cetinalp, Sibel; Ozyazici, Sefa; Gezercan, Yurdal; Okten, Ali Ihsan; Celik, Muge; Satar, Salim

2016-01-01

Objective: Since the civilian war in Syria began, thousands of seriously injured trauma patients from Syria were brought to Turkey for emergency operations and/or postoperative intensive care. The aim of this study was to present the demographics and clinical features of the wounded patients in Syrian civil war admitted to the surgical intensive care units in a tertiary care centre. Methods: The records of 80 trauma patients admitted to the Anaesthesia, General Surgery and Neurosurgery ICUs between June 1, 2012 and July 15, 2014 were included in the study. The data were reviewed regarding the demographics, time of presentation, place of reference, Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Injury Severity Score (ISS), surgical procedures, complications, length of stay and mortality. Results: A total of 80 wounded patients (70 males and 10 females) with a mean age of 28.7 years were admitted to surgical ICUs. The most frequent cause of injury was gunshot injury. The mean time interval between the occurrence of injury and time of admission was 2.87 days. Mean ISS score on admission was 21, and mean APACHE II score was 15.7. APACHE II scores of non-survivors were significantly increased compared with those of survivors (P=0.001). No significant differences was found in the age, ISS, time interval before admission, length of stay in ICU, rate of surgery before or after admission. Conclusion: The most important factor affecting mortality in this particular trauma-ICU patient population from Syrian civil war was the physiological condition of patients on admission. Rapid transport and effective initial and on-road resuscitation are critical in decreasing the mortality rate in civil wars and military conflicts. PMID:27375683

The public health impact of pediatric caustic ingestion injuries.

PubMed

Johnson, Christopher M; Brigger, Matthew T

2012-12-01

To determine the current public health burden of injuries due to caustic ingestion in children. The 2009 Kids' Inpatient Database provides data on a sample of all pediatric hospital discharges in the United States during that year. Children with caustic ingestion injuries requiring hospitalization were identified by corresponding codes from the International Classification of Diseases, Ninth Revision. Database analysis generated national estimates of summary statistics. A national database. Representative sample of all hospital discharge data on patients 18 years or younger. Public health burden related to caustic injury, including potential factors related to admission outcome, the necessity of a procedure during the admission, admission length of stay, and total charges for the admission. We estimated the prevalence of pediatric caustic ingestion injuries requiring hospitalization in the United States in 2009 to be 807 (95% CI, 731-882) children. The annual economic burden was estimated at $22 900 000 (95% CI, $15 400 000-$30 400 000) in total hospital charges. The mean charge per patient was estimated at $28 860 (95% CI, $19 799-$37 922) with a median of $9848. The mean length of admission was 4.13 (95% CI, 3.22-5.03) days with a median of 2 days. Among the 807 patients, 45.3% underwent esophagoscopy, and those admitted to teaching hospitals were more likely to undergo a procedure during their stay (P = .02). Logistic regression models suggested significant median income (P < .001) and sex (P < .001) variations. The current public health burden of pediatric caustic ingestion injuries may be less than commonly cited. This finding supports the notion that legislative efforts have been successful. Despite these successes, these injuries continue to impose a significant burden on health care resources.

The Syrian civil war: The experience of the Surgical Intensive Care Units.

PubMed

Ozdogan, Hatice Kaya; Karateke, Faruk; Ozdogan, Mehmet; Cetinalp, Sibel; Ozyazici, Sefa; Gezercan, Yurdal; Okten, Ali Ihsan; Celik, Muge; Satar, Salim

2016-01-01

Since the civilian war in Syria began, thousands of seriously injured trauma patients from Syria were brought to Turkey for emergency operations and/or postoperative intensive care. The aim of this study was to present the demographics and clinical features of the wounded patients in Syrian civil war admitted to the surgical intensive care units in a tertiary care centre. The records of 80 trauma patients admitted to the Anaesthesia, General Surgery and Neurosurgery ICUs between June 1, 2012 and July 15, 2014 were included in the study. The data were reviewed regarding the demographics, time of presentation, place of reference, Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Injury Severity Score (ISS), surgical procedures, complications, length of stay and mortality. A total of 80 wounded patients (70 males and 10 females) with a mean age of 28.7 years were admitted to surgical ICUs. The most frequent cause of injury was gunshot injury. The mean time interval between the occurrence of injury and time of admission was 2.87 days. Mean ISS score on admission was 21, and mean APACHE II score was 15.7. APACHE II scores of non-survivors were significantly increased compared with those of survivors (P=0.001). No significant differences was found in the age, ISS, time interval before admission, length of stay in ICU, rate of surgery before or after admission. The most important factor affecting mortality in this particular trauma-ICU patient population from Syrian civil war was the physiological condition of patients on admission. Rapid transport and effective initial and on-road resuscitation are critical in decreasing the mortality rate in civil wars and military conflicts.

Rates and risk factors associated with hospitalization for pneumonia with ICU admission among adults.

PubMed

Storms, Aaron D; Chen, Jufu; Jackson, Lisa A; Nordin, James D; Naleway, Allison L; Glanz, Jason M; Jacobsen, Steven J; Weintraub, Eric S; Klein, Nicola P; Gargiullo, Paul M; Fry, Alicia M

2017-12-16

Pneumonia poses a significant burden to the U.S. health-care system. However, there are few data focusing on severe pneumonia, particularly cases of pneumonia associated with specialized care in intensive care units (ICU). We used administrative and electronic medical record data from six integrated health care systems to estimate rates of pneumonia hospitalizations with ICU admissions among adults during 2006 through 2010. Pneumonia hospitalization was defined as either a primary discharge diagnosis of pneumonia or a primary discharge diagnosis of sepsis or respiratory failure with a secondary diagnosis of pneumonia in administrative data. ICU admissions were collected from internal electronic medical records from each system. Comorbidities were identified by ICD-9-CM codes coded during the current pneumonia hospitalization, as well as during medical visits that occurred during the year prior to the date of admission. We identified 119,537 adult hospitalizations meeting our definition for pneumonia. Approximately 19% of adult pneumonia hospitalizations had an ICU admission. The rate of pneumonia hospitalizations requiring ICU admission during the study period was 76 per 100,000 population/year; rates increased for each age-group with the highest rates among adults aged ≥85 years. Having a co-morbidity approximately doubled the risk of ICU admission in all age-groups. Our study indicates a significant burden of pneumonia hospitalizations with an ICU admission among adults in our cohort during 2006 through 2010, especially older age-groups and persons with underlying medical conditions. These findings reinforce current strategies aimed to prevent pneumonia among adults.

Change in Care Dependency of Stroke Patients: A Longitudinal and Multicenter Study.

PubMed

Nursiswati, Nursiswati; Halfens, Ruud J G; Lohrmann, Christa

2017-06-01

The study was conducted to investigate the change of care dependency in stroke patients from inpatient wards and outpatient units in Indonesia. This study is longitudinal and multicentered. One hundred and nine patients were included from four hospitals on the island of Java. Care dependency was assessed using the Indonesian version of the 15-item Care Dependency Scale (CDS) at five points in time: at inpatient wards for admission and discharge and at outpatient units after discharge in the 1st week, the 5th week, and the 13th week. Most of the patients were male (65.1%), and diagnosed with ischemic stroke (71.5%). The results showed that care dependency in stroke patients decreased significantly from admission to discharge, as well as from the 5th to the 13th week as measured by the CDS. At admission, 23.0% of the patients were completely dependent on care, and at the 13th week about 1.0% were. Patients' care dependency decreased significantly in all care dependency items of the CDS in the inpatient ward, but five care dependency items of the CDS did not significantly decrease in the outpatient unit. Based on the findings of this study, we recommend that hospital-based and community-based services should include continual care dependence monitoring using this comprehensive instrument. Care dependency is subject to change over time, therefore nurses have to plan and tailor adequate nursing care measures to patient needs in the different stages, especially with respect to the aspect of mobility. Copyright © 2017. Published by Elsevier B.V.

Case mix, outcome and activity for obstetric admissions to adult, general critical care units: a secondary analysis of the ICNARC Case Mix Programme Database

PubMed Central

2005-01-01

Introduction Risk prediction scores usually overestimate mortality in obstetric populations because mortality rates in this group are considerably lower than in others. Studies examining this effect were generally small and did not distinguish between obstetric and nonobstetric pathologies. We evaluated the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II model in obstetric admissions to critical care units contributing to the ICNARC Case Mix Programme. Methods All obstetric admissions were extracted from the ICNARC Case Mix Programme Database of 219,468 admissions to UK critical care units from 1995 to 2003 inclusive. Cases were divided into direct obstetric pathologies and indirect or coincidental pathologies, and compared with a control cohort of all women aged 16–50 years not included in the obstetric categories. The predictive ability of APACHE II was evaluated in the three groups. A prognostic model was developed for direct obstetric admissions to predict the risk for hospital mortality. A log-linear model was developed to predict the length of stay in the critical care unit. Results A total of 1452 direct obstetric admissions were identified, the most common pathologies being haemorrhage and hypertensive disorders of pregnancy. There were 278 admissions identified as indirect or coincidental and 22,938 in the nonpregnant control cohort. Hospital mortality rates were 2.2%, 6.0% and 19.6% for the direct obstetric group, the indirect or coincidental group, and the control cohort, respectively. Cox regression calibration analysis showed a reasonable fit of the APACHE II model for the nonpregnant control cohort (slope = 1.1, intercept = -0.1). However, the APACHE II model vastly overestimated mortality for obstetric admissions (mortality ratio = 0.25). Risk prediction modelling demonstrated that the Glasgow Coma Scale score was the best discriminator between survival and death in obstetric admissions. Conclusion This study confirms that APACHE II overestimates mortality in obstetric admissions to critical care units. This may be because of the physiological changes in pregnancy or the unique scoring profile of obstetric pathologies such as HELLP syndrome. It may be possible to recalibrate the APACHE II score for obstetric admissions or to devise an alternative score specifically for obstetric admissions.

Urinary NGAL in patients with and without acute kidney injury in a cardiology intensive care unit

PubMed Central

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

Shift climate profiles and correlates in acute psychiatric inpatient units.

PubMed

Lewin, Terry J; Carr, Vaughan J; Conrad, Agatha M; Sly, Ketrina A; Tirupati, Srinivasan; Cohen, Martin; Ward, Philip B; Coombs, Tim

2012-09-01

Inpatient psychiatric units are dynamic in nature, potentially creating a different treatment experience for each person, which may be difficult to quantify. Among the goals of this multi-centre service evaluation project was an assessment of shift-to-shift changes in unit-level events and their impact on the social-emotional environment. Over 1 year, various nurse-completed logs were used within the 11 participating Australian psychiatric units (n = 5,546 admissions) to record patient- and unit-level events per shift, including ratings of the overall social-emotional climate using a novel shift climate ratings (SCR) scale (n = 8,176 shifts). These were combined with admission-level patient characteristics to investigate shift climate profiles and correlates. Occupancy rates averaged 88% and two-thirds of admissions were involuntary. The psychometric performance of the SCR scale was considered to be satisfactory (e.g., high internal consistency, unidimensional factor structure, and evidence of discriminant and predictive validity). A series of hierarchical regressions revealed considerable variation in SCR total scores, with poorer climates being significantly associated with: day/afternoon shifts; higher occupancy levels; higher proportions of experienced staff, and male, older, or involuntary patients; higher rates of less serious aggressive incidents; reporting of additional staffing demands; and unit location in a stand-alone psychiatric hospital. The day-to-day social-emotional climate can have important consequences for patient engagement and recovery. Improved understanding of the role played by unit, staff and patient characteristics, together with routine monitoring, should facilitate the development and evaluation of targeted interventions to reduce adverse incidents and improve the overall social-emotional climate.

Oropharyngeal flora in patients admitted to the medical intensive care unit: clinical factors and acid suppressive therapy.

PubMed

Frandah, Wesam; Colmer-Hamood, Jane; Mojazi Amiri, Hoda; Raj, Rishi; Nugent, Kenneth

2013-05-01

Acid suppression therapy in critically ill patients significantly reduces the incidence of stress ulceration and gastrointestinal (GI) bleeding; however, recent studies suggest that proton pump inhibitors (PPIs) increase the risk of pneumonia. We wanted to test the hypothesis that acid suppressive therapy promotes alteration in the bacterial flora in the GI tract and leads to colonization of the upper airway tract with pathogenic species, potentially forming the biological basis for the observed increased incidence of pneumonia in these patients. This was a prospective observational study on patients (adults 18 years or older) admitted to the medical intensive care unit (MICU) at a tertiary care centre. Exclusion criteria included all patients with a diagnosis of pneumonia at admission, with infection in the upper airway, or with a history of significant dysphagia. Oropharyngeal cultures were obtained on day 1 and days 3 or 4 of admission. We collected data on demographics, clinical information, and severity of the underlying disease using APACHE II scores. There were 110 patients enrolled in the study. The mean age was 49±16 years, 50 were women, and the mean APACHE II score was 9.8 ± 6.5. Twenty per cent of the patients had used a PPI in the month preceding admission. The first oropharyngeal specimen was available in 110 cases; a second specimen at 72-96 h was available in 68 cases. Seventy-five per cent of the patients admitted to the MICU had abnormal flora. In multivariate logistic regression, diabetes mellitus and PPI use were associated with abnormal oral flora on admission. Chronic renal failure and a higher body mass index reduced the frequency of abnormal oral flora on admission. Most critically ill patients admitted to our MICU have abnormal oral flora. Patients with diabetes and a history of recent PPI use are more likely to have abnormal oral flora on admission.

[Prevalence of severe sepsis in intensive care units. A national multicentric study].

PubMed

Dougnac, Alberto L; Mercado, Marcelo F; Cornejo, Rodrigo R; Cariaga, Mario V; Hernández, Glenn P; Andresen, Max H; Bugedo, Guillermo T; Castillo, Luis F

2007-05-01

Severe sepsis (SS) is the leading cause of death in the Intensive Care Units (ICU). To study the prevalence of SS in Chilean ICUs. An observational, cross-sectional study using a predesigned written survey was done in all ICUs of Chile on April 21st, 2004. General hospital and ICU data and the number of hospitalized patients in the hospital and in the ICU at the survey day, were recorded. Patients were followed for 28 days. Ninety four percent of ICUs participated in the survey. The ICU occupation index was 66%. Mean age of patients was 57.7+/-18 years and 59% were male, APACHE II score was 15+/-7.5 and SOFA score was 6+/-4. SS was the admission diagnosis of 94 of the 283 patients (33%) and 38 patients presented SS after admission. On the survey day, 112 patients fulfilled SS criteria (40%). APACHE II and SOFA scores were significantly higher in SS patients than in non SS patients. Global case-fatality ratio at 28 days was 15.9% (45/283). Case-fatality ratio in patients with or without SS at the moment of the survey was 26.7% (30/112) and 8.7% (17/171), respectively p <0.05. Thirteen percent of patients who developed SS after admission, died. Case-fatality ratios for patients with SS from Santiago and the other cities were similar, but APACHE II score was significantly higher in patients from Santiago. In SS patients, the independent predictors of mortality were SS as cause of hospital admission, APACHE II and SOFA scores. Ninety nine percent of SS patients had a known sepsis focus (48% respiratory and 30% abdominal). Eighty five patients that presented SS after admission, had a respiratory focus. SS is highly prevalent in Chilean ICUs and represents the leading diagnosis at admission. SS as cause of hospitalization, APACHE II and SOFA scores were independent predictors of mortality.

Previous cognitive impairment and failure to thrive syndrome in patients who died in a geriatric convalescence hospitalization unit.

PubMed

Aguilera, A; Pi-Figuews, M; Arellano, M; Torres, R M; García-Caselles, M P; Robles, M J; Miralles, R; Cervera, A M

2004-01-01

Cognitive impairment and depression are commonly associated with poor outcomes in geriatric patients. Both are part of the "failure to thrive syndrome" (FTS), that is a combined group of symptoms as a result from progressive functional, mental and nutritional impairment status in older patients. This paper was aimed at evaluating the presence of FTS in the patients who died in a geriatric convalescence unit (GCU) (intermediate care facility) and comparing the characteristics of patients with primary FTS (not associated with an evident identifiable disease) and secondary FTS (associated with an evident identifiable disease). Finally, we wanted to analyze if the presence of cognitive impairment before admission was associated with the type of FTS. We analyzed 78 patients retrospectively. The presence of the next three conditions was necessary to define the FTS: (i) Impaired functional status and malnutrition. (ii) Cognitive impairment and/or depression. (iii) Absence of improvement, after a specific geriatric intervention program during the hospitalization. Functional status for basic and instrumental activities of daily living (ADL and IADL) and the presence of symptoms cognitive impairment before admission were evaluated. Of the 78 analyzed patients, there were 30 (38.4%) with symptoms of FTS. Seventeen of them (56.6%) had a secondary FTS and 13 (43.3%) a primary one. This last group of patients had a significantly higher mean age (84.7 +/- 5.8 vs. 78.6 +/- 7.2; p < 0.02) and before admission they were significantly more dependent for ADL: 10 patients (76.9%) vs. 7 (41.0%) chi2 = 3.833, p < 0.05. A higher proportion of subjects with cognitive impairment before admission was found in the group of patients with primary FTS, than in those secondary FTS, although this difference did not reach statistical significance. Patients with primary FTS seem to be older and more dependent for ADL before admission, than those with secondary FTS.

Admission of term infants to the neonatal intensive care unit in a Saudi tertiary teaching hospital: cumulative incidence and risk factors.

PubMed

Al-Wassia, Heidi; Saber, Mafaza

2017-01-01

An increasing number of term infants of appropriate birthweight receive care in neonatal intensive care units (NICUs). This study assessed the prevalence, patterns, and risk factors for admission of term infants to a NICU to identify areas for quality improvement. Cross-sectional analytical study. An academic and referral center in Jeddah, Saudi Arabia. The cases were all term infants (>=37 weeks gestational age) admitted to the NICU between 1 January and 31 December 2015. The controls were term infants who were not admitted to the NICU. Cases and controls were matched in a 1:1 ratio according to the date of birth (within one day). Prevalence, pattern, and risk factors for admission of term infants to the NICU. The rate of admission of term infants to the NICU during the study period was 4.1% (142 of 3314 live births in that year). Respiratory complications accounted for 36.6% (52/142) of admissions, followed by hypoglycemia (23/142, 16.2%) and jaundice (11/142, 7.7%). Premature membrane rupture and non-Saudi national status were the risk factors that remained significant after adjusting for confounders. A growing number of term infants are admitted unexpectedly to the NICU. The risk factors and pattern of admission of term infants to the NICU should receive more attention in quality improvement and management agendas. This was a single-center study with limited access to information about unbooked mothers and details of the hospital stay of the admitted neonates.

Admission time to hospital: a varying standard for a critical definition for admissions to an intensive care unit from the emergency department.

PubMed

Nanayakkara, Shane; Weiss, Heike; Bailey, Michael; van Lint, Allison; Cameron, Peter; Pilcher, David

2014-11-01

Time spent in the emergency department (ED) before admission to hospital is often considered an important key performance indicator (KPI). Throughout Australia and New Zealand, there is no standard definition of 'time of admission' for patients admitted through the ED. By using data submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database, the aim was to determine the differing methods used to define hospital admission time and assess how these impact on the calculation of time spent in the ED before admission to an intensive care unit (ICU). Between March and December of 2010, 61 hospitals were contacted directly. Decision methods for determining time of admission to the ED were matched to 67,787 patient records. Univariate and multivariate analyses were conducted to assess the relationship between decision method and the reported time spent in the ED. Four mechanisms of recording time of admission were identified, with time of triage being the most common (28/61 hospitals). Reported median time spent in the ED varied from 2.5 (IQR 0.83-5.35) to 5.1 h (2.82-8.68), depending on the decision method. After adjusting for illness severity, hospital type and location, decision method remained a significant factor in determining measurement of ED length of stay. Different methods are used in Australia and New Zealand to define admission time to hospital. Professional bodies, hospitals and jurisdictions should ensure standardisation of definitions for appropriate interpretation of KPIs as well as for the interpretation of studies assessing the impact of admission time to ICU from the ED. WHAT IS KNOWN ABOUT THE TOPIC?: There are standards for the maximum time spent in the ED internationally, but these standards vary greatly across Australia. The definition of such a standard is critically important not only to patient care, but also in the assessment of hospital outcomes. Key performance indicators rely on quality data to improve decision-making. WHAT DOES THIS PAPER ADD?: This paper quantifies the variability of times measured and analyses why the variability exists. It also discusses the impact of this variability on assessment of outcomes and provides suggestions to improve standardisation. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: This paper provides a clearer view on standards regarding length of stay in the ICU, highlighting the importance of key performance indicators, as well as the quality of data that underlies them. This will lead to significant changes in the way we standardise and interpret data regarding length of stay.

Impact of pandemic (H1N1) 2009 on Australasian critical care units.

PubMed

Drennan, Kelly; Hicks, Peter; Hart, Graeme

2010-12-01

To identify the resource usage by patients with influenza A H1N1 admitted to Australian and New Zealand intensive care units during the first wave of the pandemic in June, July and August 2009. Data were collected in two separate surveys: the 2007-08 resource and activity survey and the 2009 influenza pandemic survey. Participants comprised 143 of the 189 Australian and New Zealand critical care units identified by the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS CORE). Mean length of stay (LOS) and ventilation data for H1N1 patients were reported by the ANZIC Influenza Investigators study from the same units over the same time period. Mean LOS for all ICU admissions was obtained from the ANZICS CORE adult patient database 10-year study. H1N1 patient admissions as a proportion of all ICU admissions; H1N1 patient bed-days as a proportion of total bed-days; ventilation resource usage by H1N1 patients; changes in ICU admissions for elective surgery during the H1N1 pandemic. Over the period June-August 2009, among 30 222 ICU admissions to 133 ICUs contributing data, 704 patients (2.3%) had H1N1 influenza A. Twenty-eight units had no H1N1 patient admissions. The peak of the pandemic in Australia and New Zealand occurred in July 2009, when H1N1 patients represented 3.7% of all ICU admissions for July and 53.5% of all H1N1 patient admissions in the period June-August 2009. We estimate that H1N1 cases required approximately 12.4% of the ventilator resources and used 8.1% of total patient bed-days. During the pandemic, there was a 3.2 percentage-point reduction in elective admissions to public hospitals (from 32.5% to 29.3%). Low rates of admission of H1N1 patients to ICUs during the 2009 pandemic enabled the intensive care system to cope with the large demand when analysed at a jurisdictional level.

Effects of Centralizing Acute Stroke Services on Stroke Care Provision in Two Large Metropolitan Areas in England

PubMed Central

Morris, Stephen; Hoffman, Alex; Hunter, Rachael M.; Boaden, Ruth; McKevitt, Christopher; Perry, Catherine; Pursani, Nanik; Rudd, Anthony G.; Turner, Simon J.; Tyrrell, Pippa J.; Wolfe, Charles D.A.; Fulop, Naomi J.

2015-01-01

Background and Purpose— In 2010, Greater Manchester and London centralized acute stroke care into hyperacute units (Greater Manchester=3, London=8), with additional units providing ongoing specialist stroke care nearer patients’ homes. Greater Manchester patients presenting within 4 hours of symptom onset were eligible for hyperacute unit admission; all London patients were eligible. Research indicates that postcentralization, only London’s stroke mortality fell significantly more than elsewhere in England. This article attempts to explain this difference by analyzing how centralization affects provision of evidence-based clinical interventions. Methods— Controlled before and after analysis was conducted, using national audit data covering Greater Manchester, London, and a noncentralized urban comparator (38 623 adult stroke patients, April 2008 to December 2012). Likelihood of receiving all interventions measured reliably in pre- and postcentralization audits (brain scan; stroke unit admission; receiving antiplatelet; physiotherapist, nutrition, and swallow assessments) was calculated, adjusting for age, sex, stroke-type, consciousness, and whether stroke occurred in-hospital. Results— Postcentralization, likelihood of receiving interventions increased in all areas. London patients were overall significantly more likely to receive interventions, for example, brain scan within 3 hours: Greater Manchester=65.2% (95% confidence interval=64.3–66.2); London=72.1% (71.4–72.8); comparator=55.5% (54.8–56.3). Hyperacute units were significantly more likely to provide interventions, but fewer Greater Manchester patients were admitted to these (Greater Manchester=39%; London=93%). Differences resulted from contrasting hyperacute unit referral criteria and how reliably they were followed. Conclusions— Centralized systems admitting all stroke patients to hyperacute units, as in London, are significantly more likely to provide evidence-based clinical interventions. This may help explain previous research showing better outcomes associated with fully centralized models. PMID:26130092

Impact of a psychiatric unit's daily discharge rates on emergency department flow.

PubMed

Bastiampillai, Tarun; Schrader, Geoffrey; Dhillon, Rohan; Strobel, Jörg; Bidargaddi, Niranjan

2012-04-01

To investigate relationships between time spent in the emergency department (ED) in patients requiring admission to the psychiatric ward, the day of the week of presentation and the daily number of discharges from the psychiatric ward. Retrospective analysis of patient flow as a function of day of week, time of day (a.m., p.m.), number of patients requiring admission and number of ward discharges over a one-year period, for all mental health related presentations to the ED of the Queen Elizabeth Hospital in Adelaide, South Australia, before their admission to the psychiatric inpatient facility. The time spent by patients in the ED waiting for admission to the psychiatric ward was significantly greater on weekends. There were significantly fewer discharges from the psychiatric ward during weekends compared with weekdays. The average time spent by patients in the ED requiring admission to the psychiatric ward for those days when there were vacant beds was 17.9 hours (SD=14.5). More people presented to the ED with a psychiatric diagnosis in the afternoons. There was a significant inverse correlation between the time spent by patients in the ED requiring admission to the psychiatric ward per day and the number of discharges from the psychiatric ward per day. These findings demonstrate that patient flow is significantly slower on weekends because of fewer discharges from the ward, leading to longer times spent in the ED before ward transfer. Waiting times in the ED were very substantially greater than the proposed 4-hour target even when vacant beds were available, raising considerable doubt about that target being realistic for psychiatric patients.

[Appropriateness of direct admissions to acute care geriatric unit for nursing home patients: an adaptation of the AEPf GRID].

PubMed

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.

Mortality in hyperglycemic crisis: a high association with infections and cerebrovascular disease.

PubMed

Ekpebegh, C; Longo-Mbenza, B

2013-06-01

Aim of the present study was to determine syndrome specific mortality rates and the precipitating factors associated with deaths following admission for hyperglycemic crisis to a high care unit. Retrospective review of medical records for hyperglycemic crisis at Nelson Mandela Academic Hospital, Mthatha, Eastern Cape Province of South Africa from February 1 2010 to January 31 2011. All admissions were initially into the high care unit. The overall mortality rates (per admissions) was 13.9% (N.=15/108) with syndrome specific mortality rates (per admissions) of 11.9% (N.=8/67), 0% (N.=0/8) and 21.2% (N.=7/33) respectively for diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS) and hyperglycemia with dehydration (HD). The precipitating factors that were mainly associated with mortality were infections and cerebrovascular disease (CVD). The patients with CVD who died were all unconscious. There were no deaths where non-compliance with hypoglycaemic agents (14.8%, N.=16/108) was the precipitating factor. The overall mortality rates (per admissions) following high care unit admissions for hyperglycemic crisis was 13.9% with infections and CVD as the precipitating factors most associated with deaths.

32 CFR 575.2 - Admission; general.

Code of Federal Regulations, 2010 CFR

2010-07-01

... MILITARY ACADEMY § 575.2 Admission; general. (a) In one major respect, the requirements for admission to the United States Military Academy differ from the normal requirements for admission to a civilian college or university; each candidate must obtain an official nomination to the Academy. The young person...

Does routine gowning reduce nosocomial infection and mortality rates in a neonatal nursery? A Singapore experience.

PubMed

Tan, S G; Lim, S H; Malathi, I

1995-11-01

A 1 year prospective study on routine gowning before entering a neonatal unit was conducted in a maternity hospital in Singapore. This study was done based on previous work by Donowitz, Haque and Chagla and Agbayani et al., as there have been no known studies done in Singapore. The aim of the study was to test the hypothesis that routine gowning before entering a neonatal nursery does not reduce nosocomial infection and mortality rate. A total of 212 neonates from the neonatal intensive care unit (NICU) and 1694 neonates from the neonatal special care unit (NSCU) were studied. Neonates admitted during the 1 year study were assigned to the gowning (control) and no routine gowning (trial) group on every alternate 2 months. The hospital infection control nurse provided data on nosocomial infection. The overall nosocomial infection rate in the NICU was 24% (25 of 104 admissions) during gowning periods compared to 16.6% (18 of 108 admissions) when plastic aprons were not worn before entry. In the NSCU, the overall infection rate was 1.5% (12 of 800 admissions) during gowning periods compared to 2.1% (19 of 894 admissions) when no gown was worn before entry. Results of the study found no significant differences in the incidences of nosocomial infection and mortality in the neonates. The cost of gowns used during the no routine gowning periods was S$2012.8 compared to S$3708 used during the routine gowning procedure. The investigators recommend that routine gowning before entering a neonatal unit is not essential and cost effective for the purpose of reducing infection. Rather the focus should be on adequate handwashing by all hospital personnel and visitors before handling neonates.

[Central Patients Admission (CPA) unit--connecting inpatient and outpatient care].

PubMed

Fleck, Martin; Zeuner, Martin; Schölmerich, Jürgen

2009-12-15

Due to the novel reimbursement policies, hospitals face substantial conflicts regarding best patient care and optimal utilization of resources. In order to optimize patient treatment, a central patients admission (CPA) unit has been established. All patients electively referred to the hospital were primarily treated by a medical specialist at the CPA unit. According to an appropriateness evaluation protocol established with the medical service of the health insurances of Bavaria ("MDK-Bayern"), patients were treated as inpatients or outpatients. The impact of this novel admission procedure was assessed for a period of 30 months. Within 30 months following establishment of the CPA unit, 10% of the patients were treated as outpatients, whereas 90% of referred patients were admitted as inpatients. Nonetheless, numbers of inpatients increased by 20.7% after 24 months compared to 12 months following establishment of the CPA unit with a substantial increase of patients referred by external medical specialists. In addition, there were no cases of inappropriate admission. The CPA unit is an ideal instrument for treating patients cross-sectorally as well as more effectively and economically advocating reorganization. Establishment of a CPA unit leads to greater satisfaction among patients, referring physicians, and medical staff.

Recalibration of risk prediction models in a large multicenter cohort of admissions to adult, general critical care units in the United Kingdom.

PubMed

Harrison, David A; Brady, Anthony R; Parry, Gareth J; Carpenter, James R; Rowan, Kathy

2006-05-01

To assess the performance of published risk prediction models in common use in adult critical care in the United Kingdom and to recalibrate these models in a large representative database of critical care admissions. Prospective cohort study. A total of 163 adult general critical care units in England, Wales, and Northern Ireland, during the period of December 1995 to August 2003. A total of 231,930 admissions, of which 141,106 met inclusion criteria and had sufficient data recorded for all risk prediction models. None. The published versions of the Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE II UK, APACHE III, Simplified Acute Physiology Score (SAPS) II, and Mortality Probability Models (MPM) II were evaluated for discrimination and calibration by means of a combination of appropriate statistical measures recommended by an expert steering committee. All models showed good discrimination (the c index varied from 0.803 to 0.832) but imperfect calibration. Recalibration of the models, which was performed by both the Cox method and re-estimating coefficients, led to improved discrimination and calibration, although all models still showed significant departures from perfect calibration. Risk prediction models developed in another country require validation and recalibration before being used to provide risk-adjusted outcomes within a new country setting. Periodic reassessment is beneficial to ensure calibration is maintained.

The Global Contribution of Outdoor Air Pollution to the Incidence, Prevalence, Mortality and Hospital Admission for Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

PubMed Central

Song, Qingkun; Christiani, David C.; Wang, Xiaorong; Ren, Jun

2014-01-01

Objective: This study aimed to investigate the quantitative effects of outdoor air pollution, represented by 10 µg/m3 increment of PM10, on chronic obstructive pulmonary disease in China, United States and European Union through systematic review and meta-analysis. Methods: Publications in English and Chinese from PubMed and EMBASE were selected. The Cochrane Review Handbook of Generic Inverse Variance was used to synthesize the pooled effects on incidence, prevalence, mortality and hospital admission. Results: Outdoor air pollution contributed to higher incidence and prevalence of COPD. Short-term exposure was associated with COPD mortality increased by 6%, 1% and 1% in the European Union, the United States and China, respectively (p < 0.05). Chronic PM exposure produced a 10% increase in mortality. In a short-term exposure to 10 µg/m3 PM10 increment COPD mortality was elevated by 1% in China (p < 0.05) and hospital admission enrollment was increased by 1% in China, 2% in United States and 1% in European Union (p < 0.05). Conclusions: Outdoor air pollution contributes to the increasing burdens of COPD.10 µg/m3 increase of PM10 produced significant condition of COPD death and exacerbation in China, United States and European Union. Controlling air pollution will have substantial benefit to COPD morbidity and mortality. PMID:25405599

Nursing Admission Practices to Discern "Fit": A Case Study Exemplar

ERIC Educational Resources Information Center

Sinutko, Jaime M.

2014-01-01

Admission to a baccalaureate nursing school in the United States is currently a challenging proposition for a variety of reasons. This research explored a holistic nursing school admission process at a small, private, baccalaureate college using a retrospective, mixed-method, approach. The holistic method included multiple admission criteria, both…

Study of Obstetric Admissions to the Intensive Care Unit of a Tertiary Care Hospital.

PubMed

Rathod, Ashakiran T; Malini, K V

2016-10-01

To analyze obstetric admissions to intensive care unit and to identify the risk factors responsible for intensive care admission. This is a retrospective study of all obstetric cases admitted to the intensive care unit over a period of 3 years. Data were collected from case records. The risk factors responsible for ICU admission were analyzed. There were 765 obstetric admissions to ICU accounting for 1.24 % of all deliveries. 56.20 % were in the age group of 20-25 years. 38.43 % were in their first pregnancy. 36.48 % of cases were at 37-40 weeks of gestation. Postpartum admissions were 80.91 %. Major conditions responsible were obstetric hemorrhage in 44.05 %, hypertensive disorders of pregnancy in 28.88 %, severe anemia in 14.37 %, heart disease in 12.15 %, and sepsis in 7.97 % of ICU cases. 40.39 % cases required high dependency care. Maternal mortality was seen in 15.55 % of ICU cases. Commonest cause of mortality was hemorrhagic shock (26.89 %) and multiorgan dysfunction syndrome (26.05 %). Commonest risk factors for ICU admissions are obstetric hemorrhage and hypertensive disorders of pregnancy. Other major risk factors are severe anemia, heart disease, sepsis, more than one diagnosis on admission, and the need for cesarean delivery.

Self-harm in Child and Adolescent Psychiatric Inpatients: A Retrospective Study

PubMed Central

Zhand, Naista; Matheson, Katherine; Courtney, Darren

2016-01-01

Objective This study presents a comprehensive report of children and adolescents who engaged in self-harm during their admission to a psychiatric inpatient unit. Method A chart review was conducted on all admissions to an acute care psychiatric inpatient unit in a Canadian children’s hospital over a one-year period. Details on patients with self-harm behaviour during the admission were recorded, including: demographics, presentation to hospital, self-harm behaviour and outcome. Baseline variables for patients with and without self-harm behaviour during admission were compared. Results Self-harm incidents were reported in 60 of 501 (12%) admissions during the one-year period of the study. Fourteen percent of patients (50 of 351) accounted for total number of 136 self-harm incidents. Half of these incidents (49%) occurred outside of the hospital setting, when patients were on passes. Using the Beck Lethality Scale (0–10), mean severity of the self-injury attempts was 0.33, and there were no serious negative outcomes. Conclusion Self-harm behaviour during inpatient psychiatric admission is a common issue among youth, despite safety strategies in place. While self-harm behaviour is one of the most common reasons for admission to psychiatric inpatient unit, our understanding of nature of these acts during the admission and contributing factors are limited. Further research is required to better understand these factors, and to develop strategies to better support these patients. PMID:27924147

Quality assurance for patients with head injuries admitted to a regional trauma unit.

PubMed

Schwartz, M L; Sharkey, P W; Andersen, J A

1991-07-01

The efficacy of trauma systems in reducing preventable deaths has been established but the methods of auditing care are still evolving. Various "audit filters" to identify which patients' charts should be reviewed have been proposed. An analysis of all patients admitted to the Regional Trauma Unit (RTU) over a 19-month period was conducted. Of 729 patients, 135 were identified as having suffered a traumatic intracranial hemorrhage (TICH). On review, neither delay in transfer from the emergency room to the operating room nor increasing time from the incident to the operating room correlated with increasing mortality. In contrast to delay, the Glasgow Coma Scale (GCS) score on admission correlated well with outcome. The charts of patients with anomalous outcomes based on admission GCS score were reviewed, and two possibly preventable deaths were identified. There were 48 patients with TICH who had no operations but there were no deaths attributable to a missed operation. There were 76 patients for whom the GCS score at the referring hospital and the GCS score on admission to the RTU were available. Seven of 19 patients who worsened on transfer declined because of significant pulmonary injuries. Anomalous outcomes based on admission GCS score and declining GCS scores are recommended as quality assurance filters.

Primary care and survival among American Indian patients with diabetes in the Southwest United States: Evaluation of a cohort study at Gallup Indian Medical Center, 2009-2016.

PubMed

King, Caroline; Atwood, Sidney; Brown, Chris; Nelson, Adrianne Katrina; Lozada, Mia; Wei, Jennie; Merino, Maricruz; Curley, Cameron; Muskett, Olivia; Sabo, Samantha; Gampa, Vikas; Orav, John; Shin, Sonya

2018-06-01

To evaluate the role of primary care healthcare delivery on survival for American Indian patients with diabetes in the southwest United States. Data from patients with diabetes admitted to Gallup Indian Medical Center between 2009 and 2016 were analyzed using a log-rank test and Cox Proportional Hazards analyses. Of the 2661 patients included in analysis, 286 patients died during the study period. Having visited a primary care provider in the year prior to first admission of the study period was protective against all-cause mortality in unadjusted analysis (HR (95% CI)=0.47 (0.31, 0.73)), and after adjustment. The log-rank test indicated there is a significant difference in overall survival by primary care engagement history prior to admission (p<0.001). The median survival time for patients who had seen a primary care provider was 2322days versus 2158days for those who had not seen a primary care provider. Compared with those who did not see a primary care provider in the year prior to admission, having seen a primary care provider was associated with improved survival after admission. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

22 CFR 50.11 - Certificate of identity for travel to the United States to apply for admission.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 22 Foreign Relations 1 2013-04-01 2013-04-01 false Certificate of identity for travel to the United States to apply for admission. 50.11 Section 50.11 Foreign Relations DEPARTMENT OF STATE NATIONALITY AND PASSPORTS NATIONALITY PROCEDURES Procedures for Determination of United States Nationality of...

22 CFR 50.11 - Certificate of identity for travel to the United States to apply for admission.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 22 Foreign Relations 1 2012-04-01 2012-04-01 false Certificate of identity for travel to the United States to apply for admission. 50.11 Section 50.11 Foreign Relations DEPARTMENT OF STATE NATIONALITY AND PASSPORTS NATIONALITY PROCEDURES Procedures for Determination of United States Nationality of...

22 CFR 50.11 - Certificate of identity for travel to the United States to apply for admission.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 22 Foreign Relations 1 2010-04-01 2010-04-01 false Certificate of identity for travel to the United States to apply for admission. 50.11 Section 50.11 Foreign Relations DEPARTMENT OF STATE NATIONALITY AND PASSPORTS NATIONALITY PROCEDURES Procedures for Determination of United States Nationality of...

22 CFR 50.11 - Certificate of identity for travel to the United States to apply for admission.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 22 Foreign Relations 1 2014-04-01 2014-04-01 false Certificate of identity for travel to the United States to apply for admission. 50.11 Section 50.11 Foreign Relations DEPARTMENT OF STATE NATIONALITY AND PASSPORTS NATIONALITY PROCEDURES Procedures for Determination of United States Nationality of...

22 CFR 50.11 - Certificate of identity for travel to the United States to apply for admission.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 22 Foreign Relations 1 2011-04-01 2011-04-01 false Certificate of identity for travel to the United States to apply for admission. 50.11 Section 50.11 Foreign Relations DEPARTMENT OF STATE NATIONALITY AND PASSPORTS NATIONALITY PROCEDURES Procedures for Determination of United States Nationality of...

Effect of a Multidisciplinary Fall Risk Assessment on Falls Among Neurology Inpatients

PubMed Central

Hunderfund, Andrea N. Leep; Sweeney, Cynthia M.; Mandrekar, Jayawant N.; Johnson, LeAnn M.; Britton, Jeffrey W.

2011-01-01

OBJECTIVE: To evaluate whether the addition of a physician assessment of patient fall risk at admission would reduce inpatient falls on a tertiary hospital neurology inpatient unit. PATIENTS AND METHODS: A physician fall risk assessment was added to the existing risk assessment process (clinical nurse evaluation and Hendrich II Fall Risk Model score with specific fall prevention measures for patients at risk). An order to select either “Patient is” or “Patient is not at high risk of falls by physician assessment” was added to the physician electronic admission order set. Nurses and physicians were instructed to reach consensus when assessments differed. Full implementation occurred in second-quarter 2008. Preimplementation (January 1, 2006, to March 31, 2008) and postimplementation (April 1, 2008, to December 31, 2009) rates of falls were compared on the neurology inpatient unit and on 6 other medical units that did not receive intervention. RESULTS: The rate of falls during the 7 quarters after full implementation was significantly lower than that during the 9 preceding quarters (4.12 vs 5.69 falls per 1000 patient-days; P=.04), whereas the rate of falls on other medical units did not significantly change (2.99 vs 3.33 falls per 1000 patient-days; P=.24, Poisson test). The consensus risk assessment at admission correctly identified patients at risk for falls (14/325 at-risk patients fell vs 0/147 low-risk patients; P=.01, χ2 test), but the Hendrich II Fall Risk Model score, nurse, and physician assessments individually did not. CONCLUSION: A multidisciplinary approach to fall risk assessment is feasible, correctly identifies patients at risk, and was associated with a reduction in inpatient falls. PMID:21193651

Traumatic Brain Injury Rehabilitation in Riyadh, Saudi Arabia: Time to Rehabilitation Admission, Length of Stay, and Functional Outcome

PubMed Central

Mahmoud, Husam; Qannam, Hazem; Mortenson, Ben

2017-01-01

Objectives 1) To describe trends in time to rehabilitation admission and rehabilitation length of stay (LOS), and functional status, 2) To identify independent predictors of functional outcomes following rehabilitation. Design Retrospective cohort study. Setting Traumatic brain injuries rehabilitation unit of King Fahad Medical City, Riyadh, Saudi Arabia. Participants Adult patients with TBI discharged from inpatient rehabilitation between 2009–2014. Methods We collected information on time from injury to rehabilitation admission, rehabilitation LOS, Functional Independence Measure (FIM) score (admission and discharge), and demographic variables by chart review. Hierarchical regression was employed to investigate variables associated with FIM score at rehabilitation discharge. Results Data from 208 patients were obtained. Mean time from injury to rehabilitation admission was 263±274 days. Rehabilitation LOS was 66±43 days. FIM scores improved significantly during rehabilitation. After controlling for other variables, increasing time from injury to rehabilitation admission was associated with lower FIM score at discharge from rehabilitation. Conclusions Time from injury to rehabilitation admission is notably longer than reported elsewhere. Decreasing this time may improve functional outcome at discharge from rehabilitation. Ensuring that information regarding TBI severity is included throughout the continuum of care would benefit patients and provide insight into TBI aetiology in Saudi Arabia. PMID:28362120

The Epimed Monitor ICU Database®: a cloud-based national registry for adult intensive care unit patients in Brazil.

PubMed

Zampieri, Fernando Godinho; Soares, Márcio; Borges, Lunna Perdigão; Salluh, Jorge Ibrain Figueira; Ranzani, Otávio Tavares

2017-01-01

To describe the Epimed Monitor Database®, a Brazilian intensive care unit quality improvement database. We described the Epimed Monitor® Database, including its structure and core data. We presented aggregated informative data from intensive care unit admissions from 2010 to 2016 using descriptive statistics. We also described the expansion and growth of the database along with the geographical distribution of participating units in Brazil. The core data from the database includes demographic, administrative and physiological parameters, as well as specific report forms used to gather detailed data regarding the use of intensive care unit resources, infectious episodes, adverse events and checklists for adherence to best clinical practices. As of the end of 2016, 598 adult intensive care units in 318 hospitals totaling 8,160 intensive care unit beds were participating in the database. Most units were located at private hospitals in the southeastern region of the country. The number of yearly admissions rose during this period and included a predominance of medical admissions. The proportion of admissions due to cardiovascular disease declined, while admissions due to sepsis or infections became more common. Illness severity (Simplified Acute Physiology Score - SAPS 3 - 62 points), patient age (mean = 62 years) and hospital mortality (approximately 17%) remained reasonably stable during this time period. A large private database of critically ill patients is feasible and may provide relevant nationwide epidemiological data for quality improvement and benchmarking purposes among the participating intensive care units. This database is useful not only for administrative reasons but also for the improvement of daily care by facilitating the adoption of best practices and use for clinical research.

Admission to Medical Education in Ten Countries.

ERIC Educational Resources Information Center

Burn, Barbara B., Ed.

As part of a study of access and admission to higher education in Germany and the United States, a group of papers on medical admissions in various countries was commissioned. The papers presented in this book reveal wide differences in admissions policies and procedures. Barbara Burn examines some of the major issues in a foreword: representation…

Demographics of acute admissions to a National Spinal Injuries Unit.

PubMed

Lenehan, B; Boran, S; Street, J; Higgins, T; McCormack, D; Poynton, A R

2009-07-01

This prospective demographic study was undertaken to review the epidemiology and demographics of all acute admissions to the National Spinal Injuries Unit in Ireland for the 5 years to 2003. The study was conducted at the National Spinal Injuries Unit, Mater Miscericordiae University Hospital, Dublin, Ireland. Records of all patients admitted to our unit from 1999 to 2003 were compiled from a prospective computerized spinal database. In this 5-year period, 942 patients were acutely hospitalized at the National Spinal Injuries Unit. There were 686 (73%) males and 256 (27%) females, with an average age of 32 years (range 16-84 years). The leading cause of admission with a spinal injury was road traffic accidents (42%), followed by falls (35%), sport (11%), neoplasia (7.5%) and miscellaneous (4.5%). The cervical spine was most commonly affected (51%), followed by lumbar (28%) and thoracic (21%). On admission 38% of patients were ASIA D or worse, of which one-third were AISA A. Understanding of the demographics of spinal column injuries in unique populations can help us to develop preventative and treatment strategies at both national and international levels.

Mobile phone use for contacting emergency services in life-threatening circumstances.

PubMed

Wu, Olivia; Briggs, Andrew; Kemp, Tom; Gray, Alastair; MacIntyre, Kate; Rowley, Jack; Willett, Keith

2012-03-01

The potential health benefits of mobile phone use have not been widely studied, except for telemedicine-type applications. This study seeks to determine whether initial contact with emergency services via a mobile phone in life-threatening situations is associated with potential health benefits when compared to contact via a landline. A record-linkage study was carried out in which data from all emergency dispatches for immediately life-threatening events from a United Kingdom county ambulance service were linked to the Patient Admission System at two major local hospitals. Mortality (at the scene, at the emergency department [ED], and during hospitalization); transfer to the ED; admission (inpatient care, and intensive care unit); and length of stay were analyzed for calls classified as Code Red (immediately life-threatening) by initial exposure (mobile phone vs. landline), while controlling for potential confounding variables. Of 354,199 ambulances dispatched to attend emergency incidents, 66% transported patients to the hospital while 2% stood down due to death at the scene. Mobile phone compared to landline reporting of emergencies resulted in significant reductions in the risk of death at the scene (odds ratio [OR] 0.77), but not for death in the ED or during inpatient admission. The risk of being transferred to the ED and subsequent inpatient admission were significantly lower with reporting from mobile phones compared to landline (OR 0.93 and OR 0.82, respectively). In this study, evidence of statistical association was demonstrated between the use of mobile phones to alert ambulance services in life-threatening situations and improved outcomes for patients. Copyright © 2012 Elsevier Inc. All rights reserved.

Impact of Prophylactic Continuous Positive Airway Pressure on Transient Tachypnea of the Newborn and Neonatal Intensive Care Admission in Newborns Delivered by Elective Cesarean Section.

PubMed

Celebi, Miray Yilmaz; Alan, Serdar; Kahvecioglu, Dilek; Cakir, Ufuk; Yildiz, Duran; Erdeve, Omer; Arsan, Saadet; Atasay, Begum

2016-01-01

This study aims to evaluate the effect of the prophylactic continuous positive airway pressure (CPAP) administration in the delivery room to newborns who were delivered by elective cesarean section (CS). Inborn infants with gestational age between 34(0/7) to 38(6/7) and born by elective CS were prospectively randomized to receive either prophylactic CPAP for 20 minutes via face mask or standardized care without CPAP in the delivery room. Primary outcomes were the incidence of transient tachypnea of the newborn (TTN) and neonatal intensive care unit (NICU) admission due to respiratory distress. A total of 259 infants with a mean gestational age of 37.7 ± 0.8 weeks and birth weight of 3,244 ± 477 g were included. A total of 134 infants received prophylactic CPAP and 125 received control standard care. The rate of NICU admission was significantly lower in prophylactic CPAP group (p = 0.045). Although the rate of TTN was lower in the prophylactic CPAP group, the difference was not statistically significant (p = 0.059). The rate of NICU admission due to respiratory distress was significantly higher in late-preterm cohort than early-term cohort (p < 0.0001). Prophylactic CPAP administration decreases the rate of NICU admission without any side effect in late-preterm and early-term infants delivered by elective CS. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Eliciting the experiences of the adolescent-parent dyad following critical care admission: a pilot study.

PubMed

Wood, Dora; Geoghegan, Sophie; Ramnarayan, Padmanabhan; Davis, Peter J; Pappachan, John V; Goodwin, Sarah; Wray, Jo

2018-05-01

Critically ill adolescents are usually treated on intensive care units optimised for much older adults or younger children. The way they access and experience health services may be very different to most adolescent service users, and existing quality criteria may not apply to them. The objectives of this pilot study were, firstly, to determine whether adolescents and their families were able to articulate their experiences of their critical care admission and secondly, to identify the factors that are important to them during their intensive care unit (ICU) or high dependency unit (HDU) stay. Participants were 14-17 year olds who had previously had an emergency admission to an adult or paediatric ICU/HDU in one of four UK hospitals (two adult, two paediatric) and their parents. Semi-structured interviews were conducted with eight mother-adolescent dyads and one mother. Interviews were transcribed and analysed using framework analysis. The main reported determinant of high-quality care was the quality of interaction with staff. The significance of these interactions and their environment depended on adolescents' awareness of their surroundings, which was often limited in ICU and changed significantly over the course of their illness. Qualitative interview methodology would be difficult to scale up for this group. What is known • Critically ill adolescents are usually treated on intensive care units optimised for older adults or younger children. • The way they access and experience health services may be different to most adolescent patients; existing quality criteria may not apply. What is new • Reported determinants of high-quality care were age-appropriateness of the environment, respectfulness and friendliness of staff, communication and inclusion in healthcare decisions. • The significance of these depended on adolescents' awareness of their surroundings, which was often limited and changed over the course of their illness.

Potentially preventable complications in epilepsy admissions: The "weekend effect".

PubMed

Ho, Lianne; Kramer, Daniel R; Wen, Timothy; Moalem, Alimohammad S; Millett, David; Heck, Christianne N; Mack, William J; Liu, Charles Y

2017-05-01

Epilepsy affects approximately 1% of the population in the United States with frequent hospital admissions accounting for a significant burden on patients and society as a whole. Weekend admissions have generally been found to have poorer outcomes compared to weekday admissions with increased rates of preventable complications, such as nationally identified "hospital-acquired conditions" (HAC). This study aimed to assess the impact of weekend admission on HACs and mortality in the adult epilepsy population. All adult patients with epilepsy hospitalized in the U.S. from 2000 to 2010 in the Nationwide Inpatient Sample. There were 12,997,181 admissions for epilepsy with 10,106,152 (78%) weekday, 2,891,019 (22%) weekend, and 10 (<0.1%) missing admissions. Weekend admissions saw a 10% increased likelihood of both HACs (RR=1.10, 95% CI:1.09, 1.11, p<0.01) and mortality (RR=1.10, 95% CI: 1.09, 1.11, p<0.01) compared to weekday admissions. The occurrence of HAC was associated with higher inpatient charges (RR=1.36, 95% CI: 1.35, 1.36, p<0.01), pLOS (RR=1.21, 95% CI: 1.21, 1.22, p<0.01), and higher mortality (RR=1.13, 95% CI: 1.12, 1.14, p<0.01). Prior studies have shown weekend admissions are usually associated with higher rates of complications leading to higher costs and a longer hospital stay. Likewise, weekend admissions for epilepsy were associated with increased rates of HACs and mortality; however, they were also negatively associated with LOS and total charge. Thus, weekend admissions for epilepsy should be considered high risk with greater effort made to mitigate these risks. Copyright © 2017 Elsevier Inc. All rights reserved.

N-terminal pro-B-type natriuretic peptide is an independent predictor of outcome in an unselected cohort of critically ill patients.

PubMed

Meyer, Brigitte; Huelsmann, Martin; Wexberg, Paul; Delle Karth, Georg; Berger, Rudolf; Moertl, Deddo; Szekeres, Thomas; Pacher, Richard; Heinz, Gottfried

2007-10-01

Natriuretic peptides emerged during recent years as potent prognostic markers in patients with heart failure and acute myocardial infarction. In addition, natriuretic peptides show strong predictive value in patients with pulmonary embolism, sepsis, renal failure, and shock. The present study tests the prognostic information of N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) in an unselected cohort of critically ill patients. Prospective, observational study. A tertiary intensive care unit in a university hospital. A total of 289 consecutive patients admitted to the intensive care unit during a 16-month period with the following data: age 64 +/- 14 yrs, male n = 191, Simplified Acute Physiology Score II of 52 +/- 24, mechanical ventilation n = 180 (62%), vasopressors n = 179 (62%), renal failure n = 24 (8%). None. Plasma NT-pro-BNP samples (Roche Diagnostics) were obtained on intensive care unit admission. Data are given as median [range]. Intensive care unit survivors had significantly lower NT-pro-BNP values compared with intensive care unit nonsurvivors (3394 [24-35,000] vs. 6776 [303-35,000] pg/mL, survivors vs. nonsurvivors, respectively, p = .001). Hospital survivors were characterized by significantly lower NT-pro-BNP values (2656 [24-35,000] vs. 8390 [303-35,000] pg/mL, survivors vs. nonsurvivors, respectively, p = .001). NT-pro-BNP levels were not significantly different in patients with primary cardiac diagnosis compared with those with a noncardiac admission diagnosis (4794 [26-35,000], n = 202 vs. 3349 [24-35,000], n = 87, cardiac vs. noncardiac, respectively, p = .28). In a logistic regression model, Simplified Acute Physiology Score II and NT-pro-BNP were independently associated with hospital survival (chi = 35.6, p = .0001 and chi = 11.3, p = .0008, Simplified Acute Physiology Score II and NT-pro-BNP, respectively). Areas under the receiver operating characteristic curves of NT-pro-BNP and Simplified Acute Physiology Score II were not statistically significant different regarding the prediction of outcome. NT-pro-BNP on admission is an independent prognostic marker of outcome in an unselected cohort of critically ill patients. A single measurement of NT-pro-BNP might facilitate triage of emergency and intensive care unit patients.

Variation in intensive care unit utilization and mortality after blunt splenic injury.

PubMed

Kaufman, Elinore J; Wiebe, Douglas J; Martin, Niels D; Pascual, Jose L; Reilly, Patrick M; Holena, Daniel N

2016-06-15

Although trauma patients are frequently cared for in the intensive care unit (ICU), admission triage criteria are unclear and may vary among providers and institutions. The benefits of close monitoring must be weighed against the economic and opportunity costs of an ICU admission. We conducted a retrospective cohort study of patients treated for blunt splenic injuries from 2011-2014 at 30 level I and II Pennsylvania trauma centers. We used multivariable logistic regression to assess the relationship between ICU admission and mortality, adjusting for patient characteristics, injury characteristics, and physiology. We calculated center-level observed-to-expected ratios for ICU utilization and mortality and evaluated correlations with Spearman's rho. We compared the proportion of patients receiving critical care procedures, such as mechanical ventilation or central line placement between high and low-ICU-utilization centers. Of 2587 patients with blunt splenic injuries, 63.9% (1654) were admitted to the ICU. Median injury severity score was 17 overall, 13 for non-ICU patients and 17 for ICU patients (P < 0.001). In multivariable logistic regression, ICU admission was not significantly associated with mortality. Center-level risk-adjusted ICU admission rates ranged from 17.9%-87.3%. Risk-adjusted mortality rates ranged from 1.2%-9.6%. There was no correlation between observed-to-expected ratios for ICU utilization and mortality (Spearman's rho = -0.2595, P = 0.2103). Proportionately fewer ICU patients received critical care procedures at high-utilization centers than at low-utilization centers. Risk-adjusted ICU utilization rates for splenic trauma varied widely among trauma centers, with no clear relationship to mortality. Standardizing ICU admission criteria could improve resource utilization without increasing mortality. Copyright © 2016 Elsevier Inc. All rights reserved.

Pharmacist-led admission medication reconciliation before and after the implementation of an electronic medication management system.

PubMed

Sardaneh, Arwa A; Burke, Rosemary; Ritchie, Angus; McLachlan, Andrew J; Lehnbom, Elin C

2017-05-01

To investigate the impact of the introduction of an electronic medication management system on the proportion of patients with a recorded medication reconciliation on admission, the time from admission to when medication reconciliation was performed, and the characteristics of patients receiving this intervention pre-and post-implementation. An electronic medication management system was implemented in an Australian hospital from May to July 2015. A retrospective observational study was conducted in three wards across two phases; pre- (August 2014) and post- (August 2015) implementation. The study sample included every second patient admitted to these wards. A total of 370 patients were included, 179 pre- and 191 post-implementation. The proportion of recorded admission medication reconciliation significantly increased post-implementation in all study wards; coronary care unit (40 vs 68%, p=0.004), gastroenterology ward (39 vs 59%, p=0.015), and the neurology ward (19 vs 45%, p=0.002). The proportion of patients with recorded medication reconciliation within 24h of weekday admissions, or 48-72h of weekend admissions, increased from 47% pre- to 84% post-implementation. Admission medication reconciliation was recorded within a median of 1.0day for weekday admissions pre- and post-implementation (IQR 1.1 vs 0.2, respectively), and 3.5days (IQR 2.0) pre-implementation vs 1.5days (IQR 2.0) post-implementation for weekend admissions. Overall, across both phases pre-and post-implementation, admission medication reconciliation was recorded for patients who were significantly older (median 77 and 71 years, p<0.001), had a higher number of preadmission medications (median 6.5 and 5.0 medicines, p=0.001), and had a longer hospital stay (median 6.5 and 5.1days, p=0.003). A significantly higher proportion of patients with recorded medication reconciliation in the pre-implementation phase experienced polypharmacy (61%, p=0.002), hyperpolypharmacy (15%, p=0.001), and used a high-risk medication (44%, p=0.007). Implementing an electronic medication management system facilitates the medication reconciliation process leading to more high risk patients receiving this service on admission to hospital and in a more timely manner. The impact of electronic medication reconciliation on patient safety and clinical outcomes remains unknown. Copyright © 2017 Elsevier B.V. All rights reserved.

Specialist inpatient treatment for severe motor conversion disorder: a retrospective comparative study.

PubMed

McCormack, Ruaidhri; Moriarty, John; Mellers, John D; Shotbolt, Paul; Pastena, Rosa; Landes, Nadine; Goldstein, Laura; Fleminger, Simon; David, Anthony S

2014-08-01

Gold standard protocols have yet to be established for the treatment of motor conversion disorder (MCD). There is limited evidence to support inpatient, multidisciplinary intervention in chronic, severe cases. To evaluate the characteristics and outcomes of MCD patients admitted to a specialist neuropsychiatric inpatient unit. All patients admitted to the Lishman Unit (years 2007-2011) with a diagnosis of MCD were included. Data relevant to characteristics and status with regard to mobility, activities of daily living (ADLs) and Modified Rankin Scale (MRS) score at admission and discharge were extracted. Thirty-three cases (78.8% female) were included; the median duration of illness was 48 months. In comparison with brain injury patients admitted to the same unit, more cases had histories of childhood sexual abuse (36.4%, n=12), premorbid non-dissociative mental illness (81.1%, n=27) and employment as a healthcare/social-care worker (45.5%, n=15). Cases showed significant improvements in MRS scores (p<0.001), mobility (p<0.001) and ADL (p=0.002) following inpatient treatment. Patients with severe, long-standing MCD can achieve significant improvements in functioning after admission to a neuropsychiatry unit. 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.

Statewide ban on recreational fires resulted in a significant decrease in campfire-related summer burn center admissions.

PubMed

Hoang, David Manh; Reid, Dixie; Lentz, Christopher William

2013-01-01

Every summer, there is an increase in the number of burn injuries caused by accidents around campfires. Because of the prevalence of drought, high winds, and uncontrolled wild fires, a statewide ban on recreational fires was instituted in New Mexico from June to July 2011. We hypothesized that this legislation would have a significant impact on burn admissions caused by campfire-related injuries. A retrospective review of summer admissions to a state burn center was conducted to assess the effect of this ban on recreational fire injuries, and these data were compared with that of the previous summer when no ban was in effect. All burn admissions to a state burn center were reviewed from Memorial Day to Labor Day in 2010 and 2011. Data collected included cause, % TBSA, age, days of hospitalization, intensive care unit days, and total surface area grafted. Nonparametric statistical analysis was performed with Fisher exact test for dichotomous data and Mann-Whitney test for continuous data with significance at P < .05. There were 164 burn center admissions between Memorial Day and Labor Day in 2010 (n = 82) and 2011 (n = 82). Compared with all summer burn center admissions, patients injured by campfires were younger (18 vs 37 years; P = .002) with smaller total surface area burns (3.2 vs 6.2%; P = .41) and had shorter lengths of stay (10-11 vs 6-7 days; P = .62). There was more than a 3-fold decrease in burn admissions due to recreational fires during the study period (n = 14 [17%] in 2010 and 4 [5%] in 2011; P = .02). This resulted in a decrease in the number of patient-days from 91 in 2010 to 25 in 2011. Half of the camp fire admissions required skin grafts to definitively close the wounds (6/14 in 2010 and 2/4 in 2011). Recreational fire bans targeted at controlling wildfires during conditions favoring rapid spread were associated with a 3- to 4-fold decrease in campfire-related burn admissions. Compared with a summer when no fire ban was in effect, the number of patient-days decreased from 91 to 25.

Administration Time for the First Dose of Antimicrobials in Episodes of Fever and Neutropenia in Children With Cancer.

PubMed

De la Maza, Verónica; Simian, Daniela; Castro, Magdalena; Torres, Juan Pablo; Lucero, Yudeth; Sepúlveda, Fanny; Mazquiaran, Soraya; Salazar, Carolina; Segovia, Lorena; Santolaya, Maria Elena

2015-10-01

Early administration of antimicrobial (AM) is relevant in children with cancer, fever and neutropenia (FN). The recommendation is to administer the first dose of AM within the first hour of hospital admission. Our aims were to determine the time from the moment that a child with FN is admitted to the hospital until they receive their first dose of AM and to determine the association with clinical outcomes. This prospective, multicenter study evaluated the time elapsed from the admission to the first dose of AM, comparing this variable by admitting hospital and presentation location (Emergency Department/Oncology Units) and evaluating the clinical outcomes by the following variables: days of fever, days of hospitalization, hypotension, transfer to intensive care unit, sepsis and mortality. A total of 226 children with 388 episodes of FN were enrolled from 5 hospitals (July 2012-April 2014). The median time between hospital admission and administration of the first dose of AM was 132 minutes (interquartile range: 60-246 minutes). The median time to AM administration was significantly different between hospitals (70 vs. 200 minutes, P < 0.0001) and between presentation locations (Emergency Department vs. Oncology Units, median: 200 vs. 100 minutes, P < 0.0001). Twenty-five percentage of children received AM within 1 hour of admission. The administration of AM after 60 minutes was not associated with worse outcomes. Time to AM administration was longer than the recommendation. The findings described provide an opportunity to identify gaps and implement programs aimed at improving the equity and excellence of care in children with cancer and FN.

Improving patient handover between teams using a business improvement model: PDSA cycle.

PubMed

Luther, Vishal; Hammersley, Daniel; Chekairi, Ahmed

2014-01-01

Medical admission units are continuously under pressure to move patients off the unit to outlying medical wards and allow for new admissions. In a typical district general hospital, doctors working in these medical wards reported that, on average, three patients each week arrived from the medical admission unit before any handover was received, and a further two patients arrived without any handover at all. A quality improvement project was therefore conducted using a 'Plan, Do, Study, Act' cycle model for improvement to address this issue. P - Plan: as there was no framework to support doctors with handover, a series of standard handover procedures were designed. D - Do: the procedures were disseminated to all staff, and championed by key stakeholders, including the clinical director and matron of the medical admission unit. S - STUDY: Measurements were repeated 3 months later and showed no change in the primary end points. A - ACT: The post take ward round sheet was redesigned, creating a checkbox for a medical admission unit doctor to document that handover had occurred. Nursing staff were prohibited from moving the patient off the ward until this had been completed. This later evolved into a separate handover sheet. Six months later, a repeat study revealed that only one patient each week was arriving before or without a verbal handover. Using a 'Plan, Do, Study, Act' business improvement tool helped to improve patient care.

Economic outcomes of influenza in hospitalized elderly with and without ICU admission.

PubMed

Chan, Yik-Kei; Wong, Rity Yk; Ip, Margaret; Lee, Nelson Ls; You, Joyce Hs

2017-01-01

To describe direct medical costs of influenza in hospitalized elderly, with and without intensive care unit (ICU) admission, during the 2014-2015 season in Hong Kong. A retrospective study was conducted in 110 inpatients aged ≥65 years with laboratory-confirmed influenza treated by antiviral therapy during season 2014-2015 in a tertiary hospital. Resource utilization of influenza-related diagnostic and laboratory tests, medications for influenza treatment, usage of general medical ward and ICU during the influenza-related length of hospital stay (IR-LOS) were collected. There were 18 (16.4%) and 92 (83.4%) cases with and without ICU admission, respectively. The difference in influenza-related mortality rates between patients with (11.1%) and without ICU admission (2.2%) was not statistically significant (P=0.064). Patients with ICU admission reported longer IR-LOS (12.7 ±6.0 days versus 5.5 ±2.7 days; P<0.001) and higher direct costs (36,588 USD ±21,482 versus 5,773 USD ±2,017; P<0.001; 1 USD=7.8 HKD). Male gender (OR=14.50; 95% CI 1.68, 125.07) and respiratory complications (OR=9.61; 95% CI 1.90, 48.50) were positive predictors of ICU admission. Age ≥70 years (OR=0.09; 95% CI 0.02, 0.46) and antiviral therapy initiation within 7 days (OR=0.05; 95% CI 0.003, 0.79) were negative predictors of ICU admission. Influenza B was a positive predictor of high-cost hospitalization in non-ICU survivors (OR=7.33; 95% CI 1.24, 43.29). No predictor of mortality was identified. Hospitalization cost in elderly for seasonal influenza was substantial in Hong Kong. The cost in patients with ICU admission was significantly higher than those without ICU care. Respiratory complications and male gender predicted ICU admission. Influenza B infection predicted high-cost hospitalization in non-ICU survivors.

All-Cause Hospital Admissions Among Older Adults After a Natural Disaster.

PubMed

Bell, Sue Anne; Abir, Mahshid; Choi, HwaJung; Cooke, Colin; Iwashyna, Theodore

2017-08-05

We characterize hospital admissions among older adults for any cause in the 30 days after a significant natural disaster in the United States. The main outcome was all-cause hospital admissions in the 30 days after natural disaster. Separate analyses were conducted to examine all-cause hospital admissions excluding the 72 hours after the disaster, ICU admissions, all-cause inhospital mortality, and admissions by state. A self-controlled case series analysis using the 2011 Medicare Provider and Analysis Review was conducted to examine exposure to natural disaster by elderly adults located in zip codes affected by tornadoes during the 2011 southeastern superstorm. Spatial data of tornado events were obtained from the National Oceanic and Atmospheric Administration's Severe Report database, and zip code data were obtained from the US Census Bureau. All-cause hospital admissions increased by 4% for older adults in the 30 days after the April 27, 2011, tornadoes (incidence rate ratio 1.04; 95% confidence interval 1.01 to 1.07). When the first 3 days after the disaster that may have been attributed to immediate injuries were excluded, hospitalizations for any cause also remained higher than when compared with the other 11 months of the year (incidence rate ratio 1.04; 95% confidence interval 1.01 to 1.07). There was no increase in ICU admissions or inhospital mortality associated with the natural disaster. When data were examined by individual states, Alabama, which had the highest number of persons affected, had a 9% increase in both hospitalizations and ICU admissions. When all time-invariant characteristics were controlled for, this natural disaster was associated with a significant increase in all-cause hospitalizations. This analysis quantifies acute care use after disasters through examining all-cause hospitalizations and represents an important contribution to building models of resilience-the ability to recover from a disaster-and hospital surge capacity. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Early alterations of red blood cell rheology in critically ill patients.

PubMed

Reggiori, Giulia; Occhipinti, Giovanna; De Gasperi, Andrea; Vincent, Jean-Louis; Piagnerelli, Michael

2009-12-01

To investigate red blood cell rheology in a large intensive care unit population on admission, and to assess the possible influence of comorbidities on the rheology. : Prospective study. Medico-surgical intensive care unit with 31 beds. All intensive care unit admissions during a 5-month period and 20 healthy volunteers. Blood sampling. A total of 196 intensive care patients (160 without and 36 with sepsis) and 20 healthy volunteers were studied. Red blood cell rheology (deformability and aggregation) was assessed ex vivo using the laser-assisted optical rotational cell analyzer (LORCA; Mechatronics Instruments BV, AN Zwaag, Netherlands) within the first 24 hrs after intensive care unit admission. Red blood cell deformability was determined by the elongation index in relation to the shear stress (0.3 to 50 Pa) applied on the red blood cell membrane surface. Aggregation was assessed by the aggregation index. Septic patients were more likely to have anemia, coagulation abnormalities, and comorbidities than were nonseptic patients. Red blood cell deformability was significantly altered in septic compared to nonseptic patients and volunteers for the majority of shear stress rates studied. The aggregation index was greater in septic patients than in volunteers (67.9% [54.7-73.5] vs. 61.8% [58.2-68.4]; p < .05). Only sepsis and hematologic disease influenced the elongation index (both p < .01). Other comorbidities, like cancer, diabetes mellitus, cirrhosis, and terminal renal failure, had no effect on the elongation index. Aggregation index was related to the degree of organ failure (Sequential Organ Failure Assessment score), the red blood cell count, and fibrinogen concentrations. Early alterations of red blood cell rheology are common in intensive care unit patients, especially in those with sepsis. Comorbidities (other than hematologic diseases) do not significantly influence these abnormalities. These alterations could contribute to the microcirculatory alterations observed in critically ill patients.

Patient-related factors and circumstances surrounding decisions to forego life-sustaining treatment, including intensive care unit admission refusal.

PubMed

Reignier, Jean; Dumont, Romain; Katsahian, Sandrine; Martin-Lefevre, Laurent; Renard, Benoit; Fiancette, Maud; Lebert, Christine; Clementi, Eva; Bontemps, Frederic

2008-07-01

To assess decisions to forego life-sustaining treatment (LST) in patients too sick for intensive care unit (ICU) admission, comparatively to patients admitted to the ICU. Prospective observational cohort study. A medical-surgical ICU. Consecutive patients referred to the ICU during a one-yr period. None. Of 898 triaged patients, 147 were deemed too well to benefit from ICU admission. Decisions to forego LST were made in 148 of 666 (22.2%) admitted patients and in all 85 patients deemed too sick for ICU admission. Independent predictors of decisions to forego LST at ICU refusal rather than after ICU admission were: age; underlying disease; living in an institution; preexisting cognitive impairment; admission for medical reasons; and acute cardiac failure, acute central neurologic illness, or sepsis. Hospital mortality after decisions to forego LST was not significantly different in refused and admitted patients (77.5% vs. 86.5%; p = .1). Decisions to forego LST were made via telephone in 58.8% of refused patients and none of the admitted patients. Nurses caring for the patient had no direct contact with the ICU physicians for 62.3% of the decisions in refused patients, whereas meetings between nurses and physicians occurred in 70.3% of decisions to forego LST in the ICU. Patients or relatives were involved in 28.2% of decisions to forego LST at ICU refusal compared with 78.4% of decisions to forego LST in ICU patients (p < .001). All patients deemed too sick for ICU admission had decisions to forego LST. These decisions were made without direct patient examination in two-thirds of refused patients (vs. none of admitted patients) and were associated with less involvement of nurses and relatives compared with decisions in admitted patients. Further work is needed to improve decisions to forego LST made under the distinctive circumstances of triage.

Admission-Group Salary Differentials in the United States: The Significance of Labor Market Institutional Selection of High-Skilled Workers*

PubMed Central

Hao, Lingxin

2015-01-01

In 1990 a temporary-to-permanent pathway was established for highly skilled workers admitted to the United States under nonimmigrant programs. The paper argues that this policy shift has allowed employers to play a crucial role in the immigration of highly skilled workers, thereby creating labor-market institutional selection that gives a salary advantage to highly skilled temporary-admitted workers retained in the United States. Through analyses of the salary differentials among admission-category groups, the paper finds that the salary advantage is based on recruitment from Western countries, adjustment from temporary to permanent status after a second employer screening, working in the information technology sector and the private sector, holding a supervisory position, or having a skill-matched job, all of which are consequences of institutional selection rather than individual self-selection. Our results also reveal a difference between those admitted from abroad and those recruited from graduating foreign students in USA higher educational institutions, which suggests a distinction between overseas hiring and domestic hiring. Policy implications for the United States and other receiving countries are discussed. PMID:26269690

Economic recession and headache-related hospital admissions.

PubMed

Chinta, Ravi; Rao, M B; Narendran, Vivek; Malla, Ganesh; Joshi, Hem

2013-01-01

Incidence of headaches across different regions and its relationship to unemployment rates in the United States before and during an economic recession was evaluated. Years 2008 and 2009 were determined as recessionary period. Headache-related admissions, particularly the uncomplicated headaches, increased significantly during recession. Proportion of women with headaches has increased and the age group of 25-54 years was the most affected during the recession. The hospital charges have increased even though the average length and charge of stay decreased. These findings are consistent with our understanding of effects of stress and unemployment on psychological and physical health.

Early life factors associated with the exclusivity and duration of breast feeding in an Irish birth cohort study.

PubMed

Smith, Hazel Ann; O'B Hourihane, Jonathan; Kenny, Louise C; Kiely, Mairead; Murray, Deirdre M; Leahy-Warren, Patricia

2015-09-01

to investigate the influence of parental and infant characteristics on exclusive breast feeding from birth to six months of age and breast feeding rates at two, six and 12 months of age in Ireland. secondary data analysis from the Cork BASELINE Birth Cohort Study (http://www.baselinestudy.net/). Infants were seen at birth and two, six, and 12 months of age. Maternal and paternal history, neonatal course and feeding data were collected at birth and using parental questionnaires at each time point. 1094 singleton infants of primiparous women recruited at 20 weeks' gestation who were breastfeeding on discharge from the maternity hospital. at discharge from the maternity hospital and at two months, neonatal intensive-care unit admission had the strongest influence on exclusive breast feeding status (adjusted OR 0.17, 95% CI 0.07-0.41 at discharge) and at two months (adjusted OR=0.20, 95% CI 0.05-0.83). A shorter duration of breast feeding was significantly associated with younger maternal age, non-tertiary education, Irish nationality and neonatal intensive-care unit admission. There was a significant difference in the duration of any breast feeding between infants who were and were not admitted to the neonatal intensive-care unit, 28(10.50, 32) weeks versus 32(27, 40) weeks. Mothers whose maternity leave was between seven and 12 months (adjusted OR=2.76, 95% CI 1.51-5.05) breast fed for a longer duration compared to mothers who had less than six months of maternity leave. admission to the neonatal intensive care unit negatively influenced both exclusivity and duration of breast feeding. Length of maternity leave, and not employment status, was significantly associated with duration of breast feeding. additional support may be required to ensure continued breast feeding in infants admitted to the neonatal intensive-care unit. Length of maternity leave is a modifiable influence on breast feeding and offers the opportunity for intervention to improve our rates of breast feeding. Copyright © 2015 Elsevier Ltd. All rights reserved.

Incidence of bacteremia at the time of ICU admission and its impact on outcome.

PubMed

Nasa, Prashant; Juneja, Deven; Singh, Omender; Dang, Rohit; Arora, Vikas; Saxena, Sanjay

2011-11-01

Blood culture is routinely taken at the time of admission to the intensive care unit (ICU) for patients suspected to have infection. We undertook this study to determine the incidence of bacteremia at the time of ICU admission and to assess its impact on the outcome. Retrospective cohort study from all the admissions in ICU, in whom blood cultures sent at the time of admission were analyzed. Data regarding patient demographics, probable source of infection, previous antibiotic use and ICU course was recorded. Severity of illness on admission was assessed by acute physiology and chronic health evaluation II score. Qualitative data were analyzed using Chi-square or Fisher Exact test and quantitative data were analyzed using Student's t-test. Primary outcome measure was ICU mortality. Of 567 patients, 42% patients were on antibiotics. Sixty-four percent of the patients were direct ICU admission from casualty, 10.76% were from wards and 6.17% from other ICUs, and 19.05% were transfers from other hospitals. Blood cultures were positive in 10.6% patients. Mortality was significantly higher in patients with positive blood cultures (45% vs. 13.6%; P=0.000). On univariate analysis, only previous antibiotic use was statistically associated with higher mortality (P=0.011). Bacteremic patients who were already on antibiotics had a significantly higher mortality (OR 12.9, 95% CI: 1.6-100). Blood cultures may be positive in only minority of the patients with suspected infection admitted to ICU. Nevertheless, the prognosis of those patients with positive blood culture is worse, especially if culture is positive in spite of the patient being on antibiotics.

Incidence of bacteremia at the time of ICU admission and its impact on outcome

PubMed Central

Nasa, Prashant; Juneja, Deven; Singh, Omender; Dang, Rohit; Arora, Vikas; Saxena, Sanjay

2011-01-01

Context: Blood culture is routinely taken at the time of admission to the intensive care unit (ICU) for patients suspected to have infection. We undertook this study to determine the incidence of bacteremia at the time of ICU admission and to assess its impact on the outcome. Methods: Retrospective cohort study from all the admissions in ICU, in whom blood cultures sent at the time of admission were analyzed. Data regarding patient demographics, probable source of infection, previous antibiotic use and ICU course was recorded. Severity of illness on admission was assessed by acute physiology and chronic health evaluation II score. Statistical Analysis: Qualitative data were analyzed using Chi-square or Fisher Exact test and quantitative data were analyzed using Student's t-test. Primary outcome measure was ICU mortality. Results: Of 567 patients, 42% patients were on antibiotics. Sixty-four percent of the patients were direct ICU admission from casualty, 10.76% were from wards and 6.17% from other ICUs, and 19.05% were transfers from other hospitals. Blood cultures were positive in 10.6% patients. Mortality was significantly higher in patients with positive blood cultures (45% vs. 13.6%; P=0.000). On univariate analysis, only previous antibiotic use was statistically associated with higher mortality (P=0.011). Bacteremic patients who were already on antibiotics had a significantly higher mortality (OR 12.9, 95% CI: 1.6–100). Conclusions: Blood cultures may be positive in only minority of the patients with suspected infection admitted to ICU. Nevertheless, the prognosis of those patients with positive blood culture is worse, especially if culture is positive in spite of the patient being on antibiotics. PMID:22223904

Hospital costs for treatment of acute heart failure: economic analysis of the REVIVE II study.

PubMed

de Lissovoy, Greg; Fraeman, Kathy; Teerlink, John R; Mullahy, John; Salon, Jeff; Sterz, Raimund; Durtschi, Amy; Padley, Robert J

2010-04-01

Acute heart failure (AHF) is the leading cause of hospital admission among older Americans. The Randomized EValuation of Intravenous Levosimendan Efficacy (REVIVE II) trial compared patients randomly assigned to a single infusion of levosimendan (levo) or placebo (SOC), each in addition to local standard treatments for AHF. We report an economic analysis of REVIVE II from the hospital perspective. REVIVE II enrolled patients (N = 600) hospitalized for treatment of acute decompensated heart failure (ADHF) who remained dyspneic at rest despite treatment with intravenous diuretics. Case report forms documented index hospital treatment (drug administration, procedures, days of treatment by care unit), as well as subsequent hospital and emergency department admissions during follow-up ending 90 days from date of randomization. These data were used to impute cost of admission based on an econometric cost function derived from >100,000 ADHF hospital billing records selected per REVIVE II inclusion criteria. Index admission mean length of stay (LOS) was shorter for the levo group compared with standard of care (SOC) (7.03 vs 8.96 days, P = 0.008) although intensive care unit (ICU)/cardiac care unit (CCU) days were similar (levo 2.88, SOC 3.22, P = 0.63). Excluding cost for levo, predicted mean (median) cost for the index admission was levo US $13,590 (9,458), SOC $19,021 (10,692) with a difference of $5,431 (1,234) favoring levo (P = 0.04). During follow-up through end of study day 90, no significant differences were observed in numbers of hospital admissions (P = 0.67), inpatient days (P = 0.81) or emergency department visits (P = 0.41). Cost-effectiveness was performed with a REVIVE-II sub-set conforming to current labeling, which excluded patients with low baseline blood pressure. Assuming an average price for levo in countries where currently approved, there was better than 50% likelihood that levo was both cost-saving and improved survival. Likelihood that levo would be cost-effective for willingness-to-pay below $50,000 per year of life gained was about 65%. In the REVIVE II trial, patients treated with levo had shorter LOS and lower cost for the initial hospital admission relative to patients treated with SOC. Based on sub-group analysis of patients administered per the current label, levo appears cost-effective relative to SOC.

The Utility of Routine Intensive Care Admission for Patients Undergoing Intracranial Neurosurgical Procedures: A Systematic Review.

PubMed

de Almeida, Cesar Cimonari; Boone, M Dustin; Laviv, Yosef; Kasper, Burkhard S; Chen, Clark C; Kasper, Ekkehard M

2018-02-01

Patients who have undergone intracranial neurosurgical procedures have traditionally been admitted to an intensive care unit (ICU) for close postoperative neurological observation. The purpose of this study was to systematically review the evidence for routine ICU admission in patients undergoing intracranial neurosurgical procedures and to evaluate the safety of alternative postoperative pathways. We were interested in identifying studies that examined selected patients who presented for elective, non-emergent intracranial surgery whose postoperative outcomes were compared as a function of ICU versus non-ICU admission. A systematic review was performed in July 2016 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist of the Medline database. The search strategy was created based on the following key words: "craniotomy," "neurosurgical procedure," and "intensive care unit." The nine articles that satisfied the inclusion criteria yielded a total of 2227 patients. Of these patients, 879 were observed in a non-ICU setting. The most frequent diagnoses were supratentorial brain tumors, followed by patients with cerebrovascular diseases and infratentorial brain tumors. Three percent (30/879) of the patients originally assigned to floor or intermediate care status were transferred to the ICU. The most frequently observed neurological complications leading to ICU transfer were delayed postoperative neurological recovery, seizures, worsening of neurological deficits, hemiparesis, and cranial nerves deficits. Our systematic review demonstrates that routine postoperative ICU admission may not benefit carefully selected patients who have undergone elective intracranial neurosurgical procedures. In addition, limiting routine ICU admission may result in significant cost savings.

Measles in a South African paediatric intensive care unit: again!

PubMed

Coetzee, Saskia; Morrow, Brenda M; Argent, Andrew C

2014-05-01

The aim of this study is to evaluate the outcomes of children with measles-related disease (MRD) admitted to a paediatric intensive care unit (PICU) and the effect on PICU resources and elective surgery of a recent measles epidemic. This was a retrospective observational study of all patients admitted to the PICU of Red Cross War Memorial Children's Hospital, Cape Town, South Africa, with MRD from January to December 2010. Patient admission characteristics, duration of PICU admission and mortality were recorded. Costs were calculated using bed days utilised and estimated daily PICU admission cost. A total of 1274 children were admitted over the study period, 58 (4.6%) with MRD (median (interquartile range) age 7 (5-9) months). Pneumonia was the most common reason for admission (81%) and the main cause of mortality. Non-MRD mortality was 8.8% compared with MRD mortality of 31% (P < 0.0001). Standardised mortality for non-MRD was 0.7 versus 1.7 in MRD (P = 0.002). HIV comorbidity and being underweight for age were associated with increased mortality. Patients with MRD occupied 379 bed days with a median (interquartile range) duration of stay of 5.5 (3.0-9.0) days at an estimated overall cost of R4,813,300 (approximately $543,900). During the study period, 67 children booked for elective surgery, and 87 other referrals were refused PICU admission. MRD was associated with significant morbidity and mortality, and substantial strain on scarce PICU resources. © 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Hypothermia and rapid rewarming is associated with worse outcome following traumatic brain injury.

PubMed

Thompson, Hilaire J; Kirkness, Catherine J; Mitchell, Pamela H

2010-01-01

The purpose of the present study was to determine (1) the prevalence and degree of hypothermia in patients on emergency department admission and (2) the effect of hypothermia and rate of rewarming on patient outcomes. Secondary data analysis was conducted on patients admitted to a level I trauma center following severe traumatic brain injury (n = 147). Patients were grouped according to temperature on admission according to hypothermia status and rate of rewarming (rapid or slow). Regression analyses were performed. Hypothermic patients were more likely to have lower postresuscitation Glasgow Coma Scale scores and a higher initial injury severity score. Hypothermia on admission was correlated with longer intensive care unit stays, a lower Glasgow Coma Scale score at discharge, higher mortality rate, and lower Glasgow outcome score-extended scores up to 6 months postinjury (P < .05). When controlling for other factors, rewarming rates more than 0.25°C/h were associated with lower Glasgow Coma Scale scores at discharge, longer intensive care unit length of stay, and higher mortality rate than patients rewarmed more slowly although these did not reach statistical significance. Hypothermia on admission is correlated with worse outcomes in brain-injured patients. Patients with traumatic brain injury who are rapidly rewarmed may be more likely to have worse outcomes. Trauma protocols may need to be reexamined to include controlled rewarming at rates 0.25°C/h or less.

Case mix, outcome and length of stay for admissions to adult, general critical care units in England, Wales and Northern Ireland: the Intensive Care National Audit & Research Centre Case Mix Programme Database

PubMed Central

2005-01-01

Introduction The present paper describes the methods of data collection and validation employed in the Intensive Care National Audit & Research Centre Case Mix Programme (CMP), a national comparative audit of outcome for adult, critical care admissions. The paper also describes the case mix, outcome and activity of the admissions in the Case Mix Programme Database (CMPD). Methods The CMP collects data on consecutive admissions to adult, general critical care units in England, Wales and Northern Ireland. Explicit steps are taken to ensure the accuracy of the data, including use of a dataset specification, of initial and refresher training courses, and of local and central validation of submitted data for incomplete, illogical and inconsistent values. Criteria for evaluating clinical databases developed by the Directory of Clinical Databases were applied to the CMPD. The case mix, outcome and activity for all admissions were briefly summarised. Results The mean quality level achieved by the CMPD for the 10 Directory of Clinical Databases criteria was 3.4 (on a scale of 1 = worst to 4 = best). The CMPD contained validated data on 129,647 admissions to 128 units. The median age was 63 years, and 59% were male. The mean Acute Physiology and Chronic Health Evaluation II score was 16.5. Mortality was 20.3% in the CMP unit and was 30.8% at ultimate discharge from hospital. Nonsurvivors stayed longer in intensive care than did survivors (median 2.0 days versus 1.7 days in the CMP unit) but had a shorter total hospital length of stay (9 days versus 16 days). Results for the CMPD were comparable with results from other published reports of UK critical care admissions. Conclusions The CMP uses rigorous methods to ensure data are complete, valid and reliable. The CMP scores well against published criteria for high-quality clinical databases.

Case mix, outcome and length of stay for admissions to adult, general critical care units in England, Wales and Northern Ireland: the Intensive Care National Audit & Research Centre Case Mix Programme Database

PubMed Central

Harrison, David A; Brady, Anthony R; Rowan, Kathy

2004-01-01

Introduction The present paper describes the methods of data collection and validation employed in the Intensive Care National Audit & Research Centre Case Mix Programme (CMP), a national comparative audit of outcome for adult, critical care admissions. The paper also describes the case mix, outcome and activity of the admissions in the Case Mix Programme Database (CMPD). Methods The CMP collects data on consecutive admissions to adult, general critical care units in England, Wales and Northern Ireland. Explicit steps are taken to ensure the accuracy of the data, including use of a dataset specification, of initial and refresher training courses, and of local and central validation of submitted data for incomplete, illogical and inconsistent values. Criteria for evaluating clinical databases developed by the Directory of Clinical Databases were applied to the CMPD. The case mix, outcome and activity for all admissions were briefly summarised. Results The mean quality level achieved by the CMPD for the 10 Directory of Clinical Databases criteria was 3.4 (on a scale of 1 = worst to 4 = best). The CMPD contained validated data on 129,647 admissions to 128 units. The median age was 63 years, and 59% were male. The mean Acute Physiology and Chronic Health Evaluation II score was 16.5. Mortality was 20.3% in the CMP unit and was 30.8% at ultimate discharge from hospital. Nonsurvivors stayed longer in intensive care than did survivors (median 2.0 days versus 1.7 days in the CMP unit) but had a shorter total hospital length of stay (9 days versus 16 days). Results for the CMPD were comparable with results from other published reports of UK critical care admissions. Conclusions The CMP uses rigorous methods to ensure data are complete, valid and reliable. The CMP scores well against published criteria for high-quality clinical databases. PMID:15025784

Prognosis of patients presenting extreme acidosis (pH <7) on admission to intensive care unit.

PubMed

Allyn, Jérôme; Vandroux, David; Jabot, Julien; Brulliard, Caroline; Galliot, Richard; Tabatchnik, Xavier; Combe, Patrice; Martinet, Olivier; Allou, Nicolas

2016-02-01

The purpose was to determine prognosis of patients presenting extreme acidosis (pH <7) on admission to the intensive care unit (ICU) and to identify mortality risk factors. We retrospectively analyzed all patients who presented with extreme acidosis within 24 hours of admission to a polyvalent ICU in a university hospital between January 2011 and July 2013. Multivariate analysis and survival analysis were used. Among the 2156 patients admitted, 77 patients (3.6%) presented extreme acidosis. Thirty (39%) patients suffered cardiac arrest before admission. Although the mortality rate predicted by severity score was 93.6%, death occurred in 52 cases (67.5%) in a median delay of 13 (5-27) hours. Mortality rate depended on reason for admission, varying between 22% for cases linked to diabetes mellitus and 100% for cases of mesenteric infarction (P = .002), cardiac arrest before admission (P < .001), type of lactic acidosis (P = .007), high Simplified Acute Physiology Score II (P = .008), and low serum creatinine (P = .012). Patients with extreme acidosis on admission to ICU have a less severe than expected prognosis. Whereas mortality is almost 100% in cases of cardiac arrest before admission, mortality is much lower in the absence of cardiac arrest before admission, which justifies aggressive ICU therapies. Copyright © 2015 Elsevier Inc. All rights reserved.

Pre-hospital National Early Warning Score (NEWS) is associated with in-hospital mortality and critical care unit admission: A cohort study.

PubMed

Abbott, Tom E F; Cron, Nicholas; Vaid, Nidhi; Ip, Dorothy; Torrance, Hew D T; Emmanuel, Julian

2018-03-01

National Early Warning Score (NEWS) is increasingly used in UK hospitals. However, there is only limited evidence to support the use of pre-hospital early warning scores. We hypothesised that pre-hospital NEWS was associated with death or critical care escalation within the first 48 h of hospital stay. Planned secondary analysis of a prospective cohort study at a single UK teaching hospital. Consecutive medical ward admissions over a 20-day period were included in the study. Data were collected from ambulance report forms, medical notes and electronic patient records. Pre-hospital NEWS was calculated retrospectively. The primary outcome was a composite of death or critical care unit escalation within 48 h of hospital admission. The secondary outcome was length of hospital stay. 189 patients were included in the analysis. The median pre-hospital NEWS was 3 (IQR 1-5). 13 patients (6.9%) died or were escalated to the critical care unit within 48 h of hospital admission. Pre-hospital NEWS was associated with death or critical care unit escalation (OR, 1.25; 95% CI, 1.04-1.51; p = 0.02), but NEWS on admission to hospital was more strongly associated with this outcome (OR, 1.52; 95% CI, 1.18-1.97, p < 0.01). Neither was associated with hospital length of stay. Pre-hospital NEWS was associated with death or critical care unit escalation within 48 h of hospital admission. NEWS could be used by ambulance crews to assist in the early triage of patients requiring hospital treatment or rapid transport. Further cohort studies or trials in large samples are required before implementation.

Case mix, outcome and activity for patients with severe acute kidney injury during the first 24 hours after admission to an adult, general critical care unit: application of predictive models from a secondary analysis of the ICNARC Case Mix Programme Database

PubMed Central

Kolhe, Nitin V; Stevens, Paul E; Crowe, Alex V; Lipkin, Graham W; Harrison, David A

2008-01-01

Introduction This study pools data from the UK Intensive Care National Audit and Research Center (ICNARC) Case Mix Programme (CMP) to evaluate the case mix, outcome and activity for 17,326 patients with severe acute kidney injury (AKI) occurring during the first 24 hours of admission to intensive care units (ICU). Methods Severe AKI admissions (defined as serum creatinine ≥300 μmol/l and/or urea ≥40 mmol/l during the first 24 hours) were extracted from the ICNARC CMP database of 276,326 admissions to UK ICUs from 1995 to 2004. Subgroups of oliguric and nonoliguric AKI were identified by daily urine output. Data on surgical status, survival and length of stay were also collected. Severity of illness scores and mortality prediction models were compared (UK Acute Physiology and Chronic Health Evaluation [APACHE] II, Stuivenberg Hospital Acute Renal Failure [SHARF] T0, SHARF II0 and the Mehta model). Results Severe AKI occurred in 17,326 out of 276,731 admissions (6.3%). The source of admission was nonsurgical in 83.7%. Sepsis was present in 47.3% and AKI was nonoliguric in 63.9% of cases. Admission to ICU with severe AKI accounted for 9.3% of all ICU bed-days. Oliguric AKI was associated with longer length of stay for survivors and shorter length of stay for nonsurvivors compared with nonoliguric AKI. Oliguric AKI was associated with significantly greater ICU and hospital mortality (55.8% and 77.3%, respectively) compared with nonoliguric AKI (33.4% and 49.3%, respectively). Surgery during the 1 week before admission or during the first week in the CMP unit was associated with decreased odds of mortality. UK APACHE II and the Mehta scores under-predicted the number of deaths, whereas SHARF T0 and SHARF II0 over-predicted the number of deaths. Conclusions Severe AKI accounts for over 9% of all bed-days in adult, general ICUs, representing a considerable drain on resources. Although nonoliguric AKI continues to confer a survival benefit, overall survival from AKI in the ICU and survival to leave hospital remains poor. The use of APACHE II score measured during the first 24 hours of ICU stay performs well as compared with SHARF T0, SHARF II0 and the Mehta score, but it lacks perfect calibration. PMID:19105800

Predictors of poor outcome in gastrointestinal bleeding in emergency department.

PubMed

Kaya, Ender; Karaca, Mehmet Ali; Aldemir, Deniz; Ozmen, M Mahir

2016-04-28

To determine the prognostic risk factors of gastrointestinal bleeding in emergency department cases. The trial was a retrospective single-center study involving 600 patients over 18-years-old and carried out with approval by the Institutional Ethics Committee. Patient data included demographic characteristics, symptoms at admission, past medical history, vital signs, laboratory results, endoscopy and colonoscopy results, length of hospital stay, need of intensive care unit (ICU) admission, and mortality. Mortality rate was the principal endpoint of the study, while duration of hospital stay, required interventional treatment, and admission to the ICU were secondary endpoints. The mean age of patients was 61.92-years-old. Among the 600 total patients, 363 (60.5%) underwent upper gastrointestinal endoscopy and the most frequent diagnoses were duodenal ulcer (19.2%) and gastric ulcer (12.8%). One-hundred-and-fifteen (19.2%) patients required endoscopic treatment, 20 (3.3%) required surgical treatment, and 5 (0.8%) required angiographic embolization. The mean length of hospital stay was 5.21 ± 5.85 d. The mortality rate was 6.3%. The ICU admission rate was 5.3%. Patients with syncope, higher blood glucose levels, and coronary artery disease had significantly higher ICU admission rates (P = 0.029, P = 0.043, and P = 0.002, respectively). Patients with low thrombocyte levels, high creatinine, high international normalized ratio, and high serum transaminase levels had significantly longer hospital stay (P = 0.02, P = 0.001, P = 0.019, and P = 0.005, respectively). Patients who died had significantly higher serum blood urea nitrogen and creatinine levels (P = 0.016 and P = 0.038), and significantly lower mean blood pressure and oxygen saturation (P = 0.004 and P = 0.049). Malignancy and low Glasgow coma scale (GCS) were independent predictive factors of mortality. Prognostic factors for gastrointestinal bleeding in emergency room cases are malignancy, hypotension on admission, low GCS, and impaired kidney function.

A model to create an efficient and equitable admission policy for patients arriving to the cardiothoracic ICU.

PubMed

Yang, Muer; Fry, Michael J; Raikhelkar, Jayashree; Chin, Cynthia; Anyanwu, Anelechi; Brand, Jordan; Scurlock, Corey

2013-02-01

To develop queuing and simulation-based models to understand the relationship between ICU bed availability and operating room schedule to maximize the use of critical care resources and minimize case cancellation while providing equity to patients and surgeons. Retrospective analysis of 6-month unit admission data from a cohort of cardiothoracic surgical patients, to create queuing and simulation-based models of ICU bed flow. Three different admission policies (current admission policy, shortest-processing-time policy, and a dynamic policy) were then analyzed using simulation models, representing 10 yr worth of potential admissions. Important output data consisted of the "average waiting time," a proxy for unit efficiency, and the "maximum waiting time," a surrogate for patient equity. A cardiothoracic surgical ICU in a tertiary center in New York, NY. Six hundred thirty consecutive cardiothoracic surgical patients admitted to the cardiothoracic surgical ICU. None. Although the shortest-processing-time admission policy performs best in terms of unit efficiency (0.4612 days), it did so at expense of patient equity prolonging surgical waiting time by as much as 21 days. The current policy gives the greatest equity but causes inefficiency in unit bed-flow (0.5033 days). The dynamic policy performs at a level (0.4997 days) 8.3% below that of the shortest-processing-time in average waiting time; however, it balances this with greater patient equity (maximum waiting time could be shortened by 4 days compared to the current policy). Queuing theory and computer simulation can be used to model case flow through a cardiothoracic operating room and ICU. A dynamic admission policy that looks at current waiting time and expected ICU length of stay allows for increased equity between patients with only minimum losses of efficiency. This dynamic admission policy would seem to be a superior in maximizing case-flow. These results may be generalized to other surgical ICUs.

The Effect of ARDS on Survival: Do Patients Die From ARDS or With ARDS?

PubMed

Fuchs, Lior; Feng, Mengling; Novack, Victor; Lee, Joon; Taylor, Jonathan; Scott, Daniel; Howell, Michael; Celi, Leo; Talmor, Daniel

2017-01-01

To investigate the contribution of acute respiratory distress syndrome (ARDS) in of itself to mortality among ventilated patients. A longitudinal retrospective study of ventilated intensive care unit (ICU) patients. The analysis included patients ventilated for more than 48 hours. Patients were classified as having ARDS on admission (early-onset ARDS), late-onset ARDS (ARDS not present during the first 24 hours of admission), or no ARDS. Primary outcomes were mortality at 28 days, and secondary outcomes were 2-year mortality rate from ICU admission. A total of 1411 ventilated patients were enrolled: 41% had ARDS on admission, 28.5% developed ARDS during their ICU stay, and 30.5% did not meet the ARDS criteria prior to ICU discharge or death. The non-ARDS group was used as the control. We also divided the cohort based on the severity of ARDS. After adjusting for covariates, mortality risk at 28 days was not significantly different among the different groups. Both early- and late-onset ARDS as well as the severity of ARDS were found to be significant risk factors for 2 years from ICU survival. Among patients who were ventilated on ICU admission, neither the presence, the severity, or the timing of ARDS contribute independently to the short-term mortality risk. However, acute respiratory distress syndrome does contribute significantly to 2-year mortality risk. This suggests that patients may not die acutely from ARDS itself but rather from the primary disease, and during the acute phase of ARDS, clinicians should focus on improving treatment strategies for the diseases that led to ARDS.

Time intervals in the treatment of fractured femurs as indicators of the quality of trauma systems.

PubMed

Matityahu, Amir; Elliott, Iain; Marmor, Meir; Caldwell, Amber; Coughlin, Richard; Gosselin, Richard A

2014-01-01

To investigate the use of time intervals in the treatment of fractured femurs as indicators of the quality of trauma systems. Time intervals from injury to admission, admission to surgery and surgery to discharge for patients with isolated femur fractures in four low- and middle-income countries were compared with the corresponding values from one German hospital, an Israeli hospital and the National Trauma Data Bank of the United States of America by means of Student's t-tests. The correlations between the time intervals recorded in a country and that country's expenditure on health and gross domestic product (GDP) were also evaluated using Pearson's product moment correlation coefficient. Relative to patients from high-income countries, those from low- and middle-income countries were significantly more likely to be male and to have been treated by open femoral nailing, and their intervals from injury to admission, admission to surgery and surgery to discharge were significantly longer. Strong negative correlations were detected between the interval from injury to admission and government expenditure on health, and between the interval from admission to surgery and the per capita values for total expenditure on health, government expenditure on health and GDP. Strong positive correlations were detected between the interval from surgery to discharge and general government expenditure on health. The time intervals for the treatment of femur fractures are relatively long in low- and middle-income countries, can easily be measured, and are highly correlated with accessible and quantifiable country data on health and economics.

In the media: Burns as a method of assault.

PubMed

O'Halloran, E; Duke, J; Rea, S; Wood, F

2013-09-01

The aims of this study were to determine whether a change occurred in the pattern of assault burn injury cases hospitalised to the adult state burns unit, Western Australia, from 2004 to mid-year of 2012, and to compare patient and burn characteristics of adult assault burns with those admitted for unintentional burns. Study data were obtained from the Royal Perth Hospital (RPH) Burns Minimum Dataset (BMDS). Aggregated data of unintentional burn admissions during the same period were provided by the BMDS data manager to enable comparisons with assault burn patients. Assault burn admissions during 2004-2012 accounted for approximately 1% of all adult burn hospitalisations. All assault victims were burned by either thermal or scald agents. A high rate of intubation (24%) and ICU admission (1 in 3 cases) was observed in the fire assault group. The six assault cases undergoing intubation were severe burns, median TBSA 50%, most commonly affecting the face, head and torso, half of these cases had inhalational injuries and also required escharotomies. Comparison of admissions by calendar period showed no statistically significant differences in demographic, burn cause or TBSA%. However, statistically significant differences were found for pre-morbid psychiatric history (15% vs. 58%, p=0.025) and concomitant fractures or dislocations (46% vs. 2%), p=0.011). While the proportion of assault burn admissions per total burn admissions steadily increased from 0.4% in 2009 to 1.5% in mid-2012, this proportion did not exceed that peak level observed of 2.1% for 2004. Crown Copyright © 2013. Published by Elsevier Ltd. All rights reserved.

Impact of routine surgical ward and intensive care unit admission surveillance cultures on hospital-wide nosocomial methicillin-resistant Staphylococcus aureus infections in a university hospital: an interrupted time-series analysis.

PubMed

Chaberny, Iris F; Schwab, Frank; Ziesing, Stefan; Suerbaum, Sebastian; Gastmeier, Petra

2008-12-01

To determine whether a routine admission screening in surgical wards and intensive care units (ICUs) was effective in reducing methicillin-resistant Staphylococcus aureus (MRSA) infections-particularly nosocomial MRSA infections-for the whole hospital. The study used a single-centre prospective quasi-experimental design to evaluate the effect of the MRSA screening policy on the incidence density of MRSA-infected/nosocomial MRSA-infected patients/1000 patient-days (pd) in the whole hospital. The effect on incidence density was calculated by a segmented regression analysis of interrupted time series with 30 months prior to and 24 months after a 6 month implementation period. The MRSA screening policy had a highly significant hospital-wide effect on the incidence density of MRSA infections. It showed a significant change in both level [-0.163 MRSA-infected patients/1000 pd, 95% confidence interval (CI): -0.276 to -0.050] and slope (-0.01 MRSA-infected patients/1000 pd per month, 95% CI: -0.018 to -0.003) after the implementation of the MRSA screening policy. A decrease in the MRSA infections by 57% is a conservative estimate of the reduction between the last month before (0.417 MRSA-infected patients/1000 pd) and month 24 after the implementation of the MRSA screening policy (0.18 MRSA-infected patients/1000 pd). Equivalent results were found in the analysis of nosocomial MRSA-infected patients/1000 pd. This is the first hospital-wide study that investigates the impact of introducing admission screening in ICUs and non-ICUs as a single intervention to prevent MRSA infections performed with a time-series regression analysis. Admission screening is a potent tool in controlling the spread of MRSA infections in hospitals.

Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.

PubMed

Starmer, Amy J; Sectish, Theodore C; Simon, Dennis W; Keohane, Carol; McSweeney, Maireade E; Chung, Erica Y; Yoon, Catherine S; Lipsitz, Stuart R; Wassner, Ari J; Harper, Marvin B; Landrigan, Christopher P

2013-12-04

Handoff miscommunications are a leading cause of medical errors. Studies comprehensively assessing handoff improvement programs are lacking. To determine whether introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow. Prospective intervention study of 1255 patient admissions (642 before and 613 after the intervention) involving 84 resident physicians (42 before and 42 after the intervention) from July-September 2009 and November 2009-January 2010 on 2 inpatient units at Boston Children's Hospital. Resident handoff bundle, consisting of standardized communication and handoff training, a verbal mnemonic, and a new team handoff structure. On one unit, a computerized handoff tool linked to the electronic medical record was introduced. The primary outcomes were the rates of medical errors and preventable adverse events measured by daily systematic surveillance. The secondary outcomes were omissions in the printed handoff document and resident time-motion activity. Medical errors decreased from 33.8 per 100 admissions (95% CI, 27.3-40.3) to 18.3 per 100 admissions (95% CI, 14.7-21.9; P < .001), and preventable adverse events decreased from 3.3 per 100 admissions (95% CI, 1.7-4.8) to 1.5 (95% CI, 0.51-2.4) per 100 admissions (P = .04) following the intervention. There were fewer omissions of key handoff elements on printed handoff documents, especially on the unit that received the computerized handoff tool (significant reductions of omissions in 11 of 14 categories with computerized tool; significant reductions in 2 of 14 categories without computerized tool). Physicians spent a greater percentage of time in a 24-hour period at the patient bedside after the intervention (8.3%; 95% CI 7.1%-9.8%) vs 10.6% (95% CI, 9.2%-12.2%; P = .03). The average duration of verbal handoffs per patient did not change. Verbal handoffs were more likely to occur in a quiet location (33.3%; 95% CI, 14.5%-52.2% vs 67.9%; 95% CI, 50.6%-85.2%; P = .03) and private location (50.0%; 95% CI, 30%-70% vs 85.7%; 95% CI, 72.8%-98.7%; P = .007) after the intervention. Implementation of a handoff bundle was associated with a significant reduction in medical errors and preventable adverse events among hospitalized children. Improvements in verbal and written handoff processes occurred, and resident workflow did not change adversely.

COPD prevalence and hospital admissions in Galicia (Spain). An analysis using the potential of new health information systems.

PubMed

Barbosa-Lorenzo, R; Ruano-Ravina, A; Fernández-Villar, A; López-Pardo, E; Carballeira-Roca, C; Barros-Dios, J M

2018-05-05

Chronic obstructive pulmonary disease (COPD) is a major public health problem. The aim of this study was to ascertain the prevalence of COPD and whether such prevalence was positively or negatively associated with COPD admissions, using all the data of a regional health care system. We designed a descriptive cross-sectional study which included all subjects aged over 45 years, diagnosed with COPD in primary care in 2013. We also calculated the number of such patients who had a record of hospital admissions due to this disease. COPD prevalence and incidence of admissions were calculated. Poisson regression models were then used to analyse the association between cases with diagnosis of COPD and admissions due to COPD, by sex, adjusting for socio-demographic variables and distance to hospital. Sensitivity subanalyses were performed by reference to the respective municipal rurality indices. Median municipal prevalence of COPD was 5.29% in men and 2.19% in women. Among patients with COPD, 28.22% of men and 16.00% of women had at least one hospital admission. The relative risk of admission per unit of the standardised prevalence ratio was 0.37 (95% CI 0.34-0.41) for men and 0.39 (95% CI 0.34-0.45) for women. There is a significant negative association between COPD prevalence and hospital admissions due to this disease. The proportion of admissions is lower in municipalities lying furthest from hospitals. There is considerable municipal variability in terms of COPD prevalence and proportion of admissions. In-depth attention should be given to disease-management training programmes. Copyright © 2018 Sociedade Portuguesa de Pneumologia. Published by Elsevier España, S.L.U. All rights reserved.

Cost of Chronic Obstructive Pulmonary Disease in the Emergency Department and Hospital: An Analysis of Administrative Data from 218 US Hospitals.

PubMed

Stanford, Richard H; Shen, Yingjia; McLaughlin, Trent

2006-01-01

Treatment of chronic obstructive pulmonary disease (COPD) in the emergency department (ED) or hospital accounts for a significant portion of COPD costs. This study estimates the cost of a COPD ED or hospitalization visit in the US. This observational study utilized administrative data from 218 acute care hospitals. ED/hospital discharges for COPD (International Classification of Diseases - Ninth Revision - Clinical Modification codes 491.xx. 492.xx, 496.xx) during 2001 were identified. Costs were determined for three groups: (i) ED only; (ii) standard admission; and (iii) severe admissions (intensive care unit [ICU] or intubation). Severe admissions were stratified into: (i) ICU/no intubation; (ii) intubation/no ICU; and (iii) ICU + intubation. Mean total costs and length of stay (LOS) were calculated for each group. A total of 59 735 ED/hospital encounters were identified: 20 431 ED only, 33 210 standard admissions, and 6094 severe admissions (4456 ICU/no intubation, 496 intubation/no ICU, and 1142 ICU/intubation). ED visits had a mean cost of $US571 +/- 507 (year 2001 value). Inpatient costs ranged from $US5997 (+/- 5752) for a standard admission to $US36 743 (+/- 62 886) for ICU plus intubation admissions, while LOS ranged from 5.1 days (+/- 4.5) to 14.8 days (+/- 16.7), respectively. In addition, only 10% of encounters required an intubation/ICU admission, but these accounted for 34% of the cost. Cost of a COPD hospitalization is substantial in the US, with one-third of those costs being associated with severe admissions, which make up only 10% of all COPD admissions. Treatments aimed at reducing hospitalizations and length of stay could result in substantial cost savings.

The clinical significance of platelet counts in the first 24 hours after severe injury.

PubMed

Stansbury, Lynn G; Hess, Aaron S; Thompson, Kwaku; Kramer, Betsy; Scalea, Thomas M; Hess, John R

2013-04-01

Admission platelet (PLT) counts are known to be associated with all-cause mortality for seriously injured patients admitted to a trauma center. The course of subsequent PLT counts, their implications, and the effects of PLT therapy are less well known. Trauma center patients who were directly admitted from the scene of injury, received 1 or more units of uncrossmatched red blood cells in the first hour of care, survived for at least 15 minutes, and had a PLT count measured in the first hour were analyzed for the association of their admission and subsequent PLT counts in the first 24 hours with injury severity and hemorrhagic and central nervous system (CNS) causes of in-hospital mortality. Over an 8.25-year period, 1292 of 45,849 direct trauma admissions met entry criteria. Admission PLT counts averaged 228×10(9) ±90×10(9) /L and decreased by 104×10(9) /L by the second hour and 1×10(9) /L each hour thereafter. The admission count was not related to time to admission. Each 1-point increase in the injury severity score was associated with a 1×10(9) /L decrease in the PLT count at all times in the first 24 hours of care. Admission PLT counts were strongly associated with hemorrhagic and CNS injury mortality and subsequent PLT counts. Effects of PLT therapy could not be ascertained. Admission PLT counts in critically injured trauma patients are usually normal, decreasing after admission. Low PLT counts at admission and during the course of trauma care are strongly associated with mortality. © 2012 American Association of Blood Banks.

19 CFR 210.31 - Requests for admission.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 19 Customs Duties 3 2010-04-01 2010-04-01 false Requests for admission. 210.31 Section 210.31 Customs Duties UNITED STATES INTERNATIONAL TRADE COMMISSION INVESTIGATIONS OF UNFAIR PRACTICES IN IMPORT TRADE ADJUDICATION AND ENFORCEMENT Discovery and Compulsory Process § 210.31 Requests for admission. (a...

Prevalence of antenatal depression and associated factors among pregnant women hospitalized in a high-risk pregnancy unit in Greece.

PubMed

Dagklis, Themistoklis; Papazisis, Georgios; Tsakiridis, Ioannis; Chouliara, Foteini; Mamopoulos, Apostolos; Rousso, David

2016-07-01

Women who face pregnancy complications may require hospitalization in a high-risk pregnancy unit (HRPU), and this may have a negative impact on the pregnant woman's mental health. The purpose of this study was to screen for depressive symptoms in pregnant women admitted in a high-risk pregnancy unit and also to investigate associated risk factors. This was a cross-sectional study that enrolled pregnant women admitted at ≥24 gestational weeks in a university hospital HRPU, between September 2014 and November 2015. The Edinburgh Postnatal Depression Scale was used to assess depressive symptoms on admission. A cutoff score ≥13 was considered as indicative of depression. Test results were then correlated with the reasons that led to the women's admission as well as socio-demographic characteristics. Overall, 157 of the women admitted in the HRPU during the study period were eligible for the study and agreed to complete the questionnaire. The mean age of the pregnant women was 30 ± 6 years, and the mean gestational week at admission was 32 ± 3 weeks. The prevalence of antenatal depression (score ≥13) was 28 % (44/157). In the multivariate analysis, antenatal depression was significantly correlated with smoking (OR = 2.681, 95 % CI 1.089-6.601) and the existence of thoughts for pregnancy termination (OR = 3.624, 95 % CI 1.149-11.427). Approximately one quarter of pregnant women hospitalized in the HRPU may show signs of depression at the time of admission. Smoking and an unwanted pregnancy were found to be independently associated with antenatal depression, whereas no association was found with any obstetric parameters.

Integrated hospital emergency care improves efficiency.

PubMed

Boyle, A A; Robinson, S M; Whitwell, D; Myers, S; Bennett, T J H; Hall, N; Haydock, S; Fritz, Z; Atkinson, P

2008-02-01

There is uncertainty about the most efficient model of emergency care. An attempt has been made to improve the process of emergency care in one hospital by developing an integrated model. The medical admissions unit was relocated into the existing emergency department and came under the 4-hour target. Medical case records were redesigned to provide a common assessment document for all patients presenting as an emergency. Medical, surgical and paediatric short-stay wards were opened next to the emergency department. A clinical decision unit replaced the more traditional observation unit. The process of patient assessment was streamlined so that a patient requiring admission was fully clerked by the first attending doctor to a level suitable for registrar or consultant review. Patients were allocated directly to specialty on arrival. The effectiveness of this approach was measured with routine data over the same 3-month periods in 2005 and 2006. There was a 16.3% decrease in emergency medical admissions and a 3.9% decrease in emergency surgical admissions. The median length of stay for emergency medical patients was reduced from 7 to 5 days. The efficiency of the elective surgical services was also improved. Performance against the 4-hour target declined but was still acceptable. The number of bed days for admitted surgical and medical cases rose slightly. There was an increase in the number of medical outliers on surgical wards, a reduction in the number of incident forms and formal complaints and a reduction in income for the hospital. Integrated emergency care has the ability to use spare capacity within emergency care. It offers significant advantages beyond the emergency department. However, improved efficiency in processing emergency patients placed the hospital at a financial disadvantage.

Return to the Primary Acute Care Service Among Patients With Multiple Myeloma on an Acute Inpatient Rehabilitation Unit.

PubMed

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.

Riding the Escalator: How Dangerous is it Really?

PubMed Central

Schminke, Louisa H.; Jeger, Victor; Evangelopoulos, Dimitrios S.; Zimmerman, Heinz; Exadaktylos, Aristomenis K.

2013-01-01

Introduction: About 10,000 escalator-related injuries per year result in emergency department treatment in the United States. Since the 1990s, a steady increase has been reported, but few statistics on escalator-related injuries have been published worldwide. We have therefore analyzed escalator accident statistics in admissions to our hospital in Switzerland since 2000. Methods: Using retrospective electronic patient chart analysis, we included in our study patients >16 years treated over an 11-year period. We categorized patients in terms of gender, age and associated risk factors, and classified accidents according to day, time, location and cause. Resulting trauma was categorized according to type and location. We divided post-admission treatment into surgical and conservative, and into treatment as an outpatient, in a short-stay unit, or as a hospital admission. Women and men were compared using Fisher’s exact test. Results: We identified 173 patients with 285 discrete injuries. Of these, 87 patients (50%) were women. Fifty-three (61%) of the women and 38 (44%) of the men were >60 years old (P = 0.033). Fifty percent of the men (43/86) of the men, but only 7% (6/87) of the women showed signs of alcohol intoxication (P < 0.0001). Accidents in women occurred predominantly on Tuesdays (19/87; 22%) between 12pm and 6pm (35/87; 40%), and in men on Saturdays (16/86; 19%) between 6pm and 12am (29/86; 34%; P = 0.0097). Sixty-two percent (44/71) of the accidents were in public transport facilities and 30% (21/71) in shopping centers. The majority of injuries in women were to the lower extremities (49/87; 56%), while most accidents in men were to the head and neck (51/86; 59%; P = 0.0052). About half (90; 52%) of the patients were treated conservatively. Almost half of all patients (76, 44%) required hospital admission. Of those, 45% left the hospital within 24 hours of admission (short stay unit) and 55% stayed longer than 24 hours. Conclusion: Escalator accidents can result in severe trauma. Significant gender differences in escalator accidents have been observed. Alcohol intoxication and age are significant risk factors in escalator-related accidents and might be possible targets for preventive measures. PMID:23599850

An increase in the burden of neonatal admissions to a rural district hospital in Kenya over 19 years

PubMed Central

2010-01-01

Background Most of the global neonatal deaths occur in developing nations, mostly in rural homes. Many of the newborns who receive formal medical care are treated in rural district hospitals and other peripheral health centres. However there are no published studies demonstrating trends in neonatal admissions and outcome in rural health care facilities in resource poor regions. Such information is critical in planning public health interventions. In this study we therefore aimed at describing the pattern of neonatal admissions to a Kenyan rural district hospital and their outcome over a 19 year period, examining clinical indicators of inpatient neonatal mortality and also trends in utilization of a rural hospital for deliveries. Methods Prospectively collected data on neonates is compared to non-neonatal paediatric (≤ 5 years old) admissions and deliveries' in the maternity unit at Kilifi District Hospital from January 1st 1990 up to December 31st 2008, to document the pattern of neonatal admissions, deliveries and changes in inpatient deaths. Trends were examined using time series models with likelihood ratios utilised to identify indicators of inpatient neonatal death. Results The proportion of neonatal admissions of the total paediatric ≤ 5 years admissions significantly increased from 11% in 1990 to 20% by 2008 (trend 0.83 (95% confidence interval 0.45 -1.21). Most of the increase in burden was from neonates born in hospital and very young neonates aged < 7days. Hospital deliveries also increased significantly. Clinical diagnoses of neonatal sepsis, prematurity, neonatal jaundice, neonatal encephalopathy, tetanus and neonatal meningitis accounted for over 75% of the inpatient neonatal admissions. Inpatient case fatality for all ≤ 5 years declined significantly over the 19 years. However, neonatal deaths comprised 33% of all inpatient death among children aged ≤ 5 years in 1990, this increased to 55% by 2008. Tetanus 256/390 (67%), prematurity 554/1,280(43%) and neonatal encephalopathy 253/778(33%) had the highest case fatality. A combination of six indicators: irregular respiration, oxygen saturation of <90%, pallor, neck stiffness, weight < 1.5 kg, and abnormally elevated blood glucose > 7 mmol/l predicted inpatient neonatal death with a sensitivity of 81% and a specificity of 68%. Conclusions There is clear evidence of increasing burden in neonatal admissions at a rural district hospital in contrast to reducing numbers of non-neonatal paediatrics' admissions aged ≤ 5years. Though the inpatient case fatality for all admissions aged ≤ 5 years declined significantly, neonates now comprise close to 60% of all inpatient deaths. Simple indicators may identify neonates at risk of death. PMID:20925939

78 FR 62645 - Agency Information Collection Activities: Application for Permission to Reapply for Admission...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-10-22

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77 FR 43346 - Agency Information Collection Activities: Application for Permission To Reapply for Admission...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-07-24

...-0018] Agency Information Collection Activities: Application for Permission To Reapply for Admission... the Form/Collection: Application for Permission To Reapply for Admission Into the United States After...: Individuals or households. USCIS uses the information provided on Form I-212 to adjudicate applications filed...

Predictors of nursing workload in elderly patients admitted to intensive care units.

PubMed

Sousa, Cleber Ricardo de; Gonçalves, Leilane Andrade; Toffoleto, Maria Cecília; Leão, Karine; Padilha, Kátia Grillo

2008-01-01

The age of patients is a controversial issue in admission to intensive care unit (ICU). The aim of this study was to compare severity and nursing workload of elderly patients with 60-69, 70-79, and e"80 years of age and to identify predictors of nursing workload in elderly patients. A cross sectional study was performed with a sample of 71 elderly patients admitted to three ICU in the city of Sao Paulo, Brazil from October to November 2004. Data were prospectively collected using Nursing Activities Score (NAS) and Simplified Acute Physiology Score II (SAPS II). There was no significant difference in nursing workload among the elderly patients age subgroups (p=0.84). Multiple regression analysis indicated that the independent risk factors of high nursing workload were severity, age e"70 years, and to be a surgical ICU patient. Age as an isolated factor should not be discriminative for elderly patients admission to ICU.

NICU admissions and maternal stress levels.

PubMed

Chourasia, Nitish; Surianarayanan, Pushkala; Adhisivam, B; Vishnu Bhat, B

2013-05-01

To determine the stress levels among mothers of babies admitted in Neonatal Intensive Care Unit (NICU) and to identify demographic parameters that influence their stress levels. Stress levels were assessed using Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU) questionnaire among 100 NICU mothers by doctors between 6 and 8 d of admission. Maternal stress was quantified using Likert scale as low (1-2.9), medium (3-3.9) and high (4-5). The data was analyzed using SPSS Ver.16. The mean scores for the subscales sights and sounds, looks and behaviour and alteration in the parental role were 2.55, 4.1 and 4.12 respectively. Increased maternal age, prematurity of baby, longer NICU stay and inability to directly breastfeed the baby were associated with higher stress levels. NICU mothers are under significant stress and appropriate counseling targeted towards specific stressors is required.

Joining the Conversation: Predictors of Success on the United States Medical Licensing Examinations (USMLE)

ERIC Educational Resources Information Center

Gohara, Sabry; Shapiro, Joseph I.; Jacob, Adam N.; Khuder, Sadik A.; Gandy, Robyn A.; Metting, Patricia J.; Gold, Jeffrey; Kleshinski, James; and James Kleshinski

2011-01-01

The purpose of this study was to evaluate whether models based on pre-admission testing, including performance on the Medical College Admission Test (MCAT), performance on required courses in the medical school curriculum, or a combination of both could accurately predict performance of medical students on the United States Medical Licensing…

Factors associated with inter-institutional variations in sepsis rates of very-low-birth-weight infants in 34 Malaysian neonatal intensive care units

PubMed Central

Boo, Nem-Yun; Cheah, Irene Guat-Sim

2016-01-01

INTRODUCTION This study aimed to determine whether patient loads, infant status on admission and treatment interventions were significantly associated with inter-institutional variations in sepsis rates in very-low-birth-weight (VLBW) infants in the Malaysian National Neonatal Registry (MNNR). METHODS This was a retrospective study of 3,880 VLBW (≤ 1,500 g) infants admitted to 34 neonatal intensive care units (NICUs) in the MNNR. Sepsis was diagnosed in symptomatic infants with positive blood culture. RESULTS Sepsis developed in 623 (16.1%) infants; 61 (9.8%) had early-onset sepsis (EOS) and 562 (90.2%) had late-onset sepsis (LOS). The median EOS rate of all NICUs was 1.0% (interquartile range [IQR] 0%, 2.0%). Compared with NICUs reporting no EOS (n = 14), NICUs reporting EOS (n = 20) had significantly higher patient loads (total live births, admissions, VLBW infants, outborns); more mothers with a history of abortions, and antenatal steroids and intrapartum antibiotic use; more infants requiring resuscitation procedures at birth; higher rates of surfactant therapy, pneumonia and insertion of central venous catheters. The median LOS rate of all NICUs was 14.5% (IQR 7.8%, 19.2%). Compared with NICUs with LOS rates below the first quartile (n = 8), those above the third quartile (n = 8) used less intrapartum antibiotics, and had significantly bigger and more mature infants, more outborns, as well as a higher number of sick infants requiring ventilator support and total parenteral nutrition. CONCLUSION Patient loads, resuscitation at birth, status of infants on admission and treatment interventions were significantly associated with inter-institutional variations in sepsis. PMID:26996633

Factors associated with inter-institutional variations in sepsis rates of very-low-birth-weight infants in 34 Malaysian neonatal intensive care units.

PubMed

Boo, Nem-Yun; Cheah, Irene Guat-Sim

2016-03-01

This study aimed to determine whether patient loads, infant status on admission and treatment interventions were significantly associated with inter-institutional variations in sepsis rates in very-low-birth-weight (VLBW) infants in the Malaysian National Neonatal Registry (MNNR). This was a retrospective study of 3,880 VLBW (≤ 1,500 g) infants admitted to 34 neonatal intensive care units (NICUs) in the MNNR. Sepsis was diagnosed in symptomatic infants with positive blood culture. Sepsis developed in 623 (16.1%) infants; 61 (9.8%) had early-onset sepsis (EOS) and 562 (90.2%) had late-onset sepsis (LOS). The median EOS rate of all NICUs was 1.0% (interquartile range [IQR] 0%, 2.0%). Compared with NICUs reporting no EOS (n = 14), NICUs reporting EOS (n = 20) had significantly higher patient loads (total live births, admissions, VLBW infants, outborns); more mothers with a history of abortions, and antenatal steroids and intrapartum antibiotic use; more infants requiring resuscitation procedures at birth; higher rates of surfactant therapy, pneumonia and insertion of central venous catheters. The median LOS rate of all NICUs was 14.5% (IQR 7.8%, 19.2%). Compared with NICUs with LOS rates below the first quartile (n = 8), those above the third quartile (n = 8) used less intrapartum antibiotics, and had significantly bigger and more mature infants, more outborns, as well as a higher number of sick infants requiring ventilator support and total parenteral nutrition. Patient loads, resuscitation at birth, status of infants on admission and treatment interventions were significantly associated with inter-institutional variations in sepsis. Copyright: © Singapore Medical Association.

Clinical and Biological Predictors of Plasma Levels of Soluble RAGE in Critically Ill Patients: Secondary Analysis of a Prospective Multicenter Observational Study.

PubMed

Pranal, Thibaut; Pereira, Bruno; Berthelin, Pauline; Roszyk, Laurence; Godet, Thomas; Chabanne, Russell; Eisenmann, Nathanael; Lautrette, Alexandre; Belville, Corinne; Blondonnet, Raiko; Cayot, Sophie; Gillart, Thierry; Skrzypczak, Yvan; Souweine, Bertrand; Bouvier, Damien; Blanchon, Loic; Sapin, Vincent; Constantin, Jean-Michel; Jabaudon, Matthieu

2018-01-01

Although soluble forms of the receptor for advanced glycation end products (RAGE) have been recently proposed as biomarkers in multiple acute or chronic diseases, few studies evaluated the influence of usual clinical and biological parameters, or of patient characteristics and comorbidities, on circulating levels of soluble RAGE in the intensive care unit (ICU) setting. To determine, among clinical and biological parameters that are usually recorded upon ICU admission, which variables, if any, could be associated with plasma levels of soluble RAGE. Data for this ancillary study were prospectively obtained from adult patients with at least one ARDS risk factor upon ICU admission enrolled in a large multicenter observational study. At ICU admission, plasma levels of total soluble RAGE (sRAGE) and endogenous secretory (es)RAGE were measured by duplicate ELISA and baseline patient characteristics, comorbidities, and usual clinical and biological indices were recorded. After univariate analyses, significant variables were used in multivariate, multidimensional analyses. 294 patients were included in this ancillary study, among whom 62% were admitted for medical reasons, including septic shock (11%), coma (11%), and pneumonia (6%). Although some variables were associated with plasma levels of RAGE soluble forms in univariate analysis, multidimensional analyses showed no significant association between admission parameters and baseline plasma sRAGE or esRAGE. We found no obvious association between circulating levels of soluble RAGE and clinical and biological indices that are usually recorded upon ICU admission. This trial is registered with NCT02070536.

Outcomes of exertional rhabdomyolysis following high-intensity resistance training.

PubMed

Huynh, A; Leong, K; Jones, N; Crump, N; Russell, D; Anderson, M; Steinfort, D; Johnson, D F

2016-05-01

High-intensity resistance training (HIRT) programmes are increasingly popular amongst personal trainers and those attending gymnasiums. We report the experience of exertional rhabdomyolysis (ER) at two tertiary hospitals in Melbourne, Australia. To compare the clinical outcomes of ER with other causes of rhabdomyolysis. Retrospective cross-sectional study of patients presenting with a serum creatine kinase (CK) of greater than 25 000 units/L from 1 September 2013 to 31 August 2014 at two tertiary referral hospitals in Melbourne, Australia. Records were examined to identify care measures implemented during hospital stay, clinical outcomes during admission and on subsequent follow up. Thirty four cases of rhabdomyolysis with a CK of greater than 25 000 units/L (normal range: 20-180 units/L) were identified during the 12-month study period. Twelve of the 34 cases (35%) had ER with 10 of 12 related to HIRT. No acute kidney injury, intensive care admission or death were seen among those with ER. All cases were managed conservatively, with 11 admitted and 9 receiving intravenous fluids only. In contrast, patients with rhabdomyolysis from other causes experienced significantly higher rates of intensive care admission (64%, P = 0.0002), acute kidney injury (82%, P = 0.0001) and death (27%, P = 0.069). ER resulting from HIRT appears to have a benign course compared with rhabdomyolysis of other aetiologies in patients with a serum CK greater than 25 000 units/L. Conservative management of ER appears to be adequate, although this requires confirmation in future prospective studies. © 2016 Royal Australasian College of Physicians.

Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure.

PubMed

Wilson, Suprat Saely; Kwiatkowski, Gregory M; Millis, Scott R; Purakal, John D; Mahajan, Arushi P; Levy, Phillip D

2017-01-01

The purpose of this study was to compare health care resource utilization among patients who were given intravenous nitroglycerin for acute heart failure (AHF) in the emergency department (ED) by intermittent bolus, continuous infusion, or a combination of both. We retrospectively identified 395 patients that received nitroglycerin therapy in the ED for the treatment of AHF over a 5-year period. Patients that received intermittent bolus (n=124) were compared with continuous infusion therapy (n=182) and combination therapy of bolus and infusion (n=89). The primary outcomes were the frequency of intensive care unit (ICU) admission and hospital length of stay (LOS). On unadjusted analysis, rates of ICU admission were significantly lower in the bolus vs infusion and combination groups (48.4% vs 68.7% vs 83%, respectively; P<.0001) and median LOS (interquartile range) was shorter (3.7 [2.5-6.2 days]) compared with infusion (4.7 [2.9-7.1 days]) and combination (5.0 [2.9-6.7 days]) groups; P=.02. On adjusted regression models, the strong association between bolus nitroglycerin and reduced ICU admission rate remained, and hospital LOS was 1.9 days shorter compared with infusion therapy alone. Use of intubation (bolus [8.9%] vs infusion [8.8%] vs combination [16.9%]; P=.096) and bilevel positive airway pressure (bolus [26.6%] vs infusion [20.3%] vs combination [29.2%]; P=.21) were similar as was the incidence of hypotension, myocardial injury, and worsening renal function. In ED patients with AHF, intravenous nitroglycerin by intermittent bolus was associated with a lower ICU admission rate and a shorter hospital LOS compared with continuous infusion. Copyright © 2016 Elsevier Inc. All rights reserved.

Correlates of post-hospital physical function at 1 year in skilled nursing facility residents.

PubMed

Lee, Jia; Rantz, Marilyn

2008-05-01

This paper is a report of a study to examine the relationship between health-related admission factors and post-hospital physical function at 3, 6, 9 and 12 months in older adult nursing facility residents. Physical functional decline is a significant health problem for older adults and has far-reaching effects. In particular, the immediate post-hospital period is a high-risk time, because shortened hospital stays make it likely that older patients are discharged in a state of incomplete recovery. Data spanning from July 2002 to June 2005 were extracted from a comprehensive assessment tool, the Minimum Data Set, for 38,591 beneficiaries of a federal health insurance programme covering older adults in the Midwestern region of the United States of America. We investigated relationships between admission factors and post-hospital physical function at 3, 6, 9 and 12 months. The admission factors were health-related variables assessed at the time of skilled nursing facility admission from an acute care hospital. The most important admission factors related to post-hospital physical function at 3, 6, 9 and 12 months were baseline physical function, urinary incontinence and pressure ulcer. Cognitive impairment at admission demonstrated a stronger relationship with poor physical function as resident length of stay increased. Nurses in skilled nursing facilities should screen post-hospital older adults for risk of physical functional decline at admission using identified admission factors. For continuous nursing care, older adults need to be assessed at least once a month during the first 3 months after hospital discharge.

Hospital costs associated with atrial fibrillation for ischemic stroke patients aged 18-64 years in the United States

PubMed Central

Wang, Guijing; Joo, Heesoo; Tong, Xin; George, Mary G.

2015-01-01

Background and purpose Hospital costs associated with atrial fibrillation (AFib) among stroke patients have not been well-studied, especially among people younger than 65 years. We estimated the AFib-associated hospital costs in U.S. patients aged 18-64 years. Methods We identified hospital admissions with a primary diagnosis of ischemic stroke from the 2010-2012 MarketScan Commercial Claims and Encounters inpatient datasets, excluding those with capitated health insurance plans, aged <18 or >64, missing geographic region, hospital costs below the 1st or above 99th percentile, and having carotid intervention (N=40,082). We searched the data for AFib and analyzed the costs for non-repeat and repeat stroke admissions separately. We estimated the AFib-associated costs using multivariate regression models controlling for age, sex, geographic region, and Charlson comorbidity index. Results Of the 33,500 non-repeat stroke admissions, 2,407 (7.2%) had AFib. Admissions with AFib cost $4,991 more than those without AFib ($23,770 vs. $18,779). For the 6,582 repeat stroke admissions, 397 (6.0%) had AFib. The costs were $3,260 more for those with AFib than those without ($24,119 vs. $20,929). After controlling for potential confounders, AFib-associated costs for non-repeat stroke admissions were $4,905, representing 20.6% of the total costs for the admissions. Both the hospital costs and the AFib-associated costs were associated with age, but not sex. AFib-associated costs for repeat stroke admissions were not significantly higher than for non-AFib patients, except for those aged 55-64 ($3,537). Conclusions AFib increased the hospital cost of ischemic stroke substantially. Further investigation on AFib-associated costs for repeat stroke admissions is needed. PMID:25851767

Psychiatric Inpatient Admissions of Adults with Intellectual Disabilities: Predictive Factors

ERIC Educational Resources Information Center

Cowley, Amy; Newton, Jonathan; Sturmey, Peter; Bouras, Nick; Holt, Geraldine

2005-01-01

Information on admission to psychiatric inpatient units is lacking from the literature on contemporary services for people with intellectual disability and mental health needs. Here we report on predictors of admission for a cohort of 752 adults from this population living in community settings; 83 were admitted. We also report on two subsamples…

Communications Is from Mars, Admissions Is from Venus

ERIC Educational Resources Information Center

Scully, Maura King

2010-01-01

Marketing communications and admissions often have very different needs, priorities, and ways of conducting business, but the two units work toward the same end goal. Brad Ward of BlueFuego, a marketing company that specializes in social Web tools for educational institutions, explains that admissions doesn't necessarily need to [talk] to…

A review of burns patients admitted to the Burns Unit of Hospital Universiti Kebangsaan Malaysia.

PubMed

Chan, K Y; Hairol, O; Imtiaz, H; Zailani, M; Kumar, S; Somasundaram, S; Nasir-Zahari, M

2002-12-01

This is a retrospective review of 110 patients admitted to the Burns Units between October 1999 and November 2001. The aim was to determine the burns pattern of patients admitted to hospital UKM. There was an increasing trend for patients admitted. Female to male ratio was 1:2. Children consisted 34% of the total admission. Children had significant higher number of scald burns as compare to adult (p < 0.01). Domestic burns were consist of 75% overall admission. Mean percentage of TBSA (total body surface area) burns was 19%. Thirty percent of patients sustained more than 20% of TBSA. Sixty percent of patients had scald burns. Ninety percents of patients with second degree burns that were treated with biologic membrane dressing or split skin graft. Mean duration of hospital stay was 10 days. Over 70% of patients were discharged within 15 days. Overall mortality rate was 6.3%. The patients who died had significantly larger area of burns of more than 20% TBSA (p < 0.05) and a higher incidence of inhalation injury (p < 0.02). Hence, this study suggests a need for better preventive measures by the authority to prevent burns related accident and the expansion of the service provided by the Burns Unit.

Advances in neurocritical care.

PubMed

Udani, Soonu

2015-03-01

The neurologically injured child, whether from trauma or other causes, is a common admission into any Pediatric critical care unit. Whatever the cause, the risk for death and life long disability remains very high. Unlike the adult population, neurological diseases in children are diverse and arise from a variety of factors that vary greatly in age and presentation. Nervous system dysfunction is often a complication of critical illness and interventions. While neurointensive care units may be ideal for the at-risk child, in mixed units, 40 % of admissions may be neurological or have neurological complications. Improved quality of care and the application of protocols and bundles, appear to have contributed significantly to improved outcomes. Since we are constantly facing an uphill task of dealing with deterioration while trying to preserve function, detection of early shifts of any nature would be deemed helpful. The intensivist must focus not only on saving life but also on preventing disability with full awareness that responsibility does not end with discharge from the pediatric intensive care unit (PICU). Outcome audits should include not only deaths and discharge from PICU but also one year mortality and even degree of disability at the end of one year from discharge.

Predictive value of N-terminal pro-brain natriuretic peptide in severe sepsis and septic shock.

PubMed

Varpula, Marjut; Pulkki, Kari; Karlsson, Sari; Ruokonen, Esko; Pettilä, Ville

2007-05-01

The aim of this study was to evaluate the predictive value of N-terminal pro-brain natriuretic peptide (NT-proBNP) on mortality in a large, unselected patient population with severe sepsis and septic shock. Prospective observational cohort study about incidence and prognosis of sepsis in 24 intensive care units in Finland (the FINNSEPSIS study). A total of 254 patients with severe sepsis or septic shock. After informed consent, the blood tests for NT-proBNP analyses were drawn on the day of admission and 72 hrs thereafter. Patients' demographic data were collected, and intensive care unit and hospital mortality and basic hemodynamic and laboratory data were recorded daily. NT-proBNP levels at admission were significantly higher in hospital nonsurvivors (median, 7908 pg/mL) compared with survivors (median, 3479 pg/mL; p = .002), and the difference remained after 72 hrs (p = .002). The receiver operating characteristic curves of admission and 72-hr NT-proBNP levels for hospital mortality resulted in area under the curve values of 0.631 (95% confidence interval, 0.549-0.712; p = .002) and 0.648 (95% confidence interval, 0.554-0.741; p = .002), respectively. In logistic regression analyses, NT-proBNP values at 72 hrs after inclusion and Simplified Acute Physiology Score for the first 24 hrs were independent predictors of hospital mortality. Pulmonary artery occlusion pressure (p < .001), plasma creatinine clearance (p = .001), platelet count (p = .03), and positive blood culture (p = .04) had an independent effect on first-day NT-proBNP values, whereas after 72 hrs, only plasma creatinine clearance (p < .001) was significant in linear regression analysis. NT-proBNP values are frequently increased in severe sepsis and septic shock. Values are significantly higher in nonsurvivors than survivors. NT-proBNP on day 3 in the intensive care unit is an independent prognostic marker of mortality in severe sepsis.

The Effect of Race and Ethnicity on Outcomes Among Patients in the Intensive Care Unit: A Comprehensive Study Involving Socioeconomic Status and Resuscitation Preferences

PubMed Central

Erickson, Sara E.; Vasilevskis, Eduard E.; Kuzniewicz, Michael W.; Cason, Brian A.; Lane, Rondall K.; Dean, Mitzi L.; Rennie, Deborah J.; Dudley, R. Adams

2013-01-01

Objective We sought to determine whether race or ethnicity is independently associated with mortality or intensive care unit (ICU) length of stay (LOS) among critically ill patients after accounting for patients' clinical and demographic characteristics including socioeconomic status and resuscitation preferences. Design Historical cohort study of patients hospitalized in intensive care units. Setting Adult intensive care units in 35 California hospitals during the years 2001-2004. Patients A total of 9,518 ICU patients (6334 white, 655 black, 1917 Hispanic and 612 Asian/Pacific Islander patients). Measurements and Main Results The primary outcome was risk-adjusted mortality and a secondary outcome was risk-adjusted ICU LOS. Crude hospital mortality was 15.9% among the entire cohort. Asian patients had the highest crude hospital mortality at 18.6% and black patients had the lowest at 15.0%. After adjusting for age and gender, Hispanic and Asian patients had a higher risk of death compared to white patients, but these differences were not significant after additional adjustment for severity of illness. Black patients had more acute physiologic derangements at ICU admission and longer unadjusted ICU LOS. ICU LOS was not significantly different among racial/ethnic groups after adjustment for demographic, clinical, socioeconomic factors and do-not-resuscitate status. In an analysis restricted only to those who died, decedent black patients averaged 1.1 additional days in the ICU (95% CI – 0.26 to 2.6) compared to white patients who died, although this was not statistically significant. Conclusions Hospital mortality and ICU LOS did not differ by race or ethnicity among this diverse cohort of critically ill patients after adjustment for severity of illness, resuscitation status, SES, insurance status and admission type. Black patients had more acute physiologic derangements at ICU admission and were less likely to have a DNR order. These results suggest that among ICU patients, there are not racial or ethnic differences in mortality within individual hospitals. If disparities in ICU care exist, they may be explained by differences in the quality of care provided by hospitals that serve high proportions of minority patients. PMID:21187746

Family Carers' Experience of the Need for Admission of Their Relative with an Intellectual Disability to an Assessment and Treatment Unit

ERIC Educational Resources Information Center

James, Neil

2016-01-01

Background: There is limited research that explores the experiences of family carers of individuals with an intellectual disability requiring admission to a specialist National Health Service Assessment and Treatment Unit. Accordingly, this study aimed to explore family carers' experience in respect of this phenomenon and their relationships with…

Altering Public University Admission Standards to Preserve White Group Position in the United States: Results from a Laboratory Experiment

ERIC Educational Resources Information Center

Samson, Frank L.

2013-01-01

This study identifies a theoretical mechanism that could potentially affect public university admissions standards in a context of demographic change. I explore how demographic changes at a prestigious public university in the United States affect individuals' evaluations of college applications. Responding to a line graph that randomly displays a…

Acute Air Pollution Exposure and Blood Pressure at Delivery Among Women With and Without Hypertension

PubMed Central

Männistö, Tuija; Liu, Danping; Leishear, Kira; Sherman, Seth; Laughon, S. Katherine

2015-01-01

BACKGROUND Chronic air pollution exposure increases risk for hypertensive disorders of pregnancy, but the effect of acute air pollution exposure on blood pressure during pregnancy is less well known. METHODS We studied 151,276 singleton term deliveries from the Consortium on Safe Labor (2002–2008) with clinical blood pressure measured at admission to labor/delivery and diagnoses of hypertensive disorders collected from electronic medical records and hospital discharge summaries. Air pollution exposures were estimated for the admission hour and the 4 hours preceding admission using a modified version of the Community Multiscale Air Quality models and observed air monitoring data. Blood pressure was categorized as normal; high normal; and mild, moderate, or severe hypertension based on pregnancy cut points. Adjusted ordinal logistic regression estimated the odds of women having a higher admission blood pressure category as a function of air pollutant, hypertensive disorders, and their interaction effect. RESULTS Odds of high blood pressure at admission to labor/delivery were increased in normotensive women after exposure to nitrogen oxides (by 0.2%/5 units), sulfur dioxide (by 0.3%/1 unit), carbon monoxide and several air toxics (by 3%–4%/high exposure). The effects were often similar or stronger among women with gestational hypertension and preeclampsia. Exposure to particulate matter <10 μm increased odds of high blood pressure in women with preeclampsia by 3%/5 units. CONCLUSIONS Air pollution can influence admission blood pressure in term deliveries and may increase likelihood of preeclampsia screening at delivery admission. PMID:24795401

Determining quality in a unit where nursing is the primary intervention.

PubMed

Pearson, A; Durant, I; Punton, S

1989-04-01

Determining quality in a unit where nursing is the primary intervention This paper discusses the use of a variety of quantitative and qualitative methods of measuring quality in a nursing unit. It reports the result of comparing the quality of nursing care between patients admitted to the nursing unit concerned (in Oxford, England) following admission to an acute ward, with patients who spent the whole of their hospitalization in an acute ward. The findings suggest that quality can be best assessed by using a number of methods, and the quality of nursing care delivered in a unit which focuses on therapeutic nursing is significantly and consistently higher than that delivered in acute hospital wards.

Community-acquired respiratory infections in young children with congenital heart diseases in the palivizumab era: the Spanish 4-season civic epidemiologic study.

PubMed

Medrano López, Constancio; García-Guereta, Luis

2010-12-01

To investigate the epidemiology of acute respiratory tract infections (ARIs) in children younger than 24 months old with hemodynamically significant congenital heart diseases. Primary aim: incidence of hospital admission due to ARI. Secondary aims: risk factors, etiologic agents, clinical outcomes, and usefulness of preventive measures. Prospective, multicenter, epidemiologic study conducted in 57 Spanish hospitals covering four 7-month seasons (2004-2008). A total of 2613 patients were eligible for the study. Three hundred fifty-four patients (13.5%) (95% confidence interval: 12.3-14.9) required a total of 453 hospital admissions. Clinical diagnoses: bronchiolitis (54.1%), upper respiratory tract infection (21%), pneumonia (19.9%), and others (17.4%). Median length of hospital stay: 7.0 days. No etiologic agent was identified in two-thirds of the patients. In the remaining patients either a single agent (26.8%) or polymicrobial infection (5%) was identified. Respiratory syncytial virus (RSV) was the agent that was most commonly found (3.8% specific hospitalization rate). Children receiving adequate RSV prophylaxis (90.5%) had a 58.2% (95% confidence interval: 37.6-78.3) reduction in RSV hospitalization. Risk factors for admission included malnourishment, infant age, male gender, chromosome alterations, wheezing, inadequate RSV prophylaxis fulfillment, and siblings <11 years of age. Pediatric intensive care unit care was required in 21.8% of the admissions and 9 patients (0.34%) died. Hospital admission rate and severity of ARI remain as important issues in hemodynamically significant congenital heart disease patients. The strict fulfillment of prophylactic recommendations against RSV is the only protective factor that can be modulated to decrease the ARI hospital admission rate.

Proactive psychiatric consultation services reduce length of stay for admissions to an inpatient medical team.

PubMed

Desan, Paul H; Zimbrean, Paula C; Weinstein, Andrea J; Bozzo, Janis E; Sledge, William H

2011-01-01

Some studies suggest intensive psychiatric consultation services facilitate medical care and reduce length of stay (LOS) in general hospitals. To compare LOS between a consultation-as-usual model and a proactive consultation model involving review of all admissions, rapid consultation, and close follow-up. LOS was compared in an ABA design between a 33-day intervention period and 10 similar control periods, 5 before and 5 after the intervention, on an internal medical unit. During the intervention period, a staff psychiatrist met with the medical team each weekday, reviewed all admissions, provided immediate consultation as needed, and followed all cases throughout their hospital stay. Time required for initial case review was brief, 2.9 ± 2.2 minutes per patient (mean ± S.D.). Over 50% of admissions had mental health needs: 20.3% were estimated to require specialist consultation to avoid potential delay of discharge. The consultation rate for the intervention sample was 22.6%, significantly greater than in the control sample, 10.7%. Mean LOS was significantly shorter in the intervention sample, 2.90 ± 2.12 versus 3.82 ± 3.30 days, and the fraction of cases with LOS > 4 days was significantly lower, 14.5% versus 27.9%. A rough cost benefit analysis was favorable with at least a 4.2 ratio of financial benefit to cost. Psychiatric review of all admissions is feasible, indicates a high incidence of mental health barriers to discharge, identifies more necessary consultations than typically requested, and results in earlier consultation. A proactive consultation model can reduce hospital LOS. Copyright © 2011 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

Alkalosis in Critically Ill Patients with Severe Sepsis and Septic Shock

PubMed Central

Jazrawi, Allan; Miller, Jan; Baigi, Amir; Chew, Michelle

2017-01-01

Introduction Although metabolic alkalosis is a common occurrence in intensive care units (ICUs), no study has evaluated its prevalence or outcomes in patients with severe sepsis or septic shock. Methods This is a retrospective cohort study of critically ill patients suffering from severe sepsis and septic shock admitted to the ICUs of Halmstad and Varberg County hospitals. From 910 patient records, 627 patients met the inclusion criteria. We investigated the relationship between metabolic alkalosis and mortality. Further, we studied the relationship between metabolic alkalosis and ICU length of stay (LOS). Results Metabolic alkalosis was associated with decreased 30-day and 12-month mortalities. This effect was however lost when a multivariate analysis was conducted, correcting for age, gender, pH on admission, base excess (BE) on admission, Simplified Acute Physiology Score III (SAPS III) and acute kidney injury (AKI). We then analyzed for any dose-response effect between the severity of metabolic alkalosis and mortality and found no relationship. Bivariate analysis showed that metabolic alkalosis had a significant effect on the length of ICU stay. When adjusting for age, sex, pH at admission, BE at admission, SAPS III and AKI in a multivariate analysis, metabolic alkalosis significantly contributed to prolonged ICU length of stay. In two separate sensitivity analyses pure metabolic alkalosis and late metabolic alkalosis (time of onset >48 hours) were the only significant predictor of increased ICU length of stay. Conclusion Metabolic alkalosis did not have any effect on 30-day and 12-month mortalities after adjusting for age, sex, SAPS III-score, pH and BE on admission and AKI in a multivariate analysis. The presence of metabolic alkalosis was independently associated with an increased ICU length of stay. PMID:28045915

A prospective study of prolonged stay in the intensive care unit: predictors and impact on resource utilization.

PubMed

Arabi, Yaseen; Venkatesh, S; Haddad, Samir; Al Shimemeri, Abdullah; Al Malik, Salim

2002-10-01

To evaluate the predictors of prolonged Intensive Care Unit (ICU) stay and the impact on resource utilization. Prospective study. Adult medical/surgical ICU in a tertiary-care teaching hospital. All admissions to the ICU (numbering 947) over a 20-month period were enrolled. Data on demographic and clinical profile, length of stay, and outcome were collected prospectively. The ICU length of stay and mechanical ventilation days were used as surrogate parameters for resource utilization. Potential predictors were analyzed for possible association with prolonged ICU stay (length of stay > 14 days). Patients with prolonged ICU stay formed only 11% of patients, but utilized 45.1% of ICU days and 55.5% of mechanical ventilation days. Non-elective admissions, readmissions, respiratory or trauma-related reasons for admission, and first 24-hour evidence of infection, oliguria, coagulopathy, and the need for mechanical ventilation or vasopressor therapy had significant association with prolonged ICU stay. Mean APACHE II and SAPS II were slightly higher in patients with prolonged stay. ICU outcome was comparable to patients with < or = 14 days ICU stay. Patients with prolonged ICU stay form a small proportion of ICU patients, yet they consume a significant share of the ICU resources. The outcome of this group of patients is comparable to that of shorter stay patients. The predictors identified in the study can be used in targeting this group to improve resource utilization and efficiency of ICU care.

Decreased rates of nosocomial endometritis and urinary tract infection after vaginal delivery in a French surveillance network, 1997-2003.

PubMed

Ayzac, Louis; Caillat-Vallet, Emmanuelle; Girard, Raphaële; Chapuis, Catherine; Depaix, Florence; Dumas, Anne-Marie; Gignoux, Chantal; Haond, Catherine; Lafarge-Leboucher, Joëlle; Launay, Carine; Tissot-Guerraz, Françoise; Vincent, Agnès; Fabry, Jacques

2008-06-01

To identify independent risk factors for endometritis and urinary tract infection (UTI) after vaginal delivery, and to monitor changes in nosocomial infection rates and derive benchmarks for prevention. Prospective study. We analyzed routine surveillance data for all vaginal deliveries between January 1997 and December 2003 at 66 maternity units participating in the Mater Sud-Est surveillance network. Adjusted odds ratios for risk of endometritis or UTI were obtained using a logistic regression model. The overall incidence rates were 0.5% for endometritis and 0.3% for UTI. There was a significant decrease in the incidence and risk of endometritis but not of UTI during the 7-year period. Significant risk factors for endometritis were fever during labor, parity of 1, and instrumental delivery and/or manual removal of the placenta. Significant risk factors for UTI were urinary infection on admission, premature rupture of membranes (more than 12 hours before admission), blood loss of more than 800 mL, parity of 1, instrumental delivery, and receipt of more than 5 vaginal digital examinations. Each maternity unit received a poster showing graphs of the number of expected and observed cases of UTI and endometritis associated with vaginal deliveries, which enabled each maternity unit to determine their rank within the network and to initiate prevention programs. Although routine surveillance means additional work for maternity units, our results demonstrate the usefulness of regular targeted monitoring of risk factors and of the most common nosocomial infections in obstetrics. Most of the information needed for monitoring is already present in the patients' records.

Physical Therapy Utilization in Intensive Care Units: Results from a National Survey

PubMed Central

Hodgin, Katherine E.; Nordon-Craft, Amy; McFann, Kim K.; Mealer, Meredith L.; Moss, Marc

2009-01-01

Objective Patients who survive admission to the intensive care unit (ICU) commonly complain of fatigue, weakness, and poor functional status. This study sought to determine the utilization of inpatient physical therapy for patients recovering from critical illness. Design Surveys were mailed to 984 physical therapists from across the United States. Each survey included questions concerning staffing and availability of physical therapists for ICU patients, and the utilization of physical therapy (PT) for six patient scenarios requiring ICU admission and mechanical ventilation. Main Results Overall 482 physical therapists completed their survey. The majority of hospitals (89%) at which the physical therapists were employed require a physician consultation to initiate PT for ICU patients. Established hospital criteria for the initiation of PT in the ICU were present at only 10% of the hospitals. Community hospitals were more likely to routinely provide PT on weekends compared to academic hospitals (p=0.03). The likelihood of routine PT involvement varied significantly with the clinical scenario (highest 87% status post cerebrovascular accident, lowest 64% chronic obstructive pulmonary disease, p<0.001). The most common types of PT that would be performed on these critically ill patients were functional mobility retraining and therapeutic exercise. The type of PT identified by the physical therapists as having the most positive impact also significantly varied according to the clinical scenario (p<0.001). Conclusions PT is commonly administered to ICU patients during the recovery from critical illness in the United States. However the frequency and type of PT significantly varies based on the type of hospital and the clinical scenario. PMID:19114903

A modelling tool for capacity planning in acute and community stroke services.

PubMed

Monks, Thomas; Worthington, David; Allen, Michael; Pitt, Martin; Stein, Ken; James, Martin A

2016-09-29

Mathematical capacity planning methods that can take account of variations in patient complexity, admission rates and delayed discharges have long been available, but their implementation in complex pathways such as stroke care remains limited. Instead simple average based estimates are commonplace. These methods often substantially underestimate capacity requirements. We analyse the capacity requirements for acute and community stroke services in a pathway with over 630 admissions per year. We sought to identify current capacity bottlenecks affecting patient flow, future capacity requirements in the presence of increased admissions, the impact of co-location and pooling of the acute and rehabilitation units and the impact of patient subgroups on capacity requirements. We contrast these results to the often used method of planning by average occupancy, often with arbitrary uplifts to cater for variability. We developed a discrete-event simulation model using aggregate parameter values derived from routine administrative data on over 2000 anonymised admission and discharge timestamps. The model mimicked the flow of stroke, high risk TIA and complex neurological patients from admission to an acute ward through to community rehab and early supported discharge, and predicted the probability of admission delays. An increase from 10 to 14 acute beds reduces the number of patients experiencing a delay to the acute stroke unit from 1 in every 7 to 1 in 50. Co-location of the acute and rehabilitation units and pooling eight beds out of a total bed stock of 26 reduce the number of delayed acute admissions to 1 in every 29 and the number of delayed rehabilitation admissions to 1 in every 20. Planning by average occupancy would resulted in delays for one in every five patients in the acute stroke unit. Planning by average occupancy fails to provide appropriate reserve capacity to manage the variations seen in stroke pathways to desired service levels. An appropriate uplift from the average cannot be based simply on occupancy figures. Our method draws on long available, intuitive, but underused mathematical techniques for capacity planning. Implementation via simulation at our study hospital provided valuable decision support for planners to assess future bed numbers and organisation of the acute and rehabilitation services.

Factors potentially associated with the decision of admission to the intensive care unit in a middle-income country: a survey of Brazilian physicians.

PubMed

Ramos, João Gabriel Rosa; Passos, Rogerio da Hora; Baptista, Paulo Benigno Pena; Forte, Daniel Neves

2017-01-01

To evaluate the factors potentially associated with the decision of admission to the intensive care unit in Brazil. An electronic survey of Brazilian physicians working in intensive care units. Fourteen variables that were potentially associated with the decision of admission to the intensive care unit were rated as important (from 1 to 5) by the respondents and were later grouped as "patient-related," "scarcity-related" and "administrative-related" factors. The workplace and physician characteristics were evaluated for correlation with the factor ratings. During the study period, 125 physicians completed the survey. The scores on patient-related factors were rated higher on their potential to affect decisions than scarcity-related or administrative-related factors, with a mean ± SD of 3.42 ± 0.7, 2.75 ± 0.7 and 2.87 ± 0.7, respectively (p < 0.001). The patient's underlying illness prognosis was rated by 64.5% of the physicians as always or frequently affecting decisions, followed by acute illness prognosis (57%), number of intensive care unit beds available (56%) and patient's wishes (53%). After controlling for confounders, receiving specific training on intensive care unit triage was associated with higher ratings of the patient-related factors and scarcity-related factors, while working in a public intensive care unit (as opposed to a private intensive care unit) was associated with higher ratings of the scarcity-related factors. Patient-related factors were more frequently rated as potentially affecting intensive care unit admission decisions than scarcity-related or administrative-related factors. Physician and workplace characteristics were associated with different factor ratings.

Factors potentially associated with the decision of admission to the intensive care unit in a middle-income country: a survey of Brazilian physicians

PubMed Central

Ramos, João Gabriel Rosa; Passos, Rogerio da Hora; Baptista, Paulo Benigno Pena; Forte, Daniel Neves

2017-01-01

Objective To evaluate the factors potentially associated with the decision of admission to the intensive care unit in Brazil. Methods An electronic survey of Brazilian physicians working in intensive care units. Fourteen variables that were potentially associated with the decision of admission to the intensive care unit were rated as important (from 1 to 5) by the respondents and were later grouped as "patient-related," "scarcity-related" and "administrative-related" factors. The workplace and physician characteristics were evaluated for correlation with the factor ratings. Results During the study period, 125 physicians completed the survey. The scores on patient-related factors were rated higher on their potential to affect decisions than scarcity-related or administrative-related factors, with a mean ± SD of 3.42 ± 0.7, 2.75 ± 0.7 and 2.87 ± 0.7, respectively (p < 0.001). The patient's underlying illness prognosis was rated by 64.5% of the physicians as always or frequently affecting decisions, followed by acute illness prognosis (57%), number of intensive care unit beds available (56%) and patient's wishes (53%). After controlling for confounders, receiving specific training on intensive care unit triage was associated with higher ratings of the patient-related factors and scarcity-related factors, while working in a public intensive care unit (as opposed to a private intensive care unit) was associated with higher ratings of the scarcity-related factors. Conclusions Patient-related factors were more frequently rated as potentially affecting intensive care unit admission decisions than scarcity-related or administrative-related factors. Physician and workplace characteristics were associated with different factor ratings. PMID:28977256

Evaluation of a Low-risk Mild Traumatic Brain Injury and Intracranial Hemorrhage Emergency Department Observation Protocol.

PubMed

Yun, Brian J; Borczuk, Pierre; Wang, Lulu; Dorner, Stephen; White, Benjamin A; Raja, Ali S

2017-11-20

Among emergency physicians, there is wide variation in admitting practices for patients who suffered a mild traumatic brain injury (TBI) with an intracranial hemorrhage (ICH). The purpose of this study was to evaluate the effects of implementing a protocol in the emergency department (ED) observation unit for patients with mild TBI and ICH. This retrospective cohort study was approved by the institutional review board. Study subjects were patients ≥ 18 years of age with an International Classification of Diseases code corresponding to a traumatic ICH and admitted to an ED observation unit (EDOU) of an urban, academic Level I trauma center between February 1, 2015, and January 31, 2017. Patient data and discharge disposition were abstracted from the electronic health record, and imaging data, from the final neuroradiologist report. To measure kappa, two abstractors independently collected data for presence of neuro deficit from a 10% random sample of the medical charts. Using a multivariable logistic regression model with a propensity score of the probability of placement in the EDOU before and after protocol implementation as a covariate, we sought to determine the pre-post effects of implementing a protocol on the composite outcome of admission to the floor, intensive care unit, or operating room from the EDOU and the proportion of patients with worsening findings on repeat computed tomography (CT) head scan in the EDOU. A total of 379 patients were identified during the study period; 83 were excluded as they were found to have no ICH on chart review. Inter-rater reliability kappa statistic was 0.63 for 30 charts. Among the 296 patients who remained eligible and comprised the study population, 143 were in the preprotocol period and 153 after protocol implementation. The EDOU protocol was associated with an independently statistically significant decreased odds ratio (OR) for admission or worsening ICH on repeat CT scan (OR = 0.45, 95% confidence interval [CI] = 0.25-0.82, p = 0.009) in the observation unit. After a stay in the EDOU, 26% (37/143) of patients required an inpatient admission before implementation of the protocol and 13% (20/153) of patients required an inpatient admission after protocol implementation. There was no statistically significant difference in log transformed EDOU length of stay (LOS) between the groups after adjusting for propensity score (p = 0.34). While there was no difference in EDOU LOS, implementing a low-risk mild TBI and ICH protocol in the EDOU may decrease the rate of inpatient admissions from the EDOU. A protocol-driven observation unit may help physicians by standardizing eligibility criteria and by providing guidance on management. As the propensity score method limits our ability to create a straightforward predictive model, a future larger study should validate the results. © 2017 by the Society for Academic Emergency Medicine.

Test Takers' Attitudes and Beliefs about the Graduate Management Admission Test

ERIC Educational Resources Information Center

Stricker, Lawrence J.; Wilder, Gita Z.; Bridgeman, Brent

2006-01-01

The aim of this study was to assess test takers' attitudes and beliefs about an admissions test used extensively in graduate schools of business in the United States, the Graduate Management Admission Test (GMAT), and the relationships of these attitudes and beliefs to test performance. A set of attitude and belief items was administered by…

Analysis of Unplanned Intensive Care Unit Admissions in Postoperative Pediatric Patients.

PubMed

Landry, Elizabeth K; Gabriel, Rodney A; Beutler, Sascha; Dutton, Richard P; Urman, Richard D

2017-03-01

Currently, there are only a few retrospective, single-institution studies that have addressed the prevalence and risk factors associated with unplanned admissions to the pediatric intensive care unit (ICU) after surgery. Based on the limited amount of studies, it appears that airway and respiratory complications put a child at increased risk for unplanned ICU admission. A more extensive and diverse analysis of unplanned postoperative admissions to the ICU is needed to address risk factors that have yet to be revealed by the current literature. To establish a rate of unplanned postoperative ICU admissions in pediatric patients using a large, multi-institution data set and to further characterize the associated risk factors. Data from the National Anesthesia Clinical Outcomes Registry were analyzed. We recorded the overall risk of unplanned postoperative ICU admission in patients younger than 18 years and performed univariate and multivariate logistic regression analysis to identify the associated patient, surgical, and anesthetic-related characteristics. Of the 324 818 cases analyzed, 211 reported an unexpected ICU admission. There was an increased likelihood of unplanned postoperative ICU in infants (age <1 year) and children who were classified as American Society of Anesthesiologists physical status classification of III or IV. Likewise, longer case duration and cases requiring general anesthesia were also associated with unplanned ICU admissions. This study establishes a rate of unplanned ICU admission following surgery in the heterogeneous pediatric population. This is the first study to utilize such a large data set encompassing a wide range of practice environments to identify risk factors leading to unplanned postoperative ICU admissions. Our study revealed that patient, surgical, and anesthetic complexity each contributed to an increased number of unplanned ICU admissions in the pediatric population.

Clinical course of sepsis in children with acute leukemia admitted to the pediatric intensive care unit.

PubMed

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 retrospective nature of this study, we maintain a position of equipoise with regard to this association. Variation in mortality and resource use by leukemia type suggests further research is needed to develop targeted intervention strategies to enhance patient outcomes.

Clinical and financial analysis of an acute palliative care unit in an oncological department.

PubMed

Mercadante, S; Intravaia, G; Villari, P; Ferrera, P; David, F; Casuccio, A; Mangione, S

2008-09-01

The aim of this article is to describe the clinical activity and medical intervention of an acute model of palliative care unit (APC), as well as the reimbursement procedures and economic viability. A sample of 504 patients admitted at an APC in 1 year was surveyed. Indications for admission, pain and symptom intensity, analgesic treatments, procedures, instrumental examinations and modalities of discharge were recorded. For each patient, tariff for reimbursement was calculated according to the existent disease related grouping (DRG) system. The mean age was 62 years, and 246 patients were males. The mean hospital stay was 5.4 days. Pain control was the most frequent indication for admission. All patients had laboratory tests and several instrumental examinations. Almost all patients were prescribed one or more opioids at significant doses, and different routes of administration, as well as medication as needed. 59 patients received blood cell transfusions and 34 interventional procedures. Only 40 patients died in the unit, 11 of them being sedated at the end of life. Treatment efficacy was considered optimal and mild in 264 and 226 patients respectively. A mean of 3019 euros for admission was reimbursed by the Health Care System. APCs are of paramount importance within an oncological department, as they provide effective and intensive treatments during the entire course of disease, providing a simultaneous and integrated approach. Our findings also suggest both a cost and quality incentive for oncological departments to develop APC.

Negotiating Time: The Significance of Timing in Ending Inpatient Work

ERIC Educational Resources Information Center

Jones, Sarah Gustavus

2007-01-01

This paper discusses work with young people during their stay on an NHS psychiatric inpatient unit, especially focusing on the end of treatment and the appropriate timing of discharge into the community. When approaching the end of an admission, various factors are considered that seem particularly relevant to the decision of when a young person…

Reasons for refusal of admission to intensive care and impact on mortality.

PubMed

Iapichino, Gaetano; Corbella, Davide; Minelli, Cosetta; Mills, Gary H; Artigas, Antonio; Edbooke, David L; Pezzi, Angelo; Kesecioglu, Jozef; Patroniti, Nicolò; Baras, Mario; Sprung, Charles L

2010-10-01

To identify factors influencing triage decisions and investigate whether admission to the intensive care unit (ICU) could reduce mortality compared with treatment on the ward. A multicentre cohort study in 11 university hospitals from seven countries, evaluating triage decisions and outcomes of patients referred for admission to ICU who were either accepted, or refused and treated on the ward. Confounding in the estimation of the effect of ICU admission on mortality was controlled by use of a propensity score approach, which adjusted for the probability of being admitted. Variability across centres was accounted for in both analyses of factors influencing ICU admission and effect of ICU admission on mortality. Eligible were 8,616 triages in 7,877 patients referred for ICU admission. Variables positively associated with probability of being admitted to ICU included: ventilators in ward; bed availability; Karnofsky score; absence of comorbidity; presence of haematological malignancy; emergency surgery and elective surgery (versus medical treatment); trauma, vascular involvement, liver involvement; acute physiologic score II; ICU treatment (versus ICU observation). Multiple triages during patient's hospital stay and age were negatively associated with ICU admission. The area under the receiver operating characteristic (ROC) curve of the model was 0.83 [95% confidence interval (CI): 0.81-0.84], with Hosmer-Lemeshow test P = 0.300. ICU admission was associated with a statistically significant reduction of both 28-day mortality [odds ratio (OR): 0.73; 95% CI: 0.62-0.87] and 90-day mortality (0.79; 0.66-0.93). The benefit of ICU admission increased substantially in patients with greater severity of illness. We suggest that intensivists take great care to avoid ICU admission of patients judged not severe enough for ICU or with low performance status, and they tend to admit surgical patients more readily than medical patients. Interestingly, they do not judge age per se as a reason for refusal of ICU admission. Admission to ICU was associated with a reduction of both 28- and 90-day mortality, particularly in patients with greater severity of illness at time of triage.

Association Between Weekend and Holiday Admission with Pneumonia and Mortality in a Tertiary Center in Portugal: A Cross-Sectional Study.

PubMed

Cortes, Margarida Barreto; Fernandes, Samuel Raimundo; Aranha, Patricia; Avô, Luís Brito; Falcão, Luís Menezes

2017-05-31

Acute bacterial pneumonia is a common and potentially fatal disease where early recognition and treatment are crucial. Increasing medical literature suggests worse outcomes in patients admitted for medical and surgical conditions during the weekend. Little is known about this effect in patients with acute bacterial pneumonia. Obective: The aim of this study was to evaluate the impact of weekend and holiday hospital admission on the outcomes of acute bacterial pneumonia. Retrospective analysis of adult patients (> 18 years) with acute bacterial pneumonia collected from a tertiary referral center database. Length of stay, total cost, admission to intensive care unit, development of sepsis and organ failure, and mortality were compared between patients admitted on a weekday and patients admitted during a weekend or holiday. We analyzed 53 854 hospital admissions from 42 512 patients (median age 84.0 years, range 18 - 118 years), corresponding to 30 554 admissions during weekdays, 21 222 at weekends and 2078 during public holidays. Weekend and holiday admission was not associated with increased costs, length of stay, intensive care unit admission, development of sepsis, organ failure, and mortality. A weekend/holiday effect in acute bacterial pneumonia was not evident in our series.

Patient-Related Determinants of the Administration of Continuous Palliative Sedation in Hospices and Palliative Care Units: A Prospective, Multicenter, Observational Study.

PubMed

van Deijck, Rogier H P D; Hasselaar, Jeroen G J; Verhagen, Stans C A H H V M; Vissers, Kris C P; Koopmans, Raymond T C M

2016-05-01

Knowledge of determinants that are associated with the administration of continuous palliative sedation (CPS) helps physicians identify patients who are at risk of developing refractory symptoms, thereby enabling proactive care planning. This study aims to explore which patient-related factors at admission are associated with receiving CPS later in the terminal phase of life. A prospective multicenter observational study was performed in six Dutch hospices and three nursing home-based palliative care units. The association between patient-related variables at admission (age, gender, diagnosis, use of opioids or psycholeptics, number of medications, Karnofsky Performance Status scale score, Edmonton Symptom Assessment System distress score, and Glasgow Coma Scale score) and the administration of CPS at the end of life was analyzed. A total of 467 patients died during the study period, of whom 130 received CPS. In univariate analysis, statistically significant differences were noted between the sedated and nonsedated patients with respect to younger age (P = 0.009), malignancy as a diagnosis (P = 0.05), higher Karnofsky Performance Status score (P = 0.03), the use of opioids (P < 0.001), the use of psycholeptics (P = 0.003), and higher Edmonton Symptom Assessment System distress score (P = 0.05). Multivariate logistic regression analysis showed that only the use of opioids at admission (odds ratio 1.90; 95% confidence interval 1.18-3.05) was significantly associated with the administration of CPS. Physicians should be aware that patients who use opioids at admission have an increased risk for the administration of CPS at the end of life. In this group of patients, a comprehensive personalized care plan starting at admission is mandatory to try to prevent the development of refractory symptoms. Further research is recommended, to identify other determinants of the administration of CPS and to investigate which early interventions will be effective to prevent the need for CPS in patients at high risk. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Intestinal Fatty Acid Binding Protein as a Marker of Necrosis and Severity in Acute Pancreatitis.

PubMed

Kupčinskas, Juozas; Gedgaudas, Rolandas; Hartman, Hannes; Sippola, Tomi; Lindström, Outi; Johnson, Colin D; Regnér, Sara

2018-07-01

The aim of this study was to study intestinal fatty acid binding protein (i-FABP) as a potential biomarker in predicting severity of acute pancreatitis (AP). In a prospective multicenter cohort study, plasma levels of i-FABP were measured in 402 patients with AP. Severity of AP was determined based on the 1992 Atlanta Classification. Admission levels of plasma i-FABP were significantly higher in patients with pancreatic necrosis, in patients having systemic complications, in patients treated invasively, in patients treated in the intensive care unit, in patients with severe AP, and in deceased patients. Plasma i-FABP levels on admission yielded an area under curve (AUC) of 0.732 in discriminating patients with or without pancreatic necrosis and AUC of 0.669 in predicting severe AP. Combination of levels of i-FABP and venous lactate on the day of admission showed higher discriminative power in severe AP-AUC of 0.808. Higher i-FABP levels on admission were associated with pancreatic necrosis, systemic complications, and severe AP. Low levels of i-FABP had a high negative predictive value for pancreatic necrosis and severe AP. Combination of levels of i-FABP and venous lactates on admission were superior to either of markers used alone in predicting severe AP.

Acute air pollution exposure and blood pressure at delivery among women with and without hypertension.

PubMed

Männistö, Tuija; Mendola, Pauline; Liu, Danping; Leishear, Kira; Sherman, Seth; Laughon, S Katherine

2015-01-01

Chronic air pollution exposure increases risk for hypertensive disorders of pregnancy, but the effect of acute air pollution exposure on blood pressure during pregnancy is less well known. We studied 151,276 singleton term deliveries from the Consortium on Safe Labor (2002-2008) with clinical blood pressure measured at admission to labor/delivery and diagnoses of hypertensive disorders collected from electronic medical records and hospital discharge summaries. Air pollution exposures were estimated for the admission hour and the 4 hours preceding admission using a modified version of the Community Multiscale Air Quality models and observed air monitoring data. Blood pressure was categorized as normal; high normal; and mild, moderate, or severe hypertension based on pregnancy cut points. Adjusted ordinal logistic regression estimated the odds of women having a higher admission blood pressure category as a function of air pollutant, hypertensive disorders, and their interaction effect. Odds of high blood pressure at admission to labor/delivery were increased in normotensive women after exposure to nitrogen oxides (by 0.2%/5 units), sulfur dioxide (by 0.3%/1 unit), carbon monoxide and several air toxics (by 3%-4%/high exposure). The effects were often similar or stronger among women with gestational hypertension and preeclampsia. Exposure to particulate matter <10 μm increased odds of high blood pressure in women with preeclampsia by 3%/5 units. Air pollution can influence admission blood pressure in term deliveries and may increase likelihood of preeclampsia screening at delivery admission. © Published by Oxford University Press on behalf of American Journal of Hypertension Ltd 2014. This work is written by (a) US Government employees(s) and is in the public domain in the US.

Regional Variation in Neonatal Intensive Care Admissions and the Relationship to Bed Supply.

PubMed

Harrison, Wade N; Wasserman, Jared R; Goodman, David C

2018-01-01

To characterize geographic variation in neonatal intensive care unit (NICU) admission rates across the entire birth cohort and evaluate the relationship between regional bed supply and NICU admission rates. This was a population-based, cross-sectional study. 2013 US birth certificate and 2012 American Hospital Association data were used to assign newborns and NICU beds to neonatal intensive care regions. Descriptive statistics of admission rates were calculated across neonatal intensive care regions. Multilevel logistic regression was used to examine the relationship between bed supply and individual odds of admission, with adjustment for maternal and newborn characteristics. Among 3 304 364 study newborns, the NICU admission rate was 7.2 per 100 births and varied across regions for all birth weight categories. IQRs in admission rates were 84.5-93.2 per 100 births for 500-1499 g, 35.3-46.1 for 1500-2499 g, and 3.5-5.5 for ≥2500 g. Adjusted odds of admission for newborns of very low birth weight were unrelated to regional bed supply; however, newborns ≥2500 g in regions with the highest NICU bed supply were significantly more likely to be admitted to a NICU than those in regions with the lowest (aOR 1.20 [1.03-1.40]). There is persistent underuse of NICU care for newborns of very low birth weight that is not associated with regional bed supply. Among larger newborns, we find evidence of supply-sensitive care, raising concerns about the potential overuse of expensive and unnecessary care. Rather than improving access to needed care, NICU expansion may instead further deregionalize neonatal care, exacerbating underuse. Copyright © 2017 Elsevier Inc. All rights reserved.

Can generic paediatric mortality scores calculated 4 hours after admission be used as inclusion criteria for clinical trials?

PubMed Central

Leteurtre, Stéphane; Leclerc, Francis; Wirth, Jessica; Noizet, Odile; Magnenant, Eric; Sadik, Ahmed; Fourier, Catherine; Cremer, Robin

2004-01-01

Introduction Two generic paediatric mortality scoring systems have been validated in the paediatric intensive care unit (PICU). Paediatric RISk of Mortality (PRISM) requires an observation period of 24 hours, and PRISM III measures severity at two time points (at 12 hours and 24 hours) after admission, which represents a limitation for clinical trials that require earlier inclusion. The Paediatric Index of Mortality (PIM) is calculated 1 hour after admission but does not take into account the stabilization period following admission. To avoid these limitations, we chose to conduct assessments 4 hours after PICU admission. The aim of the present study was to validate PRISM, PRISM III and PIM at the time points for which they were developed, and to compare their accuracy in predicting mortality at those times with their accuracy at 4 hours. Methods All children admitted from June 1998 to May 2000 in one tertiary PICU were prospectively included. Data were collected to generate scores and predictions using PRISM, PRISM III and PIM. Results There were 802 consecutive admissions with 80 deaths. For the time points for which the scores were developed, observed and predicted mortality rates were significantly different for the three scores (P < 0.01) whereas all exhibited good discrimination (area under the receiver operating characteristic curve ≥0.83). At 4 hours after admission only the PIM had good calibration (P = 0.44), but all three scores exhibited good discrimination (area under the receiver operating characteristic curve ≥0.82). Conclusions Among the three scores calculated at 4 hours after admission, all had good discriminatory capacity but only the PIM score was well calibrated. Further studies are required before the PIM score at 4 hours can be used as an inclusion criterion in clinical trials. PMID:15312217

[Influence of postcode on paediatric admissions in Seville].

PubMed

Tornero Patricio, Sebastián; Charris-Castro, Liliana; Granero Asencio, Mercedes; Daponte Codina, Antonio

2017-12-01

The postcode (where the home is situated) is an indicator of socioeconomic status and is associated with morbidity, mortality, and the use of health services. The aim of this study was to analyse its effects on paediatric admissions and to determine the rates of the most common causes of paediatric admissions in Seville. An observational cross-sectional study with two analysis units: under 15 year-old "admissions" in public hospitals in Seville (n=2,660) and "city districts" of Seville (n=11). The independent variable analysed was whether the postcode of the admitted patients was within a Regional Government designated "area with social transformation needs". The analysis of the admissions was performed using X 2 -test, Fisher test and Student-t test, with the description of rates using the calculation of crude and specific rates, and by rate ratio. Children living in districts with a lower socioeconomic status were on average 7 months younger (P<.001), and they were significantly more likely to be admitted via the emergency department (P<.001). There was no statistical difference detected in either the length of hospital stay or mortality. The crude admission rate ratio was higher in districts with a lower socioeconomic status (1.8), with a higher specific rate ratio detected in admissions due to asthma, respiratory infections, inguinal hernia, and epilepsy/convulsions. Paediatric hospital admission rates of the main diagnoses were higher in districts with a lower socioeconomic status. Children living in these districts were more likely to be admitted younger and via the emergency department. Copyright © 2016 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.

Centre-related variability in hospital admissions of patients with spondyloarthritis.

PubMed

Andrés, Mariano; Sivera, Francisca; Pérez-Vicente, Sabina; Carmona, Loreto; Vela, Paloma

2016-09-01

The aim of this study was to explore the variability in hospital admissions of patients with spondyloarthritis (SpA) in Spain, and the centre factors that may influence that variability. Descriptive cross-sectional study, part of the emAR II study, performed in Spain (2009-2010). Health records of patients with a diagnosis of SpA and at least one visit to the rheumatology units within the previous 2 years were reviewed. Variables related to hospital admissions, to the SpA, and to the patient and centre were collected. A multilevel logistic regression analysis of random intercept with non-random slopes was performed to assess variability between centres. From 45 centres, 1168 patients' health records were reviewed. Main SpA forms were ankylosing spondylitis (55.2 %) and psoriatic arthritis (22.2 %). A total of 248 admissions were registered for 196 patients (19.2 %, n = 1020). An adjusted variability of 17.6 % in hospitalizations between centres was noted. The following hospital-related factors showed a significant association with admissions: the total number of admissions of the centre, the existence of electronic admission, and the availability of ultrasound in rheumatology. However, these factors only explained 42.9 % of the inter-centre variability. The risk of a patient with SpA of being admitted could double (median OR 2.09), depending on the hospital where the patient was being managed. Hospital admissions of patients with SpA varied between hospitals due to centre characteristics. Further studies are needed to ascertain which specific factors may be causing the variation, as studied variables explained less than half of the variability.

Admission rates and costs associated with emergency presentation of urolithiasis: analysis of the Nationwide Emergency Department Sample 2006-2009.

PubMed

Eaton, Samuel H; Cashy, John; Pearl, Jeffrey A; Stein, Daniel M; Perry, Kent; Nadler, Robert B

2013-12-01

We sought to examine a large nationwide (United States) sample of emergency department (ED) visits to determine data related to utilization and costs of care for urolithiasis in this setting. Nationwide Emergency Department Sample was analyzed from 2006 to 2009. All patients presenting to the ED with a diagnosis of upper tract urolithiasis were analyzed. Admission rates and total cost were compared by region, hospital type, and payer type. Numbers are weighted estimates that are designed to approximate the total national rate. An average of 1.2 million patients per year were identified with the diagnosis of urolithiasis out of 120 million visits to the ED annually. Overall average rate of admission was 19.21%. Admission rates were highest in the Northeast (24.88%), among teaching hospitals (22.27%), and among Medicare patients (42.04%). The lowest admission rates were noted for self-pay patients (9.76%) and nonmetropolitan hospitals (13.49%). The smallest increases in costs over time were noted in the Northeast. Total costs were least in nonmetropolitan hospitals; however, more patients were transferred to other hospitals. When assessing hospital ownership status, private for-profit hospitals had similar admission rates compared with private not-for-profit hospitals (16.6% vs 15.9%); however, costs were 64% and 48% higher for ED and inpatient admission costs, respectively. Presentation of urolithiasis to the ED is common, and is associated with significant costs to the medical system, which are increasing over time. Costs and rates of admission differ by region, payer type, and hospital type, which may allow us to identify the causes for cost discrepancies and areas to improve efficiency of care delivery.

Nationwide use and outcomes of ambulatory surgery in morbidly obese patients in the United States.

PubMed

Rosero, Eric B; Joshi, Girish P

2014-05-01

To compare the overall characteristics and perioperative outcomes in morbidly obese and nonobese patients undergoing ambulatory surgery in the United States. Retrospective, propensity-matched cohort study. Academic medical center. The association between duration of surgical procedures, postoperative complications, and unplanned hospital admission was assessed in a propensity-matched cohort of morbidly obese and nonobese patients derived from the 2006 National Survey of Ambulatory Surgery. Only 0.32% of the ambulatory procedures were performed on morbidly obese patients. The morbidly obese were significantly younger but had a higher burden of comorbidities, were more likely to undergo the procedure in hospital-based outpatient departments (HOPD; 80.1% vs 56.5%; P = 0.004), and had significantly shorter procedures than the nonobese (median [interquartile range], 28 [21-38] vs 42 [22-65] min; P < 0.0001). The incidences of postoperative hypertension, hypotension, hypoxia, cancellation of surgery, and unplanned hospital admissions did not differ significantly between groups. Similarly, adjusted rates of delayed discharge were similar in morbidly obese and nonobese patients (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.18 - 1.15; P = 0.09). In contrast, morbid obesity was associated with decreased odds of postoperative nausea and vomiting (OR, 0.27; CI, 0.09 - 0.84; P = 0.01). In 2006 in the U.S., the prevalence of ambulatory surgery in the morbidly obese was low, with most of the procedures being performed in the HOPD facilities, suggesting a conservative patient selection. The incidence of adverse postoperative outcomes and delayed discharge, as well as unplanned hospital admission after ambulatory surgery in the morbidly obese, was similar to that reported in the nonobese. Copyright © 2014 Elsevier Inc. All rights reserved.

Clinical and Biological Predictors of Plasma Levels of Soluble RAGE in Critically Ill Patients: Secondary Analysis of a Prospective Multicenter Observational Study

PubMed Central

Pranal, Thibaut; Pereira, Bruno; Berthelin, Pauline; Roszyk, Laurence; Chabanne, Russell; Eisenmann, Nathanael; Lautrette, Alexandre; Belville, Corinne; Blondonnet, Raiko; Gillart, Thierry; Skrzypczak, Yvan; Souweine, Bertrand; Bouvier, Damien; Constantin, Jean-Michel

2018-01-01

Rationale Although soluble forms of the receptor for advanced glycation end products (RAGE) have been recently proposed as biomarkers in multiple acute or chronic diseases, few studies evaluated the influence of usual clinical and biological parameters, or of patient characteristics and comorbidities, on circulating levels of soluble RAGE in the intensive care unit (ICU) setting. Objectives To determine, among clinical and biological parameters that are usually recorded upon ICU admission, which variables, if any, could be associated with plasma levels of soluble RAGE. Methods Data for this ancillary study were prospectively obtained from adult patients with at least one ARDS risk factor upon ICU admission enrolled in a large multicenter observational study. At ICU admission, plasma levels of total soluble RAGE (sRAGE) and endogenous secretory (es)RAGE were measured by duplicate ELISA and baseline patient characteristics, comorbidities, and usual clinical and biological indices were recorded. After univariate analyses, significant variables were used in multivariate, multidimensional analyses. Measurements and Main Results 294 patients were included in this ancillary study, among whom 62% were admitted for medical reasons, including septic shock (11%), coma (11%), and pneumonia (6%). Although some variables were associated with plasma levels of RAGE soluble forms in univariate analysis, multidimensional analyses showed no significant association between admission parameters and baseline plasma sRAGE or esRAGE. Conclusions We found no obvious association between circulating levels of soluble RAGE and clinical and biological indices that are usually recorded upon ICU admission. This trial is registered with NCT02070536. PMID:29861796

8 CFR 1235.11 - Admission of conditional permanent residents.

Code of Federal Regulations, 2010 CFR

2010-01-01

...) Conditional residence based on entrepreneurship. An alien seeking admission to the United States with an... unmarried minor child of an alien entrepreneur shall be admitted conditionally for a period of 2 years. At...

Soluble Suppression of Tumorigenicity-2 Predicts Hospital Mortality in Burn Patients: An Observational Prospective Cohort Pilot Study.

PubMed

Ruiz-Castilla, Mireia; Bosacoma, Pau; Dos Santos, Bruce; Baena, Jacinto; Guilabert, Patricia; Marin-Corral, Judith; Masclans, Joan R; Roca, Oriol; Barret, Juan P

2018-04-10

The IL33/ST2 pathway has been implicated in the pathogenesis of different inflammatory diseases. Our aim was to analyze whether plasma levels of biomarkers involved in the IL33/ST2 axis might help to predict mortality in burn patients. Single-center prospective observational cohort pilot study performed at the Burns Unit of the Plastic and Reconstructive Surgery Department of the Vall d'Hebron University Hospital (Barcelona). All patients aged ≥18 years old with second or third-degree burns requiring admission to the Burns Unit were considered for inclusion. Blood samples were taken to measure levels of interleukins (IL)6, IL8, IL33, and soluble suppression of tumorigenicity-2 (sST2) within 24 h of admission to the Burns Unit and at day 3. Results are expressed as medians and interquartile ranges or as frequencies and percentages. Sixty-nine patients (58 [84.1%] male, mean age 52 [35-63] years, total body surface area burned 21% [13%-30%], Abbreviated Burn Severity Index 6 [4-8]) were included. Thirteen (18.8%) finally died in the Burns Unit. Plasma levels of sST2 measured at day 3 after admission demonstrated the best prediction accuracy for survival (area under the ROC curve 0.85 [0.71-0.99]; P < 0.001). The best cutoff point for the AUROC index was estimated to be 2,561. In the Cox proportional hazards model, after adjusting for potential confounding, a plasma sST2 level ≥2,561 measured at day 3 was significantly associated with mortality (HR 6.94 [1.73-27.74]; P = 0.006). Plasma sST2 at day 3 predicts hospital mortality in burn patients.

Increased trends in the use of treatment-limiting decisions in a regional neurosurgical unit.

PubMed

Wilson, William T; McMillan, Tristan; Young, Adam M H; White, Mark A J

2017-04-01

Treatment-limiting decisions (TLDs) are employed to actively withhold treatment from patients whom clinicians feel would derive no benefit or suffer detrimental effects from further intervention. The use of such decisions has been heavily discussed in the media and clinicians in the past have been reluctant to institute them, even though it is in the best interests of the patients. Their use is influenced by several ethical, religious and social factors all of which have changed significantly over time. This study reports the trends in use of TLDs in a regional neurosurgical unit over 23 years. Patient archives were reviewed to identify the number of admissions and procedures performed at the Institute of Neurological Sciences, Glasgow, in the years 1988, 1997 and 2011. Death certificate records were used to identify mortality in the unit in the year 2011. Patient records were used to obtain details of diagnosis, time from admission to death, and the presence and timing of a TLD. The results show an increase in the use of TLDs, with decisions made for 89% of those who died in 2011, compared to 68% in 1997 and 51% in 1988. The number of admissions has increased substantially since 1988 as has the percentage of patients undergoing surgery (46, 67 and 72% in 1988, 1997 and 2011, respectively). There is a trending increase in the number of patients who have a TLD in our regional neurosurgical unit. This demonstrates an increased willingness of clinicians to recognise poor prognosis and to withdraw or withhold treatment in these cases. Continued appropriate use of the TLD is recommended but it is to only ever reflect the best interests of the patient.

Epidemiology of burns undergoing hospitalization to the National Burns Unit in the Sultanate of Oman: a 25-year review.

PubMed

Al-Shaqsi, Sultan; Al-Kashmiri, Ammar; Al-Bulushi, Taimoor

2013-12-01

The aim of this study was to describe the epidemiology of burns admitted to the National Burns Unit (NBU) in the Sultanate of Oman between 1987 and 2011. This is a retrospective review of burn patients admitted to Oman's National Burns Unit (NBU) between 1987 and 2011. The data extracted from the national burn registry. The study describes the admission rate by gender and age groups, occupation, causes of burns, time-to-admission, length of stay and in-hospital mortality of burns between 1987 and 2011. During a 25-year from 1987 to 2011, there were 3531 burn patients admitted to the National Burns Unit in Oman. The average admission rate to NBU is 7.02 per 100,000 persons per year. On average, males were more likely to be admitted to the NBU than females during the study period (P value < 0.04). Patients aged 1-10 years old constituted 46.6% of caseload during the study period. Flames and scalds caused 88.4% of burns. About half of all patients admitted to the NBU have burns to more than 11% of total body surface area (TBSA). The average stay in hospital was estimated to be 15.3 days per patient. The average in-hospital mortality rate was estimated to be 8.2% per year (range 1.9-22%). Burns are significant public health issue in the Sultanate of Oman. Children are disproportionately over-represented in this study. Prevention programmes are urgently needed to address this "silent and costly epidemic." Copyright © 2013 Elsevier Ltd and ISBI. All rights reserved.

A Sleep Education and Hypnotics Reduction Program for Hospitalized Patients at a General Hospital

PubMed Central

Youn, Soyoung; Park, Boram; Lee, Suyeon; Kim, Changnam

2018-01-01

Objective We applied a program of sleep education and hypnotics reduction for inpatients (the i-sleep program). This study explored whether the i-sleep program is effective for reducing the prescription rate of sleeping pills to inpatients in a general hospital. Methods We estimated the proportion of inpatients prescribed hypnotics at admission to and discharge from the hospital, excluding pediatric care units, before (2014) and after (2015) the program. In addition, we estimated the proportion of inpatients prescribed sleeping pills among all inpatients on the first day of each month of 2014 and 2015. Results The proportion of inpatients prescribed hypnotics as discharge medication among inpatients who had been prescribed them at the time of admission decreased significantly, from 57.0% to 46.8%, after the i-sleep program (RR=0.82, 95% CI: 0.79–0.86). The proportion of inpatients newly prescribed sleeping pills after admission to the hospital did not significantly decrease (1.97% to 2.00%; RR=1.01, 95% CI: 0.96–1.07). The mean prescription rate of sleeping pills per day was 8.18% in 2014 and 7.78% in 2015. Conclusion The i-sleep program reduced the proportion of inpatients who continued to take sleeping pills from admission until discharge, although it did't reduce the prescription rate per day. PMID:29422929

Using simulation to isolate physician variation in intensive care unit admission decision making for critically ill elders with end-stage cancer: a pilot feasibility study.

PubMed

Barnato, Amber E; Hsu, Heather E; Bryce, Cindy L; Lave, Judith R; Emlet, Lillian L; Angus, Derek C; Arnold, Robert M

2008-12-01

To determine the feasibility of high-fidelity simulation for studying variation in intensive care unit admission decision making for critically ill elders with end-stage cancer. Mixed qualitative and quantitative analysis of physician subjects participating in a simulation scenario using hospital set, actors, medical chart, and vital signs tracings. The simulation depicted a 78-yr-old man with metastatic gastric cancer, life-threatening hypoxia most likely attributable to cancer progression, and stable preferences to avoid intensive care unit admission and intubation. Two independent raters assessed the simulations and subjects completed a postsimulation web-based survey and debriefing interview. Peter M. Winter Institute for Simulation Education and Research at the University of Pittsburgh. Twenty-seven hospital-based attending physicians, including 6 emergency physicians, 13 hospitalists, and 8 intensivists. Outcomes included qualitative report of clinical verisimilitude during the debriefing interview, survey-reported diagnosis and prognosis, and observed treatment decisions. Independent variables included physician demographics, risk attitude, and reactions to uncertainty. All (100%) reported that the case and simulation were highly realistic, and their diagnostic and prognostic assessments were consistent with our intent. Eight physicians (29.6%) admitted the patient to the intensive care unit. Among the eight physicians who admitted the patient to the intensive care unit, three (37%) initiated palliation, two (25%) documented the patient's code status (do not intubate/do not resuscitate), and one intubated the patient. Among the 19 physicians who did not admit the patient to the intensive care unit, 13 (68%) initiated palliation and 5 (42%) documented code status. Intensivists and emergency physicians (p = 0.048) were more likely to admit the patient to the intensive care unit. Years since medical school graduation were inversely associated with the initiation of palliative care (p = 0.043). Simulation can reproduce the decision context of intensive care unit triage for a critically ill patient with terminal illness. When faced with an identical patient, hospital-based physicians from the same institution vary significantly in their treatment decisions.

Civil Restitution as an Objective of Department of Homeland Security Mission 3

DTIC Science & Technology

2014-06-01

applicability and effectiveness, and allow for iterations accordingly. The 1975 Georgia’s Restitution Center Program, and the 1977 Georgia’s Non-Residential...the United States without lawful admission, Vermont Service Center , Application for Permission to Reapply for Admission into the United States...Types of Research Designs.” September 23, 2013. http://libguides.usc.edu/ content.php?pid=83009&sid=818072. Vermont Service Center . Application

Risk of Death Influences Regional Variation in Intensive Care Unit Admission Rates among the Elderly in the United States.

PubMed

Cooke, Colin R

2016-01-01

The extent to which geographic variability in ICU admission across the United States is driven by patients with lower risk of death is unknown. To determine whether patients at low to moderate risk of death contribute to geographic variation in ICU admission. Retrospective cohort of hospitalizations among Medicare beneficiaries (age > 64 years) admitted for ten common medical and surgical diagnoses (2004 to 2009). We examined population-adjusted rates of ICU admission per 100 hospitalizations in 304 health referral regions (HRR), and estimated the relative risk of ICU admission across strata of regional ICU and risk of death, adjusted for patient and regional characteristics. ICU admission rates varied nearly two-fold across HRR quartiles (quartile 1 to 4: 13.6, 17.3, 20.0, and 25.2 per 100 hospitalizations, respectively). Observed mortality for patients in regions (quartile 4) with the greatest ICU use was 17% compared to 21% in regions with lowest ICU use (quartile 1) (p<0.001). After adjusting for patient and regional characteristics, including regional differences in ICU, skilled nursing, and long-term acute care bed capacity, individuals' risk of death modified the relationship between regional ICU use and an individual's risk of ICU admission (p for interaction<0.001). Region was least important in predicting ICU admission among patients with high (quartile 4) risk of death (RR 1.27, 95% CI 1.22-1.31, for high versus low ICU use regions), and most important for patients with moderate (quartile 2; RR 1.63, 95% CI 1.53-1.72, quartile 3; RR 1.56 95% CI 1.47-1.65) and low (quartile 1) risk of death (RR 1.50, 95% CI 1.41-1.59). There is wide variation in in ICU use by geography, independent of ICU beds and physician supply, for patients with low and moderate risks of death.

Heat, Heat Waves, and Hospital Admissions among the Elderly in the United States, 1992–2006

PubMed Central

Zanobetti, Antonella; Schwartz, Joel D.; Wellenius, Gregory A.; O’Neill, Marie S.

2014-01-01

Background: Heat-wave frequency, intensity, and duration are increasing with global climate change. The association between heat and mortality in the elderly is well documented, but less is known regarding associations with hospital admissions. Objectives: Our goal was to determine associations between moderate and extreme heat, heat waves, and hospital admissions for nonaccidental causes among Medicare beneficiaries ≥ 65 years of age in 114 cities across five U.S. climate zones. Methods: We used Medicare inpatient billing records and city-specific data on temperature, humidity, and ozone from 1992 through 2006 in a time-stratified case-crossover design to estimate the association between hospitalization and moderate [90th percentile of apparent temperature (AT)] and extreme (99th percentile of AT) heat and heat waves (AT above the 95th percentile over 2–8 days). In sensitivity analyses, we additionally considered confounding by ozone and holidays, different temperature metrics, and alternate models of the exposure–response relationship. Results: Associations between moderate heat and hospital admissions were minimal, but extreme heat was associated with a 3% (95% CI: 2%, 4%) increase in all-cause hospital admissions over the subsequent 8 days. In cause-specific analyses, extreme heat was associated with increased hospitalizations for renal (15%; 95% CI: 9%, 21%) and respiratory (4%; 95% CI: 2%, 7%) diseases, but not for cardiovascular diseases. An added heat-wave effect was observed for renal and respiratory admissions. Conclusion: Extreme heat is associated with increased hospital admissions, particularly for renal causes, among the elderly in the United States. Citation: Gronlund CJ, Zanobetti A, Schwartz JD, Wellenius GA, O’Neill MS. 2014. Heat, heat waves, and hospital admissions among the elderly in the United States, 1992–2006. Environ Health Perspect 122:1187–1192; http://dx.doi.org/10.1289/ehp.1206132 PMID:24905551

Pregnancies complicated by preeclampsia and non-preeclampsia-related nephrotic range proteinuria

PubMed Central

Kemp, GJ; Walkinshaw, SA; Howse, MLP

2013-01-01

Objective To examine the impact of nephrotic range proteinuria during pregnancy on renal, maternal and fetal outcomes. Methods A retrospective study of pregnant women with proteinuria greater than 3 g/24 h. Outcome measures included: gestation and mode of delivery, maternal high dependency unit admission, birth weight, maternal blood pressure and proteinuria at time of last follow-up, renal biopsy. Results Two hundred and sixty four pregnancies in 262 women were reviewed. Postnatal data were available in 180; of these 104 (57%) had urinary protein quantified postnatally. Sixty three (60%) were pure preeclampsia and nine (9%) super-imposed preeclampsia. Biopsy-proven renal disease was newly diagnosed in nine (9%). Sixty three per cent required caesarean section and 34% required high dependency unit admission. There were no maternal deaths. Birth weight corrected for gestation was below the fifth centile in 33%. Conclusions The incidence of underlying renal pathology in this cohort is significant and highlights the importance of careful follow-up. PMID:27656249

Predictors of Graduate Enrollment in Hard and Soft Academic Disciplines and the Impact of Sex and Ethnicity

ERIC Educational Resources Information Center

McAnulty, Katheryn G.

2009-01-01

Given the underrepresentation of research on graduate college choice, particularly that which utilizes a national sample of students enrolled in a wide range of institutions of higher education across the United States, this study aims to contribute significantly to the field of graduate access and admissions. Building on the work of Perna (2004)…

[Four years of raw mortality in an intensive care unit].

PubMed

Loria, Alvar; Rosas-Baruch, Agustina; Posadas, Juan Gabriel; Domínguez-Cherit, Guillermo; Rivero-Sigarroa, Eduardo

2008-01-01

To characterize magnitude and variability of raw mortality in a Mexican Intensive Care Unit (ICU). Demographic and clinical data were analyzed in 1,746 patients discharged from the ICU of the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran. The data was obtained from an administrative database and covered four years (2003-2006). Overall ICU-mortality was 23% (410/1746) and was associated with two binary variables (higher mortality in weekend admissions and non-surgical cases) and three multicategorical variables (gradient of increasing mortality with increasing age, increasing diagnostic risk and increasing number of high-rish diagnoses). First biennium mortality was significantly higher than in the second biennium (29% us 19%). This higher mortality was not associated with the high risk categories of the five variables described above nor with other ICU-variables such as number of nurses and admission and discharge criteria. The only biennium difference was a higher number of physicians (specialists + residents) in the second biennium (16-20 versus 14-15 in the first). The four-year long-term ICU-mortality showed a significant decrease in the second biennium. Number of physicians was the only variable associated with the decreased mortality.

Predicting invasive fungal disease due to Candida species in non-neutropenic, critically ill, adult patients in United Kingdom critical care units.

PubMed

Shahin, Jason; Allen, Elizabeth J; Patel, Krishna; Muskett, Hannah; Harvey, Sheila E; Edgeworth, Jonathan; Kibbler, Christopher C; Barnes, Rosemary A; Biswas, Sharmistha; Soni, Neil; Rowan, Kathryn M; Harrison, David A

2016-09-09

Given the predominance of invasive fungal disease (IFD) amongst the non-immunocompromised adult critically ill population, the potential benefit of antifungal prophylaxis and the lack of generalisable tools to identify high risk patients, the aim of the current study was to describe the epidemiology of IFD in UK critical care units, and to develop and validate a clinical risk prediction tool to identify non-neutropenic, critically ill adult patients at high risk of IFD who would benefit from antifungal prophylaxis. Data on risk factors for, and outcomes from, IFD were collected for consecutive admissions to adult, general critical care units in the UK participating in the Fungal Infection Risk Evaluation (FIRE) Study. Three risk prediction models were developed to model the risk of subsequent Candida IFD based on information available at three time points: admission to the critical care unit, at the end of 24 h and at the end of calendar day 3 of the critical care unit stay. The final model at each time point was evaluated in the three external validation samples. Between July 2009 and April 2011, 60,778 admissions from 96 critical care units were recruited. In total, 359 admissions (0.6 %) were admitted with, or developed, Candida IFD (66 % Candida albicans). At the rate of candidaemia of 3.3 per 1000 admissions, blood was the most common Candida IFD infection site. Of the initial 46 potential variables, the final admission model and the 24-h model both contained seven variables while the end of calendar day 3 model contained five variables. The end of calendar day 3 model performed the best with a c index of 0.709 in the full validation sample. Incidence of Candida IFD in UK critical care units in this study was consistent with reports from other European epidemiological studies, but lower than that suggested by previous hospital-wide surveillance in the UK during the 1990s. Risk modeling using classical statistical methods produced relatively simple risk models, and associated clinical decision rules, that provided acceptable discrimination for identifying patients at 'high risk' of Candida IFD. The FIRE Study was reviewed and approved by the Bolton NHS Research Ethics Committee (reference: 08/H1009/85), the Scotland A Research Ethics Committee (reference: 09/MRE00/76) and the National Information Governance Board (approval number: PIAG 2-10(f)/2005).

Association of waist circumference with outcomes in an acute general surgical unit.

PubMed

Ryan, Thomas; Gosal, Preet; Seal, Alexa; McGirr, Joe; Williams, Nicholas

2017-06-01

Obesity prevalence is increasing in Australia, particularly in non-metropolitan areas. The effect of obesity on acute surgical outcomes is not known. We aimed to record waist circumference (WC) (surrogate for obesity) amongst acute surgical unit (ASU) patients in a New South Wales regional hospital, and compare outcome measures (length of stay (LOS), unplanned return to theatre, readmission rates, intensive care unit (ICU) admission and mortality). Retrospective cohort study of 4 months of consecutive ASU admissions, excluding age <16, pregnancy, out-of-area transfer and incomplete data. Patients were classified according to World Health Organization WC definitions as high-risk or non-high-risk (increased-risk and no-risk). Of 695 admissions, 512 met the inclusion criteria (47.1% female, average age 52.8 years (SD 22.3)), with 85.1% (P < 0.001) of females and 69.4% (P = 0.166) of males having an increased- or high-risk WC. This compares to rates amongst inner regional populations of 71.0% (female) and 66.4% (male). LOS was longer for high-risk patients (5.0 days versus 3.7 days, P = 0.002). However, the mean age of high-risk patients was greater (56.6 years versus 46.9 years, P = 0.001) and LOS was longer for those aged ≥60 (P < 0.001). After controlling for age, high-risk WC was not associated with any outcome measure, except amongst ICU admissions, where high-risk patients stayed longer (15.5 days versus 6.8 days, P < 0.001). Increased- and high-risk WC was overrepresented amongst female ASU patients. High-risk WC was associated with a significantly greater LOS in patients admitted to ICU. High-risk WC was not associated with other outcomes independent of age. WC is useful for quantifying obesity in the inpatient setting. © 2017 Royal Australasian College of Surgeons.

Temporal trends in emergency department visits for bronchiolitis in the United States, 2006 to 2010.

PubMed

Hasegawa, Kohei; Tsugawa, Yusuke; Brown, David F M; Mansbach, Jonathan M; Camargo, Carlos A

2014-01-01

To examine temporal trends in emergency departments (EDs) visits for bronchiolitis among US children between 2006 and 2010. Serial, cross-sectional analysis of the Nationwide Emergency Department Sample, a nationally representative sample of ED patients. We used International Classification of Diseases, Ninth Revision, Clinical Modification code 466.1 to identify children <2 years of age with bronchiolitis. Primary outcome measures were rate of bronchiolitis ED visits, hospital admission rate and ED charges. Between 2006 and 2010, weighted national discharge data included 1,435,110 ED visits with bronchiolitis. There was a modest increase in the rate of bronchiolitis ED visits, from 35.6 to 36.3 per 1000 person-years (2% increase; Ptrend = 0.008), due to increases in the ED visit rate among children from 12 months to 23 months (24% increase;Ptrend < 0.001). By contrast, there was a significant decline in the ED visit rate among infants (4% decrease; Ptrend < 0.001). Although unadjusted admission rate did not change between 2006 and 2010 (26% in both years), admission rate declined significantly after adjusting for potential patient- and ED-level confounders (adjusted odds ratio for comparison of 2010 with 2006, 0.84; 95% confidence interval: 0.76-0.93; P < 0.001). Nationwide ED charges for bronchiolitis increased from $337 million to $389 million (16% increase; Ptrend < 0.001), adjusted for inflation. This increase was driven by a rise in geometric mean of ED charges per case from $887 to $1059 (19% increase; Ptrend < 0.001). Between 2006 and 2010, we found a divergent temporal trend in the rate of bronchiolitis ED visits by age group. Despite a significant increase in associated ED charges, ED-associated hospital admission rates for bronchiolitis significantly decreased over this same period.

How many schools adopt interviews during the student admission process across the health professions in the United States of America?

PubMed Central

2016-01-01

Health profession schools use interviews during the admissions process to identify certain non-cognitive skills that are needed for success in diverse, inter-professional settings. This study aimed to assess the use of interviews during the student admissions process across health disciplines at schools in the United States of America in 2014. The type and frequency of non-cognitive skills assessed were also evaluated. Descriptive methods were used to analyze a sample of interview rubrics collected as part of a national survey on admissions in the health professions, which surveyed 228 schools of medicine, dentistry, pharmacy, nursing, and public health. Of the 228 schools, 130 used interviews. The most desirable non-cognitive skills from 34 schools were identified as follows: communication skills (30), motivation (22), readiness for the profession (17), service (12), and problem-solving (12). Ten schools reported using the multiple mini-interview format, which may indicate potential for expanding this practice. Disparities in the use of interviewing across health professions should be verified to help schools adopt interviews during student admissions processes. PMID:26924541

How many schools adopt interviews during the student admission process across the health professions in the United States of America?

PubMed

Glazer, Greer; Startsman, Laura F; Bankston, Karen; Michaels, Julia; Danek, Jennifer C; Fair, Malika

2016-01-01

Health profession schools use interviews during the admissions process to identify certain non-cognitive skills that are needed for success in diverse, inter-professional settings. This study aimed to assess the use of interviews during the student admissions process across health disciplines at schools in the United States of America in 2014. The type and frequency of non-cognitive skills assessed were also evaluated. Descriptive methods were used to analyze a sample of interview rubrics collected as part of a national survey on admissions in the health professions, which surveyed 228 schools of medicine, dentistry, pharmacy, nursing, and public health. Of the 228 schools, 130 used interviews. The most desirable non-cognitive skills from 34 schools were identified as follows: communication skills (30), motivation (22), readiness for the profession (17), service (12), and problem-solving (12). Ten schools reported using the multiple mini-interview format, which may indicate potential for expanding this practice. Disparities in the use of interviewing across health professions should be verified to help schools adopt interviews during student admissions processes.

Transfer from primary maternity unit to tertiary hospital in New Zealand - timing, frequency, reasons, urgency and outcomes: Part of the Evaluating Maternity Units study.

PubMed

Grigg, Celia P; Tracy, Sally K; Tracy, Mark; Schmied, Virginia; Monk, Amy

2015-09-01

to examine the transfers from primary maternity units to a tertiary hospital in New Zealand by describing the frequency, timing, reasons and outcomes of those who had antenatal or pre-admission birthplace plan changes, and transfers in labour or postnatally. mixed methods prospective (concurrent) cohort study, which analysed transfer and clinical outcome data (407 primary unit cohort, 285 tertiary hospital cohort), and data from the six week postpartum survey (571 respondents). well, pregnant women booked to give birth in a tertiary maternity hospital or primary maternity unit in one region in New Zealand (2010-2012). All women received midwifery continuity of care, regardless of their intended or actual birthplace. fewer than half of the women who planned a primary unit birth gave birth there (191 or 46.9%). A change of plan may have been made either antenatally or before admission in labour; and transfers were made after admission to the primary unit in labour or during the postnatal stay (about 48 hours). Of the 117 (28.5%) planning a primary unit birth who changed their planned birthplace type antenatally 73 (62.4%) were due to a clinical indication. Earthquakes accounted for 28.1% of birthplace change (during the research period major earthquakes occurred in the study region). Most (73.8%) labour changes occurred before admission in labour to the primary unit. For the 76 women who changed plan at this stage the most common reasons to do so were a rapid labour (25.0%) or prolonged rupture of membranes (23.7%). Transfers in labour from primary unit to tertiary hospital occurred for 27 women (12.6%) of whom 26 (96.3%) were having their first baby. "Slow progress" of labour accounted for 21 (77.8%) of these and 17 (62.9%) were classified as 'non-emergency'. The average transfer time for 'emergency' transfers was 58 minutes. The average time for all labour transfers from specialist consultation to birth was 4.5 hours. Nine postnatal transfers (maternal or neonatal) from a primary unit occurred (4.7%), making a total post-admission transfer rate of 17.3% for the primary unit cohort. birthplace changes were not uncommon, with many women changing their birthplace plan antenatally or prior to admission in labour and some transferring between facilities during or soon after birth. Most changes were due to the development of complications or 'risk factors'. Most transfers were not urgent and took approximately one hour from the decision to arrival at the tertiary hospital. Despite the transfers the neonatal clinical outcomes were comparable between both primary and tertiary cohorts, and there was higher maternal morbidity in the tertiary cohort. although the study size is relatively small, its comprehensive documentation of transfers has the potential to inform future research and the birthplace decision-making of childbearing women and midwives. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.

On- versus off-hour care for patients with non-ST-segment elevation myocardial infarction in Germany : Exemplary results within the chest pain unit concept.

PubMed

Breuckmann, F; Remberg, F; Böse, D; Waltenberger, J; Fischer, D; Rassaf, T

2016-12-01

The aim of this study was to analyze differences in the timing of invasive management of patients with high-risk acute coronary syndrome without persistent ST-segment elevation (hr-NSTE-ACS) or myocardial infarction without persistent ST-segment elevation (NSTEMI) between on- and off-hours in a German chest pain unit (CPU). We retrospectively enrolled 160 NSTEMI patients in the study, who were admitted to two German CPUs in 2013. Patients presenting on weekdays between 8 a.m. and 6 p.m. were compared with patients presenting during off-hours. Data analysis included time intervals from admission to invasive management (goals: for hr-NSTE-ACS, <2 h; for NSTEMI, <24 h) and the resulting guideline adherence. Guideline-adherent timing of an invasive strategy did not differ significantly between the on-hour (6.5 h [3.0-22.0 h], 79.9 %) and off-hour groups (10.5 h [2.0-20.0 h], 75.3 %; p = 0.94), without additional significant differences between admissions during off-hours Monday to Thursday and weekends (10.0 h [2.0-19.0 h], 75.6 % vs. 7.5 h [2.0-20.0 h], 76.2 %; p = 0.96). Our exemplary experience in two different German CPUs demonstrates adequate timing of coronary catheterization in over 75 % of cases, irrespective of admission during on- or off-hours. Nationwide validation of our findings by the German CPU registry is mandatory.

Five-Year Experience of an Inpatient Palliative Care Unit at an Academic Referral Center.

PubMed

Shinall, Myrick C; Martin, Sara F; Nelson, Jill; Miller, Richard S; Semler, Matthew W; Zimmerman, Eli E; Noblit, Christy C; Ely, E Wesley; Karlekar, Mohana

2018-01-01

Palliative care units (PCUs) staffed by specialty-trained physicians and nurses have been established in a number of medical centers. The purpose of this study is to review the 5-year experience of a PCU at a large, urban academic referral center. We retrospectively reviewed a prospectively collected database of all admissions to the PCU at Vanderbilt University Medical Center in the first 5 years of its existence, from 2012 through 2017. Over these 5 years, there were 3321 admissions to the PCU. No single underlying disease process accounted for the majority of the patients, but the largest single category of patients were those with malignancy, who accounted for 38% of admissions. Transfers from the intensive care unit accounted for 50% of admissions, with 43% of admissions from a hospital floor and 7% coming from the emergency department or a clinic. Median length of stay in the PCU was 3 days. In hospital deaths occurred for 50% of admitted patients, while 38% of patients were discharged from the PCU to hospice. These data show that a successful PCU is enabled by buy in from a wide variety of referring specialists and by a multidisciplinary palliative care team focused on care of the actively dying patient as well as pain and symptom management, advance care planning, and hospice referral since a large proportion of referred patients do not die in house.

Hospitalized children with 2009 pandemic influenza A (H1N1): comparison to seasonal influenza and risk factors for admission to the ICU.

PubMed

Bagdure, Dayanand; Curtis, Donna J; Dobyns, Emily; Glodé, Mary P; Dominguez, Samuel R

2010-12-15

Limited data are available describing the clinical presentation and risk factors for admission to the intensive care unit for children with 2009 H1N1 infection. We conducted a retrospective chart review of all hospitalized children with 2009 influenza A (H1N1) and 2008-09 seasonal influenza at The Children's Hospital, Denver, Colorado. Of the 307 children identified with 2009 H1N1 infections, the median age was 6 years, 61% were male, and 66% had underlying medical conditions. Eighty children (26%) were admitted to the ICU. Thirty-two (40%) of the ICU patients required intubation and 17 (53%) of the intubated patients developed acute respiratory distress syndrome (ARDS). Four patients required extracorporeal membrane oxygenation. Eight (3%) of the hospitalized children died. Admission to the ICU was significantly associated with older age and underlying neurological condition. Compared to the 90 children admitted during the 2008-09 season, children admitted with 2009 H1N1 influenza were significantly older, had a shorter length of hospitalization, more use of antivirals, and a higher incidence of ARDS. Compared to the 2008-09 season, hospitalized children with 2009 H1N1 influenza were much older and had more severe respiratory disease. Among children hospitalized with 2009 H1N1 influenza, risk factors for admission to the ICU included older age and having an underlying neurological condition. Children under the age of 2 hospitalized with 2009 H1N1 influenza were significantly less likely to require ICU care compared to older hospitalized children.

40 CFR 94.803 - Admission.

Code of Federal Regulations, 2010 CFR

2010-07-01

... Protection of Environment ENVIRONMENTAL PROTECTION AGENCY (CONTINUED) AIR PROGRAMS (CONTINUED) CONTROL OF EMISSIONS FROM MARINE COMPRESSION-IGNITION ENGINES Importation of Nonconforming Engines § 94.803 Admission. (a) A nonconforming engine offered for importation may be admitted into the United States pursuant to...

8 CFR 235.11 - Admission of conditional permanent residents.

Code of Federal Regulations, 2010 CFR

2010-01-01

... based on entrepreneurship. An alien seeking admission to the United States with an immigrant visa as an alien entrepreneur (as defined in section 216A(f)(1) of the Act) or the spouse or unmarried minor child...

Weight bias in graduate school admissions.

PubMed

Burmeister, Jacob M; Kiefner, Allison E; Carels, Robert A; Musher-Eizenman, Dara R

2013-05-01

Whether weight bias occurs in the graduate school admissions process is explored here. Specifically, we examined whether body mass index (BMI) was related to letter of recommendation quality and the number of admissions offers applicants received after attending in-person interviews. Participants were 97 applicants to a psychology graduate program at a large university in the United States. They reported height, weight, and information about their applications to psychology graduate programs. Participants' letters of recommendation were coded for positive and negative statements as well as overall quality. Higher BMI significantly predicted fewer post-interview offers of admission into psychology graduate programs. Results also suggest this relationship is stronger for female applicants. BMI was not related to overall quality or the number of stereotypically weight-related adjectives in letters of recommendation. Surprisingly, higher BMI was related to more positive adjectives in letters. The first evidence that individuals interviewing applicants to graduate programs may systematically favor thinner applicants is provided here. A conscious or unconscious bias against applicants with extra body weight is a plausible explanation. Stereotype threat and social identity threat are also discussed as explanations for the relationship between BMI and interview success. Copyright © 2012 The Obesity Society.

Efficacy of a high-observation protocol in major head and neck cancer surgery: A prospective study.

PubMed

Barber, Brittany; Harris, Jeffrey; Shillington, Cameron; Rychlik, Shannon; Dort, Joseph; Meier, Michael; Estey, Angela; Elwi, Adam; Wickson, Patty; Buss, Michael; Zygun, David; Ansari, Kal; Biron, Vincent; O'Connell, Daniel; Seikaly, Hadi

2017-08-01

The purpose of this study was to optimize an existing clinical care pathway (CCP) for head and neck cancer with a high-observation protocol (HOP) and to determine the effect on length of intensive care unit (ICU) admission and length of stay in hospital (LOS). The HOP mandated initiation of spontaneous breathing trials before the conclusion of the surgery, weaning of sedation, and limiting mechanical ventilation. All patients with head and neck cancer undergoing primary surgery on the HOP were compared to a historical cohort regarding length of ICU admission, ICU readmissions, and LOS. Ninety-six and 52 patients were observed in "historical" and "HOP" cohorts. The length of ICU admission (1.9 vs 1.2 days; p = .021), LOS (20.3 vs 14.1 days; p = .020), and ICU readmissions (10.4% vs 1.9%; p = .013) were significantly decreased in the "HOP" cohort. Rapid weaning of sedation and limiting mechanical ventilation may contribute to a shorter length of ICU admission and LOS, as well as decreased ICU readmissions. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1689-1695, 2016. © 2017 Wiley Periodicals, Inc.

Systematic review of studies on telemonitoring of patients with congestive heart failure: a meta-analysis.

PubMed

Clarke, Malcolm; Shah, Anila; Sharma, Urvashi

2011-01-01

We conducted a systematic review of large, well-conducted randomised trials designed to evaluate the effectiveness of telemonitoring on patients with congestive heart failure (CHF). Two people reviewed 125 articles independently and selected 13 articles for final review. These studies concerned 3480 patients. The follow-up period of the studies was 3-15 months. Pooled estimate results showed that there was an overall reduction in all-cause mortality (P = 0.02). There was no overall reduction in all-cause hospital admission (P = 0.84), although there was a reduction in CHF hospital admission (P = 0.0004). There was no reduction in all-cause emergency admission (P = 0.67). There was no significant difference in length of stay in hospital, medication adherence or cost. Telemonitoring in conjunction with nurse home visiting and specialist unit support can be effective in the clinical management of patients with CHF and help to improve their quality of life.

Effect of antibiotic use on antimicrobial antibiotic resistance and late-onset neonatal infections over 25 years in an Australian tertiary neonatal unit.

PubMed

Carr, David; Barnes, Elizabeth Helen; Gordon, Adrienne; Isaacs, David

2017-05-01

Antibiotic resistance is a worldwide problem. We describe 25 years of responsible antibiotic use in a tertiary neonatal unit. Data on neonatal infections and antibiotic use were collected prospectively from 1990 to 2014 at a single tertiary Sydney neonatal intensive care unit attached to a maternity unit. There are approximately 5500 deliveries and 900 nursery admissions per year. The mean annual rate of late-onset sepsis was 1.64 episodes per 100 admissions. The mean number of late-onset sepsis episodes per admission to the neonatal unit decreased by 4.0% per year (95% CI 2.6% to 5.4%; p<0.0001) and occurred particularly in infants born weighing <1500 g. No infants with negative cultures relapsed with sepsis when antibiotics were stopped after 48-72 hours. Antibiotic use decreased with time. The proportion of colonising methicillin-resistant Staphylococcus aureus isolates decreased by 7.4% per year (95% CI 0.2% to 14.1%; p=0.043). The proportion of colonising Gram-negative bacilli isolates resistant to either third-generation cephalosporins or gentamicin increased by 2.9% per year (95% CI 1.0% to 4.9%; p=0.0035). Most were cephalosporin-resistant; gentamicin resistance was rare. An average of one baby per year died from late-onset sepsis, the rate not varying significantly over time. The mortality from episodes of late-onset sepsis was 25 of 332 (7.5%). Stopping antibiotics after 2-3 days if neonatal systemic cultures are negative is safe. However, it does not prevent the emergence of cephalosporin-resistant Gram-negative organisms. 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/.

Chronic nausea in advanced cancer patients: a retrospective assessment of a metoclopramide-based antiemetic regimen.

PubMed

Bruera, E; Seifert, L; Watanabe, S; Babul, N; Darke, A; Harsanyi, Z; Suarez-Almazor, M

1996-03-01

The purpose of this retrospective study is to assess the frequency and intensity of chronic nausea in patients admitted to the Palliative Care Unit and the results of a metoclopramide-based treatment regimen. We reviewed the medical records of 100 consecutive patients admitted to the Palliative Care Unit at the Edmonton General Hospital until death during 1992-1993. All patients had terminal cancer and normal cognitive function. All patients completed the Functional Analogue Scale for appetite, nausea, pain, activity, shortness of breath, and sensation of well-being at 1000 and 1600 hours every day. Patients who complained of nausea initially received metoclopramide 10 mg every 4 hr orally or subcutaneously (Step 1). If nausea persisted, dexamethasone 10 mg twice daily was added (Step 2). Step 3 consisted of a continuous subcutaneous infusion of metoclopramide of 60-120 mg/day plus dexamethasone. If no response was observed, other antiemetics were administered (Step 4). Upon admission to the unit, 32 patients (32%) presented with nausea. During the average admission of 25 +/- 13 days, 98 patients (98%) developed nausea. Twenty-five patients (25%) required other antiemetics because of bowel obstruction (18), extrapyramidal side effects (3), or other reasons (4). Most patients without bowel obstruction achieved excellent control of nausea using the metoclopramide-based regimen. During the first 5 days and last 5 days of admission, nausea had significantly lower intensity than the rest of the symptoms that were monitored. Our results suggest that, although nausea is very frequent, it can be well controlled in the majority of patients using safe and simple antiemetic regimens.

Description and comparison of pharmacy technician training programs in the United States.

PubMed

Anderson, Douglas C; Draime, Juanita A; Anderson, Timothy S

2016-01-01

To describe pharmacy technician training programs in the United States and to compare pharmacy technician program characteristics between programs with and without a pharmacist on faculty and between programs with different accreditation status. Descriptive, cross-sectional study. Not applicable. United States pharmacy technician programs. Not applicable. Student class size, faculty credentials, coursework components, program length, tuition rates, and admission criteria. Currently, there are more than 698 pharmacy technician programs across 1114 campuses, with complete data available for 216 programs. Programs varied widely in terms of class sizes, faculty credentials, and admission criteria. Programs with pharmacists on faculty were significantly less expensive than were those without pharmacists (P = 0.009). Accreditation had no impact on tuition prices. This is the first study of its kind to describe and characterize pharmacy technician training programs. There is relatively little control of technician training by the profession of pharmacy. The quality of these programs in terms of student outcomes is unknown, and it should be explored. Rigorous debate and discussion is needed regarding the future of pharmacy technician roles and the training required for those roles. Copyright © 2016 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Incidence and Outcomes for Patients With Cirrhosis Admitted to the United Kingdom Critical Care Units.

PubMed

McPhail, Mark J W; Parrott, Francesca; Wendon, Julia A; Harrison, David A; Rowan, Kathy A; Bernal, William

2018-05-01

To assess the epidemiology and outcome of patients with cirrhosis following critical care unit admission. Retrospective cohort study. Critical care units in England, Wales, and Northern Ireland participating in the U.K. Intensive Care National Audit and Research Centre Case Mix Programme. Thirty-one thousand three hundred sixty-three patients with cirrhosis identified of 1,168,650 total critical care unit admissions (2.7%) admitted to U.K. critical care units between 1998 and 2012. None. Ten thousand nine hundred thirty-six patients had alcohol-related liver disease (35%). In total, 1.6% of critical care unit admissions in 1998 had cirrhosis rising to 3.1% in 2012. The crude critical care unit mortality of patients with cirrhosis was 41% in 1998 falling to 31% in 2012 (p < 0.001). Crude hospital mortality fell from 58% to 46% over the study period (p < 0.001). Mean(SD) Acute Physiology and Chronic Health Evaluation II score in 1998 was 20.3 (8.5) and 19.5 (7.1) in 2012. Mean Acute Physiology and Chronic Health Evaluation II score for patients with alcohol-related liver disease in 2012 was 20.6 (7.0) and 19.0 (7.2) for non-alcohol-related liver disease (p < 0.001). In adjusted analysis, alcohol-related liver disease was associated with increased risk of death (odds ratio, 1.51 [95% CI, 1.42-1.62; p < 0.001]) with a year-on-year reduction in hospital mortality (adjusted odds ratio, 0.95/yr, [0.94-0.96, p < 0.001]). More patients with cirrhosis are being admitted to critical care units but with increasing survival rates. Patients with alcohol-related liver disease have reduced survival rates partly explained by higher levels of organ failure at admission. Patients with cirrhosis and organ failure warrant a trial of organ support and universal prognostic pessimism is not justified.

Symptoms, functioning and quality of life after treatment in a residential sub-acute mental health service in Australia.

PubMed

Thomas, Kerry A; Rickwood, Debra J; Brown, Patricia M

2017-01-01

The aim of this study was to assess clients' and service providers' perspectives on changes in mental health after an admission to a residential recovery-focused, sub-acute service, in Australia. Clients were either step-up clients, entering the service directly from the community, or step-down clients who were transitioning from an inpatient unit to home. During the 30-month period of data collection (August 2011 to January 2014) all clients (N = 102) were invited to participate in the longitudinal study and 41 clients consented to be involved (38% response rate). At admission and exit, participants completed the Behaviour and Symptom Identification Scale (Basis-32) and service providers completed the Life Skills Profile-16 and Health of the Nations Outcome Scales. Follow-up data 3 months after exit were available for 12 clients, including the Basis-32 and a self-report measure of quality of life (Assessment of Quality of Life 8-dimension). Both client groups reported positive improvements between admission and exit in the areas of relation to self and others, psychosis, daily living and presence of depression or anxiety symptoms. Service providers reported gains for clients in the areas of self-care, level of symptoms and presence of social problems. At 3 months, clients generally reported positive quality of life, although there was no significant change in symptoms and functioning. This study demonstrates that after an admission to a sub-acute service, step-up clients experience an improvement in their symptoms and functioning, have avoided a hospital admission and are well enough to return home. Step-down clients also experience further improvements in their symptoms and functioning, indicating that the service has assisted them in their transition to independent living after a hospital admission. Sub-acute residential units provide a continuation of care for inpatients preparing to return home, and people with a mental health problem living in the community who experience an escalation in symptoms and prefer an alternative to hospital. © 2015 John Wiley & Sons Ltd.

40 CFR 91.703 - Admission.

Code of Federal Regulations, 2010 CFR

2010-07-01

... Protection of Environment ENVIRONMENTAL PROTECTION AGENCY (CONTINUED) AIR PROGRAMS (CONTINUED) CONTROL OF EMISSIONS FROM MARINE SPARK-IGNITION ENGINES Importation of Nonconforming Marine Engines § 91.703 Admission. (a) A nonconforming marine SI engine offered for importation may only be imported into the United...

Age as an independent risk factor for intensive care unit admission or death due to 2009 pandemic influenza A (H1N1) virus infection.

PubMed

Nickel, Katelin B; Marsden-Haug, Nicola; Lofy, Kathryn H; Turnberg, Wayne L; Rietberg, Krista; Lloyd, Jennifer K; Marfin, Anthony A

2011-01-01

This study evaluated risk factors for intensive care unit (ICU) admission or death among people hospitalized with 2009 pandemic influenza A (pH1N1) virus infection. We based analyses on data collected in Washington State from April 27 to September 18, 2009, on deceased or hospitalized people with laboratory-confirmed pH1N1 infection reported by health-care providers and hospitals as part of enhanced public health surveillance. We used bivariate analyses and multivariable logistic regression to identify risk factors associated with ICU admission or death due to pH1N1. We identified 123 patients admitted to the hospital but not an ICU and 61 patients who were admitted to an ICU or died. Independent of high-risk medical conditions, both older age and delayed time to hospital admission were identified as risk factors for ICU admission or death due to pH1N1. Specifically, the odds of ICU admission or death were 4.44 times greater among adults aged 18-49 years (95% confidence interval [CI] 1.97, 10.02) and 5.93 times greater among adults aged 50-64 years (95% CI 2.24, 15.65) compared with pediatric patients < 18 years of age. Likewise, hospitalized cases admitted more than two days after illness onset had 2.17 times higher odds of ICU admission or death than those admitted within two days of illness onset (95% CI 1.10, 4.25). Although certain medical conditions clearly influence the need for hospitalization among people infected with pH1N1 virus, older age and delayed time to admission each played an independent role in the progression to ICU admission or death among hospitalized patients.

Epidemiology of Australian Influenza-Related Paediatric Intensive Care Unit Admissions, 1997-2013.

PubMed

Kaczmarek, Marlena C; Ware, Robert S; Coulthard, Mark G; McEniery, Julie; Lambert, Stephen B

2016-01-01

Influenza virus predictably causes an annual epidemic resulting in a considerable burden of illness in Australia. Children are disproportionately affected and can experience severe illness and complications, which occasionally result in death. We conducted a retrospective descriptive study using data collated in the Australian and New Zealand Paediatric Intensive Care (ANZPIC) Registry of influenza-related intensive care unit (ICU) admissions over a 17-year period (1997-2013, inclusive) in children <16 years old. National laboratory-confirmed influenza notifications were used for comparison. Between 1997 and 2013, a total of 704 influenza-related ICU admissions were recorded, at a rate of 6.2 per 1,000 all-cause ICU admissions. Age at admission ranged from 0 days and 15.9 years (median = 2.1 years), with 135 (19.2%) aged <6 months. Pneumonia/pneumonitis and bronchiolitis were the most common primary diagnoses among influenza-related admissions (21.9% and 13.6%, respectively). More than half of total cases (59.2%) were previously healthy (no co-morbidities recorded), and in the remainder, chronic lung disease (16.7%) and asthma (12.5%) were the most common co-morbidities recorded. Pathogen co-detection occurred in 24.7% of cases, most commonly with respiratory syncytial virus or a staphylococcal species. Median length of all ICU admissions was 3.2 days (range 2.0 hours- 107.4 days) and 361 (51.3%) admissions required invasive respiratory support for a median duration of 4.3 days (range 0.2 hours- 107.5 days). There were 27 deaths recorded, 14 (51.9%) in children without a recorded co-morbidity. Influenza causes a substantial number of ICU admissions in Australian children each year with the majority occurring in previously healthy children.

An Integrative Literature Review of Organisational Factors Associated with Admission and Discharge Delays in Critical Care

PubMed Central

Peltonen, Laura-Maria; McCallum, Louise; Siirala, Eriikka; Haataja, Marjaana; Lundgrén-Laine, Heljä; Salanterä, Sanna; Lin, Frances

2015-01-01

The literature shows that delayed admission to the intensive care unit (ICU) and discharge delays from the ICU are associated with increased adverse events and higher costs. Identifying factors related to delays will provide information to practice improvements, which contribute to better patient outcomes. The aim of this integrative review was to explore the incidence of patients' admission and discharge delays in critical care and to identify organisational factors associated with these delays. Seven studies were included. The major findings are as follows: (1) explanatory research about discharge delays is scarce and one study on admission delays was found, (2) delays are a common problem mostly due to organisational factors, occurring in 38% of admissions and 22–67% of discharges, and (3) redesigning care processes by improving information management and coordination between units and interdisciplinary teams could reduce discharge delays. In conclusion, patient outcomes can be improved through efficient and safe care processes. More exploratory research is needed to identify factors that contribute to admission and discharge delays to provide evidence for clinical practice improvements. Shortening delays requires an interdisciplinary and multifaceted approach to the whole patient flow process. Conclusions should be made with caution due to the limited number of articles included in this review. PMID:26558286

Sobriety as an admission criterion for transitional housing: a multi-site comparison of programs with a sobriety requirement to programs with no sobriety requirement.

PubMed

Tsai, Jack; Rosenheck, Robert A; Kasprow, Wesley J; McGuire, James F

2012-10-01

This study examined whether homeless clients enrolled in transitional housing programs that required sobriety (SR) as an admission criterion have outcomes comparable to clients enrolled in programs that did not require sobriety (NSR) as an admission criterion. A total of 1062 military veterans in 40 transitional housing programs funded by the United States Department of Veterans Affairs were grouped based on whether they were in SR or NSR programs and followed over a one-year period after program discharge. Participants in SR and NSR programs were compared on their ratings of the social climate of the program, and housing and psychosocial outcomes. Participants in SR programs reported more days housed and better psychosocial outcomes than participants in NSR programs, although the differences were small and there were no differences in ratings of their social climate. Both participants in SR and NSR programs showed improvements on most outcomes after discharge from transitional housing. There were no significant differences in outcomes between participants actively abusing substances at program entry compared to those who were not. Requiring sobriety as an admission criterion in transitional housing made only a small difference in housing outcomes post-discharge. Further study is needed to determine whether requiring sobriety at admission in transitional housing is necessary for successful client outcomes. Published by Elsevier Ireland Ltd.

Management of patients with nonvariceal upper gastrointestinal hemorrhage before and after the adoption of the Rockall score, in the Italian Gastroenterology Units.

PubMed

Soncini, Marco; Triossi, Omero; Leo, Pietro; Magni, Giovanna; Bertelè, Anna Maria; Grasso, Tiziana; Ferraris, Luca; Caruso, Stefano; Spadaccini, Antonio; Brambilla, Gianfranco; Verta, Mario; Muratori, Rosangela; Attinà, Antonio; Grasso, Gianalberto

2007-07-01

Nonvariceal upper gastrointestinal hemorrhage is a frequent reason for ordinary hospital admission. In Italy the use of prognostic scores to stratify the risk has not been adequately validated: the impact on clinical management of a rating system like the Rockall score remains to be established. RING is a 'register' that has been collecting hospital discharge files from hospital gastroenterology units, giving a broad picture of the patients admitted for this pathology. We analyzed the hospital discharge files collected between 2001 and 2005 from 12 gastroenterology units, which issued more than 26,000 hospital discharge files for ordinary hospital admission and have been using the Rockall score for defining nonvariceal upper gastrointestinal hemorrhage since 2003. There were 2832 hospital discharge files with a main diagnosis of nonvariceal upper gastrointestinal hemorrhage: 1335 'before' the Rockall score was introduced, 1497 'after' the introduction. Patients' mean age was 67.7+/-16.7 years, with a male/female ratio of 1.7 and no significant changes over the years. There were no differences in the distribution of diagnoses in nonvariceal upper gastrointestinal hemorrhage patients before/after the introduction of the Rockall score, though the mean hospital stay became shorter (7.1+/-5.0 vs. 6.3+/-4.5 days), and mortality declined (2.8 vs. 2.3%), in parallel with the caselist as a whole. For 1102 ordinary hospital admission Rockall score was calculated. Diagnoses were more accurate: significantly fewer undefined causes and an increase in peptic ulcer. The mean Rockall score was 4.6+/-2.2: 17.8% low (0-2), 48.7% intermediate (3-5), and 33.5% high (>or=6). Mean hospital stay, rebleeding, and mortality were correlated with the severity of the score. The Rockall score enables the clinician to formulate a more precise diagnosis and substantially shortens the time in hospital, especially for patients at low-risk of rebleeding and death, so more resources can be dedicated to critically ill patients.

Acceptability and Feasibility of Universal Offer of Rapid Point of Care Testing for HIV in an Acute Admissions Unit: Results of the RAPID Project

PubMed Central

Burns, Fiona; Edwards, Simon G.; Woods, Jeremy; Haidari, Golaleh; Calderon, Yvette; Leider, Jason; Morris, Stephen; Tobin, Rose; Cartledge, Jonathan; Brown, Michael

2012-01-01

Background UK guidance recommend all acute medical admissions be offered an HIV test. Our aim was to determine whether a dedicated staff member using a multimedia tool, a model found to be effective in the USA, is an acceptable, feasible, and cost-effective model when translated to a UK setting. Design Between 14th Jan to 12th May 2010, a Health advisor (HA) approached 19–65 year olds at a central London acute medical admissions unit (AAU) and offered a rapid HIV point of care test (POCT) with the aid of an educational video. Patients with negative results had the option to watch a post-test video providing risk-reduction information. For reactive results the HA arranged a confirmatory test, and ensured linkage into HIV specialist care. Feasibility and acceptability were assessed through surveys and uptake rates. Costs per case of HIV identified were established. Results Of the 606 eligible people admitted during the pilot period, 324 (53.5%) could not be approached or testing was deemed inappropriate. In total 23.0% of eligible admissions had an HIV POCT. Of the patients who watched the video and had not recently tested for HIV, 93.6% (131/140) agreed to an HIV test; four further patients had an HIV test but did not watch the video. Three tests (2.2%, 3/135) were reactive and all were confirmed HIV positive on laboratory testing. 97.5% felt HIV testing in this setting was appropriate, and 90.1% liked receiving the information via video. The cost per patient of the intervention was £21. Discussion Universal POCT HIV testing in an acute medical setting, facilitated by an educational video and dedicated staff appears to be acceptable, feasible, effective, and low cost. These findings support the recommendation of HIV testing all admissions to AAU in high prevalence settings, although with the model used a significant proportion remained untested. PMID:22558129

Burden of Clostridium difficile infection between 2010 and 2013: Trends and outcomes from an academic center in Eastern Europe.

PubMed

Kurti, Zsuzsanna; Lovasz, Barbara D; Mandel, Michael D; Csima, Zoltan; Golovics, Petra A; Csako, Bence D; Mohas, Anna; Gönczi, Lorant; Gecse, Krisztina B; Kiss, Lajos S; Szathmari, Miklos; Lakatos, Peter L

2015-06-07

To analyze the incidence and possible risk factors in hospitalized patients treated with Clostridium difficile infection (CDI). A total of 11751 patients were admitted to our clinic between 1 January 2010 and 1 May 2013. Two hundred and forty-seven inpatients were prospectively diagnosed with CDI. For the risk analysis a 1:3 matching was used. Data of 732 patients matched for age, sex, and inpatient care period and unit were compared to those of the CDI population. Inpatient records were collected from an electronic hospital database and comprehensively reviewed. Incidence of CDI was 21.0/1000 admissions (2.1% of all-cause hospitalizations and 4.45% of total inpatient days). The incidence of severe CDI was 12.6% (2.63/1000 of all-cause hospitalizations). Distribution of CDI cases was different according to the unit type, with highest incidence rates in hematology, gastroenterology and nephrology units (32.9, 25 and 24.6/1000 admissions, respectively) and lowest rates in 1.4% (33/2312) in endocrinology and general internal medicine (14.2 and 16.9/1000 admissions) units. Recurrence of CDI was 11.3% within 12 wk after discharge. Duration of hospital stay was longer in patients with CDI compared to controls (17.6 ± 10.8 d vs 12.4 ± 7.71 d). CDI accounted for 6.3% of all-inpatient deaths, and 30-d mortality rate was 21.9% (54/247 cases). Risk factors for CDI were antibiotic therapy [including third-generation cephalosporins or fluoroquinolones, odds ratio (OR) = 4.559; P < 0.001], use of proton pump inhibitors (OR = 2.082, P < 0.001), previous hospitalization within 12 mo (OR = 3.167, P < 0.001), previous CDI (OR = 15.32; P < 0.001), while presence of diabetes mellitus was associated with a decreased risk for CDI (OR = 0.484; P < 0.001). Treatment of recurrent cases was significantly different from primary infections with more frequent use of vancomycin alone or in combination (P < 0.001), and antibiotic therapy duration was longer (P < 0.02). Severity, mortality and outcome of primary infections and relapsing cases did not significantly differ. CDI was accounted for significant burden with longer hospitalization and adverse outcomes. Antibiotic, PPI therapy and previous hospitalization or CDI were risk factors for CDI.

Burden of Clostridium difficile infection between 2010 and 2013: Trends and outcomes from an academic center in Eastern Europe

PubMed Central

Kurti, Zsuzsanna; Lovasz, Barbara D; Mandel, Michael D; Csima, Zoltan; Golovics, Petra A; Csako, Bence D; Mohas, Anna; Gönczi, Lorant; Gecse, Krisztina B; Kiss, Lajos S; Szathmari, Miklos; Lakatos, Peter L

2015-01-01

AIM: To analyze the incidence and possible risk factors in hospitalized patients treated with Clostridium difficile infection (CDI). METHODS: A total of 11751 patients were admitted to our clinic between 1 January 2010 and 1 May 2013. Two hundred and forty-seven inpatients were prospectively diagnosed with CDI. For the risk analysis a 1:3 matching was used. Data of 732 patients matched for age, sex, and inpatient care period and unit were compared to those of the CDI population. Inpatient records were collected from an electronic hospital database and comprehensively reviewed. RESULTS: Incidence of CDI was 21.0/1000 admissions (2.1% of all-cause hospitalizations and 4.45% of total inpatient days). The incidence of severe CDI was 12.6% (2.63/1000 of all-cause hospitalizations). Distribution of CDI cases was different according to the unit type, with highest incidence rates in hematology, gastroenterology and nephrology units (32.9, 25 and 24.6/1000 admissions, respectively) and lowest rates in 1.4% (33/2312) in endocrinology and general internal medicine (14.2 and 16.9/1000 admissions) units. Recurrence of CDI was 11.3% within 12 wk after discharge. Duration of hospital stay was longer in patients with CDI compared to controls (17.6 ± 10.8 d vs 12.4 ± 7.71 d). CDI accounted for 6.3% of all-inpatient deaths, and 30-d mortality rate was 21.9% (54/247 cases). Risk factors for CDI were antibiotic therapy [including third-generation cephalosporins or fluoroquinolones, odds ratio (OR) = 4.559; P < 0.001], use of proton pump inhibitors (OR = 2.082, P < 0.001), previous hospitalization within 12 mo (OR = 3.167, P < 0.001), previous CDI (OR = 15.32; P < 0.001), while presence of diabetes mellitus was associated with a decreased risk for CDI (OR = 0.484; P < 0.001). Treatment of recurrent cases was significantly different from primary infections with more frequent use of vancomycin alone or in combination (P < 0.001), and antibiotic therapy duration was longer (P < 0.02). Severity, mortality and outcome of primary infections and relapsing cases did not significantly differ. CONCLUSION: CDI was accounted for significant burden with longer hospitalization and adverse outcomes. Antibiotic, PPI therapy and previous hospitalization or CDI were risk factors for CDI. PMID:26074711

Use of an Early Labor Lounge to Promote Admission in Active Labor.

PubMed

Paul, Julie A; Yount, Susan M; Breman, Rachel Blankstein; LeClair, Melissa; Keiran, Diane M; Landry, Nannette; Dever, Kimberly

2017-03-01

Professional maternity care organizations within the United States are aligned in the goal to prevent the first cesarean birth in nulliparous women with a term, singleton, vertex fetus. Currently, one in 3 women are at risk for having a cesarean birth. The most common reason for cesarean in the United States is labor dystocia. The evidence supports delaying admission to the birthing unit until active labor is established, thereby minimizing the inadvertent diagnosis of labor dystocia. Providers are familiar with the rationale supporting delayed admission to the birthing unit until active labor is established; however, there is very little evidence on how to effectively promote this delay. Provider apprehension and the lack of early labor support are challenges to sending women home to await the onset of active labor. Maternal anxiety, fear, pain, and unpreparedness also play a part in this reluctance. To address these obstacles, South Shore Hospital created an early labor lounge with stations aimed at instilling confidence in the birth team, promoting teamwork, facilitating relaxation, and reducing anxiety for laboring women. A literature review focusing on women's perceptions of promoting admission in active labor, maternal anxiety, and nonpharmacologic strategies for managing early labor are discussed within the context of the creation, implementation, and evaluation of an early labor lounge. © 2017 by the American College of Nurse-Midwives.

Temporal trends in patient characteristics and survival of intensive care admissions with sepsis: a multicenter analysis*.

PubMed

Dreiher, Jacob; Almog, Yaniv; Sprung, Charles L; Codish, Shlomi; Klein, Moti; Einav, Sharon; Bar-Lavie, Yaron; Singer, Pierre P; Nimrod, Adi; Sachs, Jeffrey; Talmor, Daniel; Friger, Michael; Greenberg, Dan; Olsfanger, David; Hersch, Moshe; Novack, Victor

2012-03-01

To estimate in-hospital, 1-yr, and long-term mortality and to assess time trends in incidence and outcomes of sepsis admissions in the intensive care unit. A population-based, multicenter, retrospective cohort study. Patients hospitalized with sepsis in the intensive care unit in seven general hospitals in Israel during 2002-2008. None. Survival data were collected and analyzed according to demographic and background clinical characteristics, as well as features of the sepsis episode, using Kaplan-Meier approach for long-term survival. A total of 5,155 patients were included in the cohort (median age: 70, 56.3% males; median Charlson comorbidity index: 4). The mean number of intensive care unit admissions per month increased over time, while no change in in-hospital mortality was observed. The proportion of patients surviving to hospital discharge was 43.9%. The 1-, 2-, 5-, and 8-yr survival rates were 33.0%, 29.8%, 23.3%, and 19.8%, respectively. Mortality was higher in older patients, patients with a higher Charlson comorbidity index, and those with multiorgan failure, and similar in males and females. One-year age-standardized mortality ratio was 21-fold higher than expected, based on the general population rates. Mortality following intensive care unit sepsis admission remains high and is correlated with underlying patients' characteristics, including age, comorbidities, and the number of failing organ systems.

Early graft function and carboxyhemoglobin level in liver transplanted patients.

PubMed

Ali, Yasser; Negmi, H; Elmasry, N; Sadek, M; Riaz, A; Al Ouffi, H; Khalaf, H

2007-10-01

Heme-Oxygenase-1 catalyzes hemoglobin into bilirubin, iron, and carbon monoxide, a well known vasodilator. Heme-Oxygenase-1 expression and carbon monoxide production as measured by blood carboxyhemoglobin levels, increase in end stage liver disease patients. We hypothesized that there may be a correlation between carboxyhemoglobin level and early graft function in patients undergoing liver transplant surgeries. In a descriptive retrospective study, 39 patients who underwent liver transplantation between the year 2005 and 2006 at KFSH&RC, are included in the study. All patients received general anesthesia with isoflurane in 50% oxygen and air. Levels of oxyhemoglobin, carboxyhemoglobin and methemoglobin concentration in percentage were recorded at preoperative time, anhepatic phase, end of surgery, ICU admission and 24 hr after surgery. The level of lactic acid, prothrombin time (PT), partial thrombin time (PTT), serum total bilirubin and ammonia were also recorded at ICU admission and 24 hr after surgery. The numbers of blood units transfused were recorded. 39 patients were included in the study with 13/39 for living donor liver transplant (LDLT) compared to 26/39 patients scheduled for deceased donor liver transplant (DDLT). The mean age was 35.9 +/- 16.9 years while the mean body weight was 60.3 +/- 20.9 Kg. Female to male ratio was 21/18. The median packed red blood cell (PRBC) units was 4 (Rang 0-40). There was a significant increase in carboxyhemoglobin level during the anhepatic phase, end of surgery and on ICU admission compared with preoperative value (p<0.005). However, there was insignificant changes in methemoglobin level and significant decrease in oxyhemoglobin levels throughout the study period compared to the preoperative value (p<0.005). The changes in carboxyhemoglobin level on ICU admission and 24 hrs postoperatively were positively correlated with the changes in serum total bilirubin and prothrombin time (R = 0.35, 0.382, 0.325 and 0.31) respectively p<0.05) but not with the changes in serum lactic acid. The same strong correlation was found when analysing LDLT and DDLT patients separately between carboxyhemoglobin concentration and PT and total bilirubin while still the correlation with lactic acid was weak. There was no correlation between average perioperative carboxyhemoglobin concentration during different timing of measurements and average units of transfused blood (R = -0.02) p>0.05. The changes in carboxyhemoglobin level significantly correlate with the Changes in graft functions particularly prothrombin time and serum total bilirubin and may be used as an early, rapid and simple test for early evaluation of graft function.

How does active substance use at psychiatric admission impact suicide risk and hospital length-of-stay?

PubMed

Miller, Keith A; Hitschfeld, Mario J; Lineberry, Timothy W; Palmer, Brian A

2016-01-01

Despite their high prevalence, little is known about the effects of substance use disorders and active substance use on the suicide risk or length-of-stay of psychiatric inpatients. This study examines the relationship between active substance use at the time of psychiatric hospitalization and changes in suicide risk measures and length-of-stay. Admission and discharge ratings on the Suicide Status Form-II-R, diagnoses, and toxicology data from 2,333 unique psychiatric inpatients were examined. Data for patients using alcohol, tetrahydrocannabinol, methamphetamines, cocaine, benzodiazepines, opiates, barbiturates, phencyclidine, and multiple substances on admission were compared with data from 1,426 admissions without substance use. Patients with substance use by toxicology on admission had a 0.9 day shorter length-of-stay compared to toxicology-negative patients. During initial nurse evaluation on the inpatient unit, these patients reported lower suicide measures (i.e., suicidal ideation frequency, overall suicide risk, and wish-to-die). No significant between-group differences were seen at discharge. Patients admitted with a substance use disorder diagnosis had a 1.0 day shorter length-of-stay than those without, while those with a substance use disorder diagnosis and positive toxicology reported the lowest measures of suicidality on admission. These results remained independent of psychiatric diagnosis. For acute psychiatric inpatients, suicide risk is higher and length-of-stay is longer in patients with substance use disorders who are NOT acutely intoxicated compared with patients without a substance use disorder. Toxicology-positive patients are less suicidal on admission and improve faster than their toxicology-negative counterparts. This study gives support to the clinical observation that acutely intoxicated patients may stabilize quickly with regard to suicidal urges and need for inpatient care.

Short- and Long-Term Outcomes in Very Low Birth Weight Infants with Admission Hypothermia.

PubMed

Chang, Hung-Yang; Sung, Yi-Hsiang; Wang, Shwu-Meei; Lung, Hou-Ling; Chang, Jui-Hsing; Hsu, Chyong-Hsin; Jim, Wai-Tim; Lee, Ching-Hsiao; Hung, Hsiao-Fang

2015-01-01

Neonatal hypothermia remains a common problem and is related to elevated morbidities and mortality. However, the long-term neurodevelopmental effects of admission hypothermia are still unknown. This study attempted to determine the short-term and long-term consequences of admission hypothermia in VLBW preterm infants. This retrospective study measured the incidence and compared the outcomes of admission hypothermia in very low birth weight (VLBW) preterm infants in a tertiary-level neonatal intensive care unit. Infants were divided into the following groups: normothermia (36.5-37.5°C), mild hypothermia (36.0-36.4°C), moderate hypothermia (32.0-35.9°C), and severe hypothermia (< 32°C). We compared the distribution, demographic variables, short-term outcomes, and neurodevelopmental outcomes at 24 months of corrected age among groups. We studied 341 infants: 79 with normothermia, 100 with mild hypothermia, 162 with moderate hypothermia, and 0 with severe hypothermia. Patients in the moderate hypothermia group had significantly lower gestational ages (28.1 wk vs. 29.7 wk, P < .02) and smaller birth weight (1004 g vs. 1187 g, P < .001) compared to patients in the normothermia group. Compared to normothermic infants, moderately hypothermic infants had significantly higher incidences of 1-min Apgar score < 7 (63.6% vs. 31.6%, P < .001), respiratory distress syndrome (RDS) (58.0% vs. 39.2%, P = .006), and mortality (18.5% vs. 5.1%, P = .005). Moderate hypothermia did not affect neurodevelopmental outcomes at 2 years' corrected age. Mild hypothermia had no effect on short-term or long-term outcomes. Admission hypothermia was common in VLBW infants and correlated inversely with birth weight and gestational age. Although moderate hypothermia was associated with higher RDS and mortality rates, it may play a limited role among multifactorial causes of neurodevelopmental impairment.

Physicians' perceptions and attitudes regarding inappropriate admissions and resource allocation in the intensive care setting.

PubMed

Giannini, A; Consonni, D

2006-01-01

Physicians' perceptions regarding intensive care unit (ICU) resource allocation and the problem of inappropriate admissions are unknown. We carried out an anonymous, self-administered questionnaire survey to assess the perceptions and attitudes of ICU physicians at all 20 ICUs in Milan, Italy, regarding inappropriate admissions and resource allocation. Eighty-seven percent (225/259) of physicians responded. Inappropriate admissions were acknowledged by 86% of respondents. The reasons given were clinical doubt (33%); limited decision time (32%); assessment error (25%); pressure from superiors (13%), referring clinician (11%) or family (5%); threat of legal action (5%); and an economically advantageous 'Diagnosis Related Group' (1%). Respondents reported being pressurized to make more 'productive' use of ICU beds by Unit heads (frequently 16%), hospital management (frequently 10%) and colleagues (frequently 4%). Five percent reported refusing appropriate admissions following 'indications' not to admit financially disadvantageous cases. Admissions after elective surgery prioritized patients from profitable surgical departments: frequently for 6% of respondents and occasionally for 15%. Sixty-seven percent said they frequently received requests for appropriate admissions when no beds were available. This was considered sufficient reason to withdraw treatment from patients with lower survival probability (sometimes 21%) or for whom nothing more could be done (sometimes 51%, frequently 11%). Inappropriate ICU admissions were perceived as a common event but were mainly attributed to difficulties in assessing suitability. Physicians were aware that their decisions were often influenced by factors other than medical necessity. Economic influences were perceived as limited but not negligible. Decisions to forgo treatment could be influenced by the need to admit other patients.

Serious neck injuries in U19 rugby union players: an audit of admissions to spinal injury units in Great Britain and Ireland.

PubMed

MacLean, James G B; Hutchison, James D

2012-06-01

To obtain data regarding admissions of U19 rugby players to spinal injury units in Great Britain and Ireland and to compare this with a recent peak in presentation in Scotland. To assess the current state of data collection and subsequent analysis of serious neck injuries. To analyse the mechanism of injury in this group of at-risk players. Retrospective case series. Spinal injury units in Great Britain and Ireland. Annual frequency of serious neck injuries. Analysis of injury types, neurological deficit and mechanism of injury. 36 Injuries were recorded. 10 Of these occurred in Scotland since 1996 of which six have occurred in the past 4 years. This compared with 14 in Ireland over the same period. 12 Cases were traced in England and Wales since 2000; records were not available before this date. No prospective collation of data is performed by the home unions and inconsistency of data collection exists. The mean age was 16.2 years. 16 Of the 36 admissions had complete neurological loss, 9 had incomplete neurological injury and 11 had cervical column injury without spinal cord damage. The mechanism of injury was tackle in 17 (47%), scrum in 13 (36%), two each due to the maul and collision, and one each due to a kick and a ruck. Some degree of spinal cord injury occurred in 92% of scrum injuries (61% complete) and 53% of tackle injuries (29% complete). U19 rugby players continue to sustain serious neck injuries necessitating admission to spinal injury units with a low but persistent frequency. The recent rate of admission in Scotland is disproportionately high when the respective estimated playing populations are considered. While more injuries were sustained in the tackle, spinal cord injury was significantly more common in neck injury sustained in the scrum (p<0.001). No register of catastrophic neck injuries exists despite repeated calls over the past three decades, and a study such as this has not been reported before. Data collection of this serious category of injury is incomplete and very variable across the home unions, as a consequence a large proportion of the serious neck injuries that have occurred in U19 players over the past 14 years have not been analysed. Rigorous data collection and analysis have to be established so that problem areas of the game such as scrum engagement and the tackle can be made safer.

To develop a regional ICU mortality prediction model during the first 24 h of ICU admission utilizing MODS and NEMS with six other independent variables from the Critical Care Information System (CCIS) Ontario, Canada.

PubMed

Kao, Raymond; Priestap, Fran; Donner, Allan

2016-01-01

Intensive care unit (ICU) scoring systems or prediction models evolved to meet the desire of clinical and administrative leaders to assess the quality of care provided by their ICUs. The Critical Care Information System (CCIS) is province-wide data information for all Ontario, Canada level 3 and level 2 ICUs collected for this purpose. With the dataset, we developed a multivariable logistic regression ICU mortality prediction model during the first 24 h of ICU admission utilizing the explanatory variables including the two validated scores, Multiple Organs Dysfunctional Score (MODS) and Nine Equivalents Nursing Manpower Use Score (NEMS) followed by the variables age, sex, readmission to the ICU during the same hospital stay, admission diagnosis, source of admission, and the modified Charlson Co-morbidity Index (CCI) collected through the hospital health records. This study is a single-center retrospective cohort review of 8822 records from the Critical Care Trauma Centre (CCTC) and Medical-Surgical Intensive Care Unit (MSICU) of London Health Sciences Centre (LHSC), Ontario, Canada between 1 Jan 2009 to 30 Nov 2012. Multivariable logistic regression on training dataset (n = 4321) was used to develop the model and validate by bootstrapping method on the testing dataset (n = 4501). Discrimination, calibration, and overall model performance were also assessed. The predictors significantly associated with ICU mortality included: age (p < 0.001), source of admission (p < 0.0001), ICU admitting diagnosis (p < 0.0001), MODS (p < 0.0001), and NEMS (p < 0.0001). The variables sex and modified CCI were not significantly associated with ICU mortality. The training dataset for the developed model has good discriminating ability between patients with high risk and those with low risk of mortality (c-statistic 0.787). The Hosmer and Lemeshow goodness-of-fit test has a strong correlation between the observed and expected ICU mortality (χ (2) = 5.48; p > 0.31). The overall optimism of the estimation between the training and testing data set ΔAUC = 0.003, indicating a stable prediction model. This study demonstrates that CCIS data available after the first 24 h of ICU admission at LHSC can be used to create a robust mortality prediction model with acceptable fit statistic and internal validity for valid benchmarking and monitoring ICU performance.

Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France: A Randomized Clinical Trial.

PubMed

Guidet, Bertrand; Leblanc, Guillaume; Simon, Tabassome; Woimant, Maguy; Quenot, Jean-Pierre; Ganansia, Olivier; Maignan, Maxime; Yordanov, Youri; Delerme, Samuel; Doumenc, Benoit; Fartoukh, Muriel; Charestan, Pierre; Trognon, Pauline; Galichon, Bertrand; Javaud, Nicolas; Patzak, Anabela; Garrouste-Orgeas, Maïté; Thomas, Caroline; Azerad, Sylvie; Pateron, Dominique; Boumendil, Ariane

2017-10-17

The high mortality rate in critically ill elderly patients has led to questioning of the beneficial effect of intensive care unit (ICU) admission and to a variable ICU use among this population. To determine whether a recommendation for systematic ICU admission in critically ill elderly patients reduces 6-month mortality compared with usual practice. Multicenter, cluster-randomized clinical trial of 3037 critically ill patients aged 75 years or older, free of cancer, with preserved functional status (Index of Independence in Activities of Daily Living ≥4) and nutritional status (absence of cachexia) who arrived at the emergency department of one of 24 hospitals in France between January 2012 and April 2015 and were followed up until November 2015. Centers were randomly assigned either to use a program to promote systematic ICU admission of patients (n=1519 participants) or to follow standard practice (n=1518 participants). The primary outcome was death at 6 months. Secondary outcomes included ICU admission rate, in-hospital death, functional status, and quality of life (12-Item Short Form Health Survey, ranging from 0 to 100, with higher score representing better self-reported health) at 6 months. One patient withdrew consent, leaving 3036 patients included in the trial (median age, 85 [interquartile range, 81-89] years; 1361 [45%] men). Patients in the systematic strategy group had an increased risk of death at 6 months (45% vs 39%; relative risk [RR], 1.16; 95% CI, 1.07-1.26) despite an increased ICU admission rate (61% vs 34%; RR, 1.80; 95% CI, 1.66-1.95). After adjustments for baseline characteristics, patients in the systematic strategy group were more likely to be admitted to an ICU (RR, 1.68; 95% CI, 1.54-1.82) and had a higher risk of in-hospital death (RR, 1.18; 95% CI, 1.03-1.33) but had no significant increase in risk of death at 6 months (RR, 1.05; 95% CI, 0.96-1.14). Functional status and physical quality of life at 6 months were not significantly different between groups. Among critically ill elderly patients in France, a program to promote systematic ICU admission increased ICU use but did not reduce 6-month mortality. Additional research is needed to understand the decision to admit elderly patients to the ICU. clinicaltrials.gov Identifier: NCT01508819.

A brief report on Hispanic youth marijuana use: Trends in substance abuse treatment admissions in the United States.

PubMed

Marzell, Miesha; Sahker, Ethan; Pro, George; Arndt, Stephan

2017-01-01

Increases in Hispanic youth admissions to substance abuse treatment programs for marijuana use are a growing public health concern. In this study, we investigated trends in Hispanic youth from 1995 to 2012 utilizing the Treatment Episode Data Set-Admissions of the Substance Abuse Mental Health Services Administration. Hispanic youth marijuana admissions are associated with youth 15-17 years old, in high school, and living in a dependent situation. Notably, female admissions increased at greater rates than males. Results also point to decreasing tolerance of minor marijuana use by schools and community agencies. Findings highlight the need for targeted, culturally specific, and cost-effective treatment and prevention efforts.

Pre-hospital transfusion of plasma in hemorrhaging trauma patients independently improves hemostatic competence and acidosis.

PubMed

Henriksen, Hanne H; Rahbar, Elaheh; Baer, Lisa A; Holcomb, John B; Cotton, Bryan A; Steinmetz, Jacob; Ostrowski, Sisse R; Stensballe, Jakob; Johansson, Pär I; Wade, Charles E

2016-12-09

The early use of blood products has been associated with improved patient outcomes following severe hemorrhage or traumatic injury. We aimed to investigate the influence of pre-hospital blood products (i.e. plasma and/or RBCs) on admission hemostatic properties and patient outcomes. We hypothesized that pre-hospital plasma would improve hemostatic function as evaluated by rapid thrombelastography (rTEG). We conducted a prospective observational study recruiting 257 trauma patients admitted to a Level I trauma center having received either blood products pre-hospital or in-hospital within 6 hours of admission. Clinical data on patient demographics, blood biochemistry, injury severity score and mortality were collected. Admission rTEG was conducted to characterize the coagulation profile and hemostatic function. 75 patients received pre-hospital plasma and/or RBCs (PH group; nearly half received both RBCs and plasma) whereas 182 patients only received in-hospital blood products (RBCs, Plasma and Platelets) within 6 hours of admission (IH group). PH patients had lower Glasgow coma scale (GCS) scores, more penetrating injuries, lower systolic blood pressures, lower hemoglobin levels, lower platelet counts and greater acidosis upon ED admission than the IH group (all p < 0.05). Despite differences in type of injury and admission vitals indicating that the PH group had more signs of bleeding than the IH group, there were no significant differences in in-hospital mortality (PH 26.7% vs. IH 20.9% p = 0.31). When comparing rTEG variables between PH patients transfused with 0, 1 or 2 units of plasma, more pre-hospital plasma transfusion was tendency towards improved rTEG variables. When adjusting for pre-hospital RBC, pre-hospital plasma was associated with significantly higher rTEG MA (p = 0.012) at hospital admission. After adjusting for pre-hospital RBCs, pre-hospital plasma transfusion was independently associated with increased rTEG MA, as well as arrival indices of shock and hemodynamic instability. Besides more severe injury and worse clinical presentation, the group that received pre-hospital transfusion had early and late mortality similar to patients not transfused pre-hospital. These data suggest that early administration of plasma can provide significant hemostatic and potential survival benefit to severely hemorrhaging trauma patients.

Global case management: Scotland. Real-time monitoring of patient flow as an instrument to optimize quality of care in acute receiving units.

PubMed

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.

Understanding psychiatric nursing care with nonsuicidal self-harming patients in acute psychiatric admission units: the views of psychiatric nurses.

PubMed

O'Donovan, Aine; Gijbels, Harry

2006-08-01

Self-harm in the absence of suicidal intent is an underexplored area in psychiatric nursing research. This article reports on findings of a study undertaken in two acute psychiatric admission units in Ireland. The purpose of this study was to gain an understanding of the practices of psychiatric nurses in relation to people who self-harm but who are not considered suicidal. Semistructured interviews were held with eight psychiatric nurses. Content analysis revealed several themes, some of which will be presented and discussed in this article, namely, the participants' understanding of self-harm, their approach to care, and factors in the acute psychiatric admission setting, which impacted on their care. Recommendations for further research are offered.

Indicators of violence and asthma: An ecological study.

PubMed

Tabalipa, Fábio de Oliveira; Daitx, Rodrigo Boff; Traebert, Jefferson Luiz; Meyer, Adriano Schaefer; da Silva, Jane

2015-10-01

Global studies on asthma point to socioeconomic status as one of the main variables in terms of prevalence and disease severity in various parts of the world. Social factors related to community violence have been linked to higher incidence of asthma in the current studies. This study investigates the relationship between indicators of both community violence and development and hospital admissions due to asthma. This was an analytical ecological study of multiple groups, using public databases with information up until 2006. All Brazilian municipalities with more than 100,000 inhabitants were considered as units of analysis. The main index used as socioeconomic indicator was the FIRJAN Index of Municipal Development (FIMD). The Index of Youth Vulnerability to Violence (IYVV) was used as indicators of community violence. The rate of admissions due to asthma was used as the outcome. Pearson's correlation was used for multivariate analyses. The coefficient of determination (R(2)) was calculated and the simple linear regression model adjusted for significant correlations. There was an inverse correlation between asthma admissions and FIMD (r = -0.354, p < 0.001), with statistical significance for all dimensions of the index. Admissions due to asthma were associated with the IYVV (r = 0.240, p < 0.001) and its component related to school attendance and employment (r = 0.315, p < 0.001), homicides (r = 0.112, p = 0.034), and poverty (r = 0.303, p < 0.001). There was a direct correlation between indicators of violence and rates of admission due asthma, and an inverse correlation with indicators of development. These results suggest that social detriment can act as a risk factor for hospital admissions due to asthma. Copyright © 2015 Japanese Society of Allergology. Production and hosting by Elsevier B.V. All rights reserved.

Validity of the stroke rehabilitation assessment of movement scale in acute rehabilitation: a comparison with the functional independence measure and stroke impact scale-16.

PubMed

Ward, Irene; Pivko, Susan; Brooks, Gary; Parkin, Kate

2011-11-01

To demonstrate sensitivity to change of the Stroke Rehabilitation Assessment of Movement (STREAM) as well as the concurrent and predictive validity of the STREAM in an acute rehabilitation setting. Prospective cohort study. Acute, in-patient rehabilitation department within a tertiary-care teaching hospital in the United States. Thirty adults with a newly diagnosed, first ischemic stroke. Clinical assessments were conducted on admission and then again on discharge from the rehabilitation hospital with the STREAM (total STREAM and upper extremity, lower extremity, and mobility subscales), Functional Independence Measure (FIM), and Stroke Impact Scale-16 (SIS-16). Sensitivity to change was determined with the Wilcoxon signed rank test and by the calculation of standardized response means. Spearman correlations were used to assess concurrent validity of the total STREAM and STREAM subscales with the FIM and SIS-16 on admission and discharge. We determined predictive validity for all instruments by correlating admission scores with actual and predicted length of stay and by testing associations between admission scores and discharge destination (home vs subacute facility). Not applicable. For all instruments, there was statistically significant improvement from admission to discharge. The standardized response means for the total STREAM and STREAM subscales were large. Spearman correlations between the total STREAM and STREAM subscales and the FIM and SIS-16 were moderate to excellent, both on admission and discharge. Among change scores, only the SIS-16 correlated with the total STREAM. All 3 instruments were significantly associated with discharge destination; however, the associations were strongest for the total STREAM and STREAM subscales. All instruments showed moderate-to-excellent correlations with predicted and actual length of stay. The STREAM is sensitive to change and demonstrates good concurrent and predictive validity as compared with the FIM and SIS-16 in the acute inpatient rehabilitation population. Copyright © 2011 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

45 CFR 618.105 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... ON THE BASIS OF SEX IN EDUCATION PROGRAMS OR ACTIVITIES RECEIVING FEDERAL FINANCIAL ASSISTANCE... unit means a school, department, or college of an educational institution (other than a local educational agency) admission to which is independent of admission to any other component of such institution...

Extended plasma cannabinoid excretion in chronic frequent cannabis smokers during sustained abstinence and correlation with psychomotor performance.

PubMed

Karschner, Erin L; Swortwood, Madeleine J; Hirvonen, Jussi; Goodwin, Robert S; Bosker, Wendy M; Ramaekers, Johannes G; Huestis, Marilyn A

2016-07-01

Cannabis smoking increases motor vehicle accident risk. Empirically defined cannabinoid detection windows are important to drugged driving legislation. Our aims were to establish plasma cannabinoid detection windows in frequent cannabis smokers and to determine if residual cannabinoid concentrations were correlated with psychomotor performance. Twenty-eight male chronic frequent cannabis smokers resided on a secure research unit for up to 33 days with daily blood collection. Plasma specimens were analyzed for Δ(9) -tetrahydrocannabinol (THC), 11-hydroxy-THC (11-OH-THC), and 11-nor-9-carboxy-THC (THCCOOH) by gas chromatography-mass spectrometry. Critical tracking and divided attention tasks were administered at baseline (after overnight stay to ensure lack of acute intoxication) and after 1, 2, and 3 weeks of cannabis abstinence. Twenty-seven of the twenty-eight participants were THC-positive at admission (median 4.2 µg/L). THC concentrations significantly decreased 24 h after admission, but were still ≥2 µg/L in 16 of the 28 participants 48 h after admission. THC was detected in 3 of 5 specimens on day 30. The last positive 11-OH-THC specimen was 15 days after admission. THCCOOH was measureable in 4 of 5 participants after 30 days of abstinence. Years of prior cannabis use significantly correlated with THC concentrations on admission, and days 7 and 14. Tracking error, evaluated by the Divided Attention Task, was the only evaluated psychomotor assessment significantly correlated with cannabinoid concentrations at baseline and day 8 (11-OH-THC only). Median THC was 0.3 µg/L in 5 chronic frequent cannabis smokers' plasma samples after 30 days of sustained abstinence. Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

Isolated transient loss of consciousness is an indicator of significant injury.

PubMed

Owings, J T; Wisner, D H; Battistella, F D; Perlstein, J; Walby, W F; Tharratt, R S

1998-09-01

To determine if isolated transient loss of consciousness is an indicator of significant injury. University-based level I trauma center. Phase 1 retrospective case series of all patients with trauma admitted directly from the emergency department to the operating room or an intensive care unit who had transient loss of consciousness as their only trauma triage criterion. Phase 2 prospective case series of all trauma patients transported by emergency medical system personnel with transient loss of consciousness as their only trauma triage criterion. Emergency operation and intensive care unit admission. Phase 1: From January 1, 1992, to March 31, 1995, we admitted 10255 patients with trauma. Three hundred seven (3%) met the enrollment criteria and were admitted to the operating room (n = 168) or intensive care unit (n = 139). Of these, 58 (18.9%) were taken to the operating room emergently to manage life-threatening injuries: 11 (4%) had craniotomies and 47 (15%) had non-neurosurgical operations. Phase 2: From July 1 to December 31, 1996, 2770 trauma patients were transported to our facility; 135 (4.9%) met the enrollment criteria. Forty-one (30.4%) of these required admission, and 6 (4.4%) were taken emergently to the operating room from the emergency department (1 [1%] for a craniotomy, 3 [2.2%] for intra-abdominal bleeding, and 2 [1.5%] for other procedures). Two (1.5%) of the 135 patients died. Patients with isolated transient loss of consciousness are at significant risk of critical surgical and neurosurgical injuries. These patients should be triaged to trauma centers or hospitals with adequate imaging, surgical, and neurosurgical resources.

Reducing hypothermia in preterm infants with polyethylene wrap.

PubMed

Rohana, Jaafar; Khairina, Wan; Boo, Nem Yun; Shareena, Ishak

2011-08-01

Occlusive plastic applied immediately after birth to reduce evaporative heat loss has been proven effective in preterm infants <28 weeks' gestation. However its effectiveness on preterm infants >28 weeks' gestation has not been shown. This study aimed to determine the effect of occlusive wrap at birth on the temperature at neonatal intensive care unit (NICU) admission among infants of greater than or equal to 24 weeks' and less than 34 weeks' gestation. Study infants were randomly assigned to "wrap" or "control" groups. Newborns in the wrap group were wrapped with polyethylene plastic sheets within the first min after birth. Infants randomized to the control group were dried immediately after birth with warmed towels under a warmer, according to the guidelines of Neonatal Resuscitation. Infants' axillary temperatures were measured on admission to the NICU, and after having been stabilized in incubators in the NICU. A total of 110 infants were recruited into the study. The mean admission temperature was significantly higher in the wrap group (35.8 vs 34.8°C, P < 0.01). Admission hypothermia (axillary temperature <36.5°C) was present in 38 (78%) and 58 (98%) infants in the wrap and control groups, respectively. Among infants of <28 weeks' gestation, the post-stabilization temperature was significantly higher in the wrap group. Wrapping premature infants with gestational age <34 weeks in polyethylene plastics immediately after birth is associated with lower incidence of hypothermia. © 2011 The Authors. Pediatrics International © 2011 Japan Pediatric Society.

Redesigned geriatric emergency care may have helped reduce admissions of older adults to intensive care units.

PubMed

Grudzen, Corita; Richardson, Lynne D; Baumlin, Kevin M; Winkel, Gary; Davila, Carine; Ng, Kristen; Hwang, Ula

2015-05-01

Charged with transforming geriatric emergency care by applying palliative care principles, a process improvement team at New York City's Mount Sinai Medical Center developed the GEDI WISE (Geriatric Emergency Department Innovations in Care through Workforce, Informatics, and Structural Enhancements) model. The model introduced workforce enhancements for emergency department (ED) and adjunct staff, including role redefinition, retraining, and education in palliative care principles. Existing ED triage nurses screened patients ages sixty-five and older to identify those at high risk of ED revisit and hospital readmission. Once fully trained, these nurses screened all but 6 percent of ED visitors meeting the screening criteria. Newly hired ED nurse practitioners identified high-risk patients suitable for and desiring palliative and hospice care, then expedited referrals. Between January 2011 and May 2013 the percentage of geriatric ED admissions to the intensive care unit fell significantly, from 2.3 percent to 0.9 percent, generating an estimated savings of more than $3 million to Medicare. The decline in these admissions cannot be confidently attributed to the GEDI WISE program because other geriatric care innovations were implemented during the study period. GEDI WISE programs are now running at Mount Sinai and two partner sites, and their potential to affect the quality and value of geriatric emergency care continues to be examined. Project HOPE—The People-to-People Health Foundation, Inc.

Nosocomial infections in a neonatal intensive care unit in South Brazil

PubMed Central

Dal-Bó, Karla; da Silva, Rosemeri Maurici; Sakae, Thiago Mamôru

2012-01-01

Objective The aim of this study was to describe the incidence and epidemiology of nosocomial infection in newborns who were admitted to a neonatal intensive care unit in a hospital in south Santa Catarina, Brazil. Methods A prospective cohort study was conducted for 1 year among 239 neonates who remained as in-patients 48 hours after admission. The criteria that were used to diagnose infection were in accordance with the Centers for Disease Control and Prevention and the National Health Surveillance Agency. Results The incidence of nosocomial infection was 45.8%. The primary reasons for admission were primary bloodstream infection (80.7%) and pneumonia (6.7%). Coagulase-negative Staphylococcus was the most commonly identified agent in the blood cultures and in the hospital unit. Prematurity was the most prevalent reason for admission. The general mortality rate was 12.1%, and mortality from nosocomial infection was 33.8%. Conclusions The incidence of nosocomial infection in the hospital unit was higher than rates that have been reported in other national studies. The major types of nosocomial infection were primary bloodstream infection and pneumonia. PMID:23917937

8 CFR 207.8 - Physical presence in the United States.

Code of Federal Regulations, 2010 CFR

2010-01-01

... ADMISSION OF REFUGEES § 207.8 Physical presence in the United States. For the purpose of adjustment of... the United States is computed from the date the applicant entered the United States as a refugee. [46...

Psychiatric units in Brazilian general hospitals: a growing philanthropic field.

PubMed

Botega, Neury José

2002-06-01

Some countries, mainly in North America and Europe, have adopted psychiatric wards in the general hospital as an alternative to the classic psychiatric hospital. In Brazil there are 6,169 general hospitals, 1.3% of which with a psychiatric unit. This service strategy is scarcely developed in the country and comprises only 4% of all psychiatric admissions. There was no information on the facilities and functioning of the psychiatric units in general hospitals. To determine the main characteristics of psychiatric units in Brazilian general hospitals and to assess the current trends in the services provided. A mailing survey assessed all 94 Brazilian general hospitals which made psychiatric admissions. A two-page questionnaire was designed to determine the main characteristics of each institution and of the psychiatric unit. Seventy-nine (84%) questionnaires were returned. In contrast to the 1970s and 1980s, in the last decade the installation of psychiatric units has spread to smaller philanthropic institutions that are not linked to medical schools. A fifth of hospitals admit psychiatric patients to medical wards because there is no specialist psychiatric ward. They try to meet all the local emergency demands, usually alcohol-dependent patients who need short term admission. This could signal the beginning of a program through which mental health professionals may become an integral part of general health services. The inauguration of psychiatric wards in philanthropic hospitals, as well as the admission of psychiatric patients in their medical wards, is a phenomenon peculiar to this decade. The installation of psychiatric services in these and other general hospitals would overcome two of major difficulties encountered: prejudice and a lack of financial resources.

Utility of CT classifications to predict unfavorable outcomes in children with acute pancreatitis.

PubMed

Izquierdo, Yojhan E; Fonseca, Eileen V; Moreno, Luz-Ángela; Montoya, Rubén D; Guerrero Lozano, Rafael

2018-02-21

Computed tomography (CT) is useful for the diagnosis of local complications in children with acute pancreatitis but its role as a prognostic tool remains controversial. To establish the correlation between the CT Severity Index and the Revised Atlanta Classification regarding unfavorable outcomes such as severe acute pancreatitis and need for Pediatric Special Care Unit attention in children with acute pancreatitis. We conducted a retrospective and concordance cohort study in which we obtained abdominal CT scans from 30 patients ages 0 to 18 years with acute pancreatitis. Two pediatric radiologists interpreted the results using the CT Severity Index and the Revised Atlanta Classification. The kappa coefficient was determined for each scale. The association among severe acute pancreatitis, need for admission to the Pediatric Special Care Unit and CT systems were established using chi-square or Mann-Whitney U tests. The best CT Severity Index value to predict the need for admission to the Pediatric Special Care Unit was estimated through a receiver operating characteristic (ROC) curve. Mean CT Severity Index was 5.1±2.8 (mean ± standard deviation on a scale of 0 to 10) for the severe acute pancreatitis group vs. 3.8±2.7 for the mild acute pancreatitis group (P=0.230). The CT Severity Index for the children who were not hospitalized at the Pediatric Special Care Unit was 2.2±2.2 vs. 5.6±2.4 for the group hospitalized at the Pediatric Special Care Unit (P=0.001). Only parenchymal necrosis >30% was associated with severe acute pancreatitis (P=0.021). A CT Severity Index ≥3 has a sensitivity of 89% and specificity of 72% to predict need for admission to the Pediatric Special Care Unit. None of the Revised Atlanta Classification categories was associated with severe acute pancreatitis or admission to the Pediatric Special Care Unit. A CT Severity Index ≥3 in children with acute pancreatitis who require CT assessment based on clinical criteria is associated with the need for admission to the Pediatric Special Care Unit. We found that pancreatic necrosis greater than 30% is the only tomographic parameter related to severe acute pancreatitis. New studies with a greater sample size are necessary to confirm this result.

Costs Associated with Anesthesia-Related Adverse Events During Labor and Delivery in New York State, 2010.

PubMed

Hunt, Tristan D; Guglielminotti, Jean; Li, Guohua

2016-06-01

The safety of anesthetic care provided during childbirth has improved during the past 2 decades in the United States, with a marked decrease in the rate of anesthesia-related adverse events (ARAEs). To date, there is little research on the costs of ARAEs in obstetrics. This study aims to assess the excess cost and cost per admission associated with ARAEs during labor and delivery. Data came from the New York State Inpatient Database 2010. Discharge records indicating labor and delivery and ARAEs were identified with International Classification of Diseases, Ninth Revision, Clinical Modification codes. ARAEs were defined as minor if not associated with maternal death, cardiac arrest, or severe morbidity. Costs were calculated as the product of hospital charges and the group average all-payer inpatient charge-to-cost conversion ratio. Excess cost was calculated as the difference between the mean cost of discharges with and without ARAEs. The cost per admission was calculated as the product of the excess cost and ARAE incidence. Excess costs and cost per admission were also calculated for 2 pregnancy-related complications: postpartum hemorrhage and preeclampsia/eclampsia. There were 228,104 delivery-related discharges in the study; of these, 1053 recorded at least 1 ARAE (4.6 per 1000), with 1034 (98.2%) of the ARAEs being minor. The adjusted excess cost associated with ARAEs was $1189 (95% confidence interval [CI], 1033-1350) and the cost per admission $5.49 (95% CI, 4.77-6.23). The incidence of postpartum hemorrhage and preeclamspia/eclampsia was 25.1 and 43.8 per 1000, respectively. The adjusted excess cost was $679 (95% CI, 608-748) and $1328 (95% CI, 1272-1378), respectively; the cost per admission was $17.07 (95% CI, 15.27-18.81) and $58.16 (95% CI, 55.72-60.34), respectively. ARAEs during labor and delivery are associated with significant excess cost. However, the excess cost per admission for ARAEs is significantly less compared with the excess cost per admission for preeclampsia/eclampsia and postpartum hemorrhage.

Obesity is associated with higher risk of intensive care unit admission and death in influenza A (H1N1) patients: a systematic review and meta-analysis.

PubMed

Fezeu, L; Julia, C; Henegar, A; Bitu, J; Hu, F B; Grobbee, D E; Kengne, A-P; Hercberg, S; Czernichow, S

2011-08-01

The aim of this study was to assess the association between obesity and the risk of intensive care unit (ICU) admission and death among patients hospitalized for influenza A (H1N1) viral infection. A systematic review of the Medline and Cochrane databases using 'obesity', 'hospitalization', 'influenza A viral infection', various synonyms, and reference lists of retrieved articles from January 2009 to January 2010. Studies comparing the prevalence of obesity among patients with confirmed infection for influenza A virus and who were either hospitalized or admitted to ICU/died were included. A total of 3059 subjects from six cross-sectional studies, who were hospitalized for influenza A (H1N1) viral infection, were included in this meta-analysis. Severely obese H1N1 patients (body mass index ≥ 40 kg m(-2), n = 804) were as twice as likely to be admitted to ICU or die (odds ration: 2.01, 95% confidence interval: 1.29-3.14, P < 0.002) compared with H1N1 patients who were not severely obese. Having a body mass index ≥ 30 kg m(-2) was similarly associated with a more than twofold increased risk of ICU admission or death although this did not reach statistical significance (2.14, 0.92-4.99, P < 0.07). This meta-analysis supports the view that obesity is associated with higher risks of ICU admission or death in patients with influenza A (H1N1) infection. Therefore, morbid obese patients should be monitored more intensively when hospitalized. © 2011 The Authors. obesity reviews © 2011 International Association for the Study of Obesity.

Transmission Dynamics of Carbapenemase-Producing Klebsiella Pneumoniae and Anticipated Impact of Infection Control Strategies in a Surgical Unit

PubMed Central

Sypsa, Vana; Psichogiou, Mina; Bouzala, Georgia-Aikaterina; Hadjihannas, Linos; Hatzakis, Angelos; Daikos, Georgios L.

2012-01-01

Background Carbapenemase-producing Klebsiella pneumoniae (CPKP) has been established as important nosocomial pathogen in many geographic regions. Transmission from patient to patient via the hands of healthcare workers is the main route of spread in the acute-care setting. Methodology/Principal Findings Epidemiological and infection control data were recorded during a prospective observational study conducted in a surgical unit of a tertiary-care hospital in Greece. Surveillance culture for CPKP were obtained from all patients upon admission and weekly thereafter. The Ross-Macdonald model for vector-borne diseases was applied to obtain estimates for the basic reproduction number R0 (average number of secondary cases per primary case in the absence of infection control) and assess the impact of infection control measures on CPKP containment in endemic and hyperendemic settings. Eighteen of 850 patients were colonized with CPKP on admission and 51 acquired CPKP during hospilazation. R0 reached 2 and exceeded unity for long periods of time under the observed hand hygiene compliance (21%). The minimum hand hygiene compliance level necessary to control transmission was 50%. Reduction of 60% to 90% in colonized patients on admission, through active surveillance culture, contact precautions and isolation/cohorting, in combination with 60% compliance in hand hygiene would result in rapid decline in CPKP prevalence within 8–12 weeks. Antibiotics restrictions did not have a substantial benefit when an aggressive control strategy was implemented. Conclusions/Significance Surveillance culture on admission and isolation/cohorting of colonized patients coupled with moderate hand hygiene compliance and contact precautions may lead to rapid control of CPKP in endemic and hyperendemic healthcare settings. PMID:22859965

Paramyxovirus Infection: Mortality and Morbidity in a Pediatric Intensive Care Unit.

PubMed

Tong, Alice S W; Hon, Kam Lun; Tsang, Yin Ching K; Chan, Renee Wan Yi; Chan, Ching Ching; Leung, Ting Fan; Chan, Paul K S

2016-10-01

We investigated mortality and morbidity of patients admitted to a pediatric intensive care unit (PICU) with paramyxovirus infection. A retrospective study between October 2002 and March 2015 of children with a laboratory-confirmed paramyxovirus infection was included. In all, 98 (5%) PICU admissions were tested positive to have paramyxovirus infection (respiratory syncytial virus =  66, parainfluenza  =  27 and metapneumovirus  =  5). The majority of admissions were young patients (median age 1.05 years). Bacteremia and bacterial isolation in any site were present in 10% and 28%, respectively; 41% were mechanically ventilated, and 20% received inotropes. The three respiratory viruses caused similar mortality and morbidity in the PICU. Fatality (seven patients) was associated with malignancy, positive bacterial culture in blood, the use of mechanical ventilation, inotrope use, lower blood white cell count and higher C reactive protein (p  =  0.02-0.0005). Backward binary logistic regression for these variables showed bacteremia (odds ratio [OR]: 31.7; 95% CI: 2.3-427.8; p  =  0.009), malignancy (OR: 45.5; 95% CI: 1.4-1467.7; p  =  0.031) and use of inotropes (OR: 15.0; 95% CI: 1.1-196.1; p  =  0.039) were independently associated with non-survival. March and July appeared to be the two peak months for PICU hospitalizations with paramyxovirus infection. Infections with paramyxoviruses account for 5% of PICU admissions and significant morbidity. Patient with premorbid history of malignancy and co-morbidity of bacteremia are associated with non-survival. March and July appeared to be the two peak months for PICU admissions with paramyxoviruses. © The Author [2016]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

An analysis of the predictors of mortality and morbidity in patients admitted after suicidal hanging to an Indian multidisciplinary Intensive Care Unit

PubMed Central

Renuka, MK; Kalaiselvan, MS; Arunkumar, AS

2017-01-01

Background and Aims: Hanging is a frequently used method to attempt suicide in India. There is a lack of data in the Indian population regarding clinical features and outcomes of suicidal hanging. The purpose of this study was to evaluate the factors affecting mortality and morbidity in patients admitted with suicidal hanging to the Intensive Care Unit (ICU). Methods: A 6-year retrospective study of adult patients admitted to the ICU with suicidal hanging was analysed for demographics, mode of hanging, lead time to emergency room (ER) admission, clinical presentation, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, admission Glasgow coma scale (GCS) and neurological outcomes. The primary outcome was in-hospital mortality rate. Secondary outcomes were hospital length of stay (LOS), ICU-LOS, time for neurological recovery, organ support and duration of mechanical ventilation. Statistical analysis was performed using the Student's t-test for continuous variables and Chi-square test for categorical variables. Results: We analysed data of 106 patients. The median age was 27 years [Interquartile Range (IQR) (22–34)]. The median lead time to ER admission was 1 h [IQR (0.5–1.4)] with median ICU stay of 3 days [IQR (2–4)]. Vasopressors were administered to 27.4% patients. GCS was ≤7 in 65% patients, and 84.9% patients received mechanical ventilation. Mortality rate was 10.3%. Survivors recovered with normal organ function. Conclusion: Suicidal hanging is associated with significant mortality. Admission GCS, APACHE II and 48 h SOFA score were predictors of poor outcome. PMID:28794524

Collaborative Audit of Risk Evaluation in Medical Emergency Treatment (CARE-MET I) - an international pilot.

PubMed

Subbe, C P; Gauntlett, W; Kellett, J G

2010-06-01

The absence of an accepted model for risk-adjustment of acute medical admissions leads to suboptimal clinical triage and serves as a disincentive to compare outcomes in different hospitals. The Simple Clinical Score (SCS) is a model based on 16 clinical parameters affecting hospital mortality. We undertook a feasibility pilot in 21 hospitals in Europe and New Zealand each collecting data for 12 or more consecutive medical emergency admissions. Data from 281 patients was analysed. Severity of illness as estimated by SCS was related to risk of admission to the Intensive Care Unit (p<0.001) but not to the Coronary Care Unit. Mortality increased from 0% in the Very Low Risk group to 22% in the Very High Risk Group (p<0.0001). Very low scores were associated with earlier discharge as opposed to very high scores (mean length of stay of 2.4 days vs 5.6 days, p<0.001). There were differences in the pattern of discharges in different hospitals with comparable SCS data. Clinicians reported no significant problems with the collection of data for the score in a number of different health care settings. The SCS appears to be a feasible tool to assist clinical triage of medical emergency admissions. The ability to view the profile of the SCS for different clinical centres opens up the possibility of accurate comparison of outcomes across clinical centres without distortion by different regional standards of health care. This pilot study demonstrates that the adoption of the SCS is practical across an international range of hospitals. Copyright 2010 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Effect of Fireworks Laws on Pediatric Fireworks-Related Burn Injuries.

PubMed

Myers, John; Lehna, Carlee

Changes in U.S. fireworks laws have allowed younger children to purchase fireworks. In addition, the changes have allowed individuals to purchase more powerful fireworks. The purpose of this study is to examine the epidemiology of pediatric firework-related burn injuries among a nationally representative sample of the United States for the years 2006 to 2012. We examined inpatient admissions for pediatric firework-related burn patients from 2006 to 2012 using the nationwide inpatient sample and examined emergency department admissions using the nationwide emergency department sample. Both data sources are part of the Healthcare Cost and Utilization Project. Trajectories over time were evaluated. A total of 3193 injuries represented an estimated 90,257 firework-related injuries treated in the United States from 2006 to 2012. A majority of injuries were managed in the emergency department (n = 2008, 62.9%). The incidence generally increased over time; increasing from 4.28 per 100,000 population in 2006 to 5.12 per 100,000 population in 2012, P = .019. However, the proportion of injuries requiring inpatient admission (28.9% in 2006 to 50.0% in 2012, P < .001) and mean length of stay in the hospital (3.12 days in 2006 to 7.35 days in 2012, P < .001) significantly increased over time, while the mean age decreased over time (12.1-year-old in 2006 to 11.4-year-old in 2012, P = .006). The relaxing of U.S. fireworks laws may have had a modest effect on incidence of related injuries and the age of purchaser. However, it has had a dramatic effect on the severity of the related injuries, resulting in more inpatient admissions and longer length of stay in the hospital. Preventative methods should be taken to reduce the rate and severity of firework-related injuries among U.S. youths.

[Medication reconciliation: an innovative experience in an internal medicine unit to decrease errors due to inacurrate medication histories].

PubMed

Pérennes, Maud; Carde, Axel; Nicolas, Xavier; Dolz, Manuel; Bihannic, René; Grimont, Pauline; Chapot, Thierry; Granier, Hervé

2012-03-01

An inaccurate medication history may prevent the discovery of a pre-admission iatrogenic event or lead to interrupted drug therapy during hospitalization. Medication reconciliation is a process that ensures the transfer of medication information at admission to the hospital. The aims of this prospective study were to evaluate the interest in clinical practice of this concept and the resources needed for its implementation. We chose to include patients aged 65 years or over admitted in the internal medicine unit between June and October 2010. We obtained an accurate list of each patient's home medications. This list was then compared with medication orders. All medication variances were classified as intended or unintended. An internist and a pharmacist classified the clinical importance of each unintended variance. Sixty-one patients (mean age: 78 ± 7.4 years) were included in our study. We identified 38 unintended discrepancies. The average number of unintended discrepancies was 0.62 per patient. Twenty-five patients (41%) had one or more unintended discrepancies at admission. The contact with the community pharmacist permitted us to identify 21 (55%) unintended discrepancies. The most common errors were the omission of a regularly used medication (76%) and an incorrect dosage (16%). Our intervention resulted in order changes by the physician for 30 (79%) unintended discrepancies. Fifty percent of the unintended variances were judged by the internist and 76% by the pharmacist to be clinically significant. The admission to the hospital is a critical transition point for the continuity of care in medication management. Medication reconciliation can identify and resolve errors due to inaccurate medication histories. Copyright © 2011 Elsevier Masson SAS. All rights reserved.

Association between bullying and pediatric psychiatric hospitalizations.

PubMed

Leader, Hadassa; Singh, Jasmine; Ghaffar, Ayesha; de Silva, Cheryl

2018-01-01

Bullying is a serious public health issue. We sought to demonstrate an association between bullying victimization and hospital admissions for acute psychiatric problems. We described the demographics and types of bullying in a sample of hospitalized patients in Staten Island, NY, and compared bullying victimization scores with psychiatric versus medical admissions. Patients in grades 3-12 were recruited from the Staten Island University Hospital Inpatient Pediatrics unit and emergency department. Patients completed the validated Olweus Bully/Victim Questionnaire (OBQ) was analyzed to formulate a report of bullying in our sample as well as a sub-score measurement of bullying victimization. Pediatric residents simultaneously documented whether the subject was a medical versus an in-patient psychiatry admission. Statistical analysis was performed to look for an association between the victimization sub-score and a psychiatric indication for admission. A total of 185 surveys were analyzed. Peak bullying occurred in 7th and 8th grades. Demographics and types of bullying in our sample were described. A strong association between bullying victimization and hospitalization for in-patient psychiatry was demonstrated. Association between bullying victimization and suicidal ideation, psychiatry, and social work consults was also shown. Concern for an association between hospitalization for psychogenic illness and bullying victimization was also raised. There is a significant association between bullying victimization and psychiatric hospital admissions. This raises the specter of the serious consequences of bullying as it is the first study to prospectively link hospital admissions to bullying. Studies using a valid measure of psychogenic illness to look for an association with bullying victimization are needed.

Using Lean Management to Reduce Emergency Department Length of Stay for Medicine Admissions.

PubMed

Allaudeen, Nazima; Vashi, Anita; Breckenridge, Julia S; Haji-Sheikhi, Farnoosh; Wagner, Sarah; Posley, Keith A; Asch, Steven M

The practice of boarding admitted patients in the emergency department (ED) carries negative operational, clinical, and patient satisfaction consequences. Lean tools have been used to improve ED workflow. Interventions focused on reducing ED length of stay (LOS) for admitted patients are less explored. To evaluate a Lean-based initiative to reduce ED LOS for medicine admissions. Prospective quality improvement initiative performed at a single university-affiliated Department of Veterans Affairs (VA) medical center from February 2013 to February 2016. We performed a Lean-based multidisciplinary initiative beginning with a rapid process improvement workshop to evaluate current processes, identify root causes of delays, and develop countermeasures. Frontline staff developed standard work for each phase of the ED stay. Units developed a daily management system to reinforce, evaluate, and refine standard work. The primary outcome was the change in ED LOS for medicine admissions pre- and postintervention. ED LOS at the intervention site was compared with other similar VA facilities as controls over the same time period using a difference-in-differences approach. ED LOS for medicine admissions reduced 26.4%, from 8.7 to 6.4 hours. Difference-in-differences analysis showed that ED LOS for combined medicine and surgical admissions decreased from 6.7 to 6.0 hours (-0.7 hours, P = .003) at the intervention site compared with no change (5.6 hours, P = .2) at the control sites. We utilized Lean management to significantly reduce ED LOS for medicine admissions. Specifically, the development and management of standard work were key to sustaining these results.

Association between bullying and pediatric psychiatric hospitalizations

PubMed Central

Leader, Hadassa; Singh, Jasmine; Ghaffar, Ayesha; de Silva, Cheryl

2018-01-01

Objectives: Bullying is a serious public health issue. We sought to demonstrate an association between bullying victimization and hospital admissions for acute psychiatric problems. We described the demographics and types of bullying in a sample of hospitalized patients in Staten Island, NY, and compared bullying victimization scores with psychiatric versus medical admissions. Methods: Patients in grades 3–12 were recruited from the Staten Island University Hospital Inpatient Pediatrics unit and emergency department. Patients completed the validated Olweus Bully/Victim Questionnaire (OBQ) was analyzed to formulate a report of bullying in our sample as well as a sub-score measurement of bullying victimization. Pediatric residents simultaneously documented whether the subject was a medical versus an in-patient psychiatry admission. Statistical analysis was performed to look for an association between the victimization sub-score and a psychiatric indication for admission. Results: A total of 185 surveys were analyzed. Peak bullying occurred in 7th and 8th grades. Demographics and types of bullying in our sample were described. A strong association between bullying victimization and hospitalization for in-patient psychiatry was demonstrated. Association between bullying victimization and suicidal ideation, psychiatry, and social work consults was also shown. Concern for an association between hospitalization for psychogenic illness and bullying victimization was also raised. Conclusions: There is a significant association between bullying victimization and psychiatric hospital admissions. This raises the specter of the serious consequences of bullying as it is the first study to prospectively link hospital admissions to bullying. Studies using a valid measure of psychogenic illness to look for an association with bullying victimization are needed. PMID:29326819

Prognostic Factors for Hospital Mortality and ICU Admission in Patients With ANCA-Related Pulmonary Vasculitis

PubMed Central

Holguin, Fernando; Ramadan, Bassel; Gal, Anthony A.; Roman, Jesse

2015-01-01

Background The objective of this study was to evaluate the factors predictive of 28-day mortality and admission to Intensive Care Unit (ICU) in patients with ANCA-related pulmonary vasculitis. Methods We reviewed the medical records and imaging studies of 65 patients diagnosed with ANCA-related vasculitis hospitalized with pulmonary complications between February 1985 and November 2002. All patients underwent open or video-assisted thoracoscopic lung biopsy, had a positive ANCA serology, and were negative for glomerular basement membrane antibodies. Results At presentation, 72% had dyspnea, 68% fever, 47% cough, 45% elevated blood pressure, 32.3% hemoptysis, 26.1% sinus involvement, 15% renal failure, and 4.6% scleritis. Pathological findings included alveolar hemorrhage (60%), granulomatous inflammation (46%), and capillaritis (38%). A significant number required mechanical ventilation (27.7%), hemodialysis (24.6%), continuous renal replacement therapy (3.1%), and plasmapheresis (3.1%). The 28-day mortality was 16.9% (11/65). Mechanical ventilation (OR 68, P < 0.005), admission to ICU (OR 18.5, P < 0.01), and blood transfusion (OR 22.4, P < 0.004) were strong predictors of increased mortality within 28 days after admission. Respiratory failure (OR 31, P < 0.0007), hemoptysis (OR 2.9, P < 0.06), smoking (OR 5.9, P < 0.02), and acute renal failure (OR 7.8, P < 0.01) were also predictors for admission to the ICU. Conclusion In patients with ANCA-related pulmonary vasculitis several clinical factors, but not pathologic findings or ANCA titers, are associated with ICU admission and/or 28-day mortality. PMID:18854674

The Effect of Utilization Review on Emergency Department Operations.

PubMed

Desai, Shoma; Gruber, Phillip F; Eiting, Erick; Seabury, Seth A; Mack, Wendy J; Voyageur, Christian; Vasquez, Veronica; Kim, Hyung T; Terp, Sophie

2017-11-01

Increasingly, hospitals are using utilization review software to reduce hospital admissions in an effort to contain costs. Such practices have the potential to increase the number of unsafe discharges, particularly in public safety-net hospitals. Utilization review software tools are not well studied with regard to their effect on emergency department (ED) operations. We study the effect of prospectively used admission decision support on ED operations. In 2012, Los Angeles County + University of Southern California Medical Center implemented prospective use of computerized admission criteria. After implementation, only ED patients meeting primary review (diagnosis-based criteria) or secondary review (medical necessity as determined by an on-site emergency physician) were assigned inpatient beds. Data were extracted from electronic medical records from September 2011 through December 2013. Outcomes included operational metrics, 30-day ED revisits, and 30-day admission rates. Excluding a 6-month implementation period, monthly summary metrics were compared pre- and postimplementation with nonparametric and negative binomial regression methods. All adult ED visits, excluding incarcerated and purely behavioral health visits, were analyzed. The primary outcomes were disposition rates. Secondary outcomes were 30-day ED revisits, 30-day admission rate among return visitors to the ED, and estimated cost. Analysis of 245,662 ED encounters was performed. The inpatient admission rate decreased from 14.2% to 12.8%. Increases in discharge rate (82.4% to 83.4%) and ED observation unit utilization (2.5% to 3.4%) were found. Thirty-day revisits increased (20.4% to 24.4%), although the 30-day admission rate decreased (3.2% to 2.8%). Estimated cost savings totaled $193.17 per ED visit. The prospective application of utilization review software in the ED led to a decrease in the admission rate. This was tempered by a concomitant increase in ED observation unit utilization and 30-day ED revisits. Cost savings suggest that resources should be redirected to the more highly affected ED and ED observation unit, although more work is needed to confirm the generalizability of these findings. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

The effects of cognitive intervention on cognitive impairments after intensive care unit admission.

PubMed

Zhao, Jingjing; Yao, Li; Wang, Changqing; Sun, Yun; Sun, Zhongwu

2017-04-01

Patients who survive critical illness commonly suffer cognitive impairments. We aimed to study the effects of cognitive intervention to treat the long-term impairments observed among different populations of intensive care unit (ICU) survivors. The results showed that the intervention significantly suppressed the deterioration of cognitive function in these patients. Medical and neurological ICU survivors were more susceptible than post-anaesthesia ICU patients to severe cognitive damage. In the former, the deterioration of impairments can be slowed by cognitive intervention. In comparison, intervention exerted significantly positive effects on the recovery of the cognitive functions of post-anaesthesia care unit patients. Furthermore, young populations were more likely than older populations to recover from acute cognitive impairments, and the impairment observed among the older population seemed to be multi-factorial and irreversible.

28 CFR 54.220 - Admissions.

Code of Federal Regulations, 2010 CFR

2010-07-01

... Judicial Administration DEPARTMENT OF JUSTICE (CONTINUED) NONDISCRIMINATION ON THE BASIS OF SEX IN...) Admissions to educational institutions prior to June 24, 1973, are not covered by these Title IX regulations... §§ 54.300 through 54.310, each administratively separate unit shall be deemed to be an educational...

BISAP, RANSON, lactate and others biomarkers in prediction of severe acute pancreatitis in a European cohort.

PubMed

Valverde-López, Francisco; Matas-Cobos, Ana M; Alegría-Motte, Carlos; Jiménez-Rosales, Rita; Úbeda-Muñoz, Margarita; Redondo-Cerezo, Eduardo

2017-09-01

The study aims to assess and compare the predicting ability of some scores and biomarkers in acute pancreatitis. We prospectively collected data from 269 patients diagnosed of acute pancreatitis, admitted to Virgen de las Nieves University Hospital between June 2010 and June 2012. Blood urea nitrogen (BUN), C-reactive protein, and creatinine were measured on admission and after 48 h, lactate and bedside index for severity acute pancreatitis (BISAP) only on admission and RANSON within the first 48 h. Definitions from 2012 Atlanta Classification were used. Area under the curve (AUC) was calculated for each scoring system for predicting severe acute pancreatitis (SAP), mortality, and intensive care unit (ICU) admission, obtaining optimal cut-off values from the receiver operating characteristic curves. Eight (3%) patients died, 17 (6.3%) were classified as SAP, and 10 (3.7%) were admitted in ICU. BISAP was the best predictor on admission for SAP, mortality, and ICU admission with an AUC of 0.9 (95% CI 0.83-0.97); 0.97 (95% CI 0.95-0.99); and 0.89 (95% CI 0.79-0.99), respectively. After 48 h, BUN 48 h was the best predictor of SAP (AUC = 0.96 CI: 0.92-0.99); BUN 48 h and BISAP were the best predictors for mortality (AUC = 0.97 CI: 0.95-0.99) and creatinine 48 h for ICU admission (AUC = 0.96 CI: 0.92-0.99). Lactate showed an AUC of 0.79 (CI: 0.71-0.88), 0.87 (CI: 0.78-0.96), and 0.77 (CI: 0.67-0.87) for SAP, mortality, and ICU admission, respectively. All parameters were predictors for SAP, mortality, and ICU admission, but C-reactive protein on admission was only a significant predictor of SAP. Bedside index for severity acute pancreatitis is a good predictive system for SAP, mortality, and ICU admission, being useful for triaging patients for ICU management. Lactate could be useful for developing new scores. © 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

Results of a protocol of transfusion threshold and surgical technique on transfusion requirements in burn patients.

PubMed

O'Mara, Michael S; Hayetian, Fernando; Slater, Harvey; Goldfarb, I William; Tolchin, Eric; Caushaj, Philip F

2005-08-01

Blood loss and high rates of transfusion in burn centers remains an area of ongoing concern. Blood use brings the risk of infection, adverse reaction, and immunosuppression. A protocol to reduce blood loss and blood use was implemented. Analysis included 3-year periods before and after institution of the protocol. All patients were transfused for a hemoglobin below 8.0 gm/dL. Operations per admission did not change during the two time periods (0.78 in each). Overall units transfused per operation decreased from 1.56+/-0.06 to 1.25+/-0.14 units after instituting the protocol (p<0.05). Also, units transfused per admission decreased from 1.21+/-0.15 to 0.96+/-0.06 units of blood (p<0.05). This was noticed particularly in burns of less than 20% surface area, declining from 386 to 46 units after protocol institution, from 0.37 to 0.04 units per admission, and from 0.79 to 0.08 units per operation in this group of smallest burns. There was no change noted in the larger burns. This study suggests that a defined protocol of hemostasis, technique, and transfusion trigger should be implemented in the process of burn excision and grafting. This will help especially those patients with the smallest burns, essentially eliminating transfusion need in that group.

Effect of nutritional support on mitochondrial complex I activity in malnourished patients with anorexia nervosa.

PubMed

De-Mateo-Silleras, Beatriz; Alonso-Torre, Sara R; Redondo-del-Río, Paz; Jeejeebhoy, Khursheed; Miján-de-la-Torre, Alberto

2013-11-01

Previous studies have shown a reduction in lymphocyte mitochondrial complex I activity (CIA) in malnourished patients, which is restored after refeeding. Our aim was to evaluate the usefulness of CIA as an indicator of nutritional status in anorexia nervosa patients. Twelve malnourished anorexia nervosa females (mean age, 24.5 years) were admitted to the Eating Disorders Unit. Basal and weekly anthropometrics, bioelectric impedance (BIA), body composition, and CIA were performed until discharge. Patients were matched to 25 healthy females and refeeding was adjusted according to the Unit's protocol. Statistics were used as appropriated and significance was reached at p < 0.05. Patients showed a significant reduction in body mass index, fat mass and fat free mass (FFM), triceps skinfold, and waist circumference on admission as compared with the control group. Parameters improved during hospitalization, but they failed to reach normal values at discharge. Compared with controls, CIA was significantly lower in patients on admission (2.16 vs. 5.68 nmol·min(-1)·mg protein(-1)). Refeeding and weight gain did not restore CIA. A positive association (r(2) = 0.69) was found between FFM and CIA in patients at discharge. Malnourished females with anorexia nervosa have lower CIA than controls that is not recovered after refeeding. This could be because of a low FFM exacerbated by physical inactivity while in hospital.

Out-of-office hours' elective surgical intensive care admissions and their associated complications.

PubMed

Morgan, David J R; Ho, Kwok Ming; Ong, Yang Jian; Kolybaba, Marlene L

2017-11-01

The 'weekend' effect is a controversial theory that links reduced staffing levels, staffing seniority and supportive services at hospitals during 'out-of-office hours' time periods with worsening patient outcomes. It is uncertain whether admitting elective surgery patients to intensive care units (ICU) during 'out-of-office hours' time periods mitigates this affect through higher staffing ratios and seniority. Over a 3-year period in Western Australia's largest private hospital, this retrospective nested-cohort study compared all elective surgical patients admitted to the ICU based on whether their admission occurred 'in-office hours' (Monday-Friday 08.00-18.00 hours) or 'out-of-office hours' (all other times). The main outcomes were surgical complications using the Dindo-Clavien classification and length-of-stay data. Of the total 4363 ICU admissions, 3584 ICU admissions were planned following elective surgery resulting in 2515 (70.2%) in-office hours and 1069 (29.8%) out-of-office hours elective ICU surgical admissions. Out-of-office hours ICU admissions following elective surgery were associated with an increased risk of infection (P = 0.029), blood transfusion (P = 0.020), total parental nutrition (P < 0.001) and unplanned re-operations (P = 0.027). Out-of-office hours ICU admissions were also associated with an increased hospital length-of-stay, with (1.74 days longer, P < 0.0001) and without (2.8 days longer, P < 0.001) adjusting for severity of acute and chronic illnesses and inter-hospital transfers (12.3 versus 9.8%, P = 0.024). Hospital mortality (1.2 versus 0.7%, P = 0.111) was low and similar between both groups. Out-of-office hours ICU admissions following elective surgery is common and associated with serious post-operative complications culminating in significantly longer hospital length-of-stays and greater transfers with important patient and health economic implications. © 2017 Royal Australasian College of Surgeons.

Adverse outcomes after planned surgery with anticipated intensive care admission in out-of-office-hours time periods: a multicentre cohort study.

PubMed

Morgan, D J; Ho, K M; Kolybaba, M L; Ong, Y J

2018-06-01

Increasing mortality for patients admitted to hospitals during the weekend is a contentious but well described phenomenon. However, it remains uncertain whether adverse outcomes, including prolonged hospital length-of-stay (LOS), may also occur after patients undergoing major planned surgery are admitted to an intensive care unit (ICU) out-of-office-hours, either during weeknights (after 18:00) or on weekends. All planned surgical admissions requiring admission to one of 183 ICUs across Australia and New Zealand between 2006 and 2016 were included in this retrospective population-based cohort study. Primary outcomes were hospital LOS and hospital mortality. Of the total 504 713 planned postoperative ICU admissions, 33.6% occurred during out-of-office-hours. After adjusting for available risk factors, out-of-office-hours ICU admissions were associated with a significant increase in hospital LOS [+2.6 days, 95% confidence interval (CI) 2.5-2.6], mortality [odd ratio (OR) 1.5, 95%CI 1.4-1.6], and a reduced chance of being directly discharged home (OR 0.8, 95%CI 0.8-0.8). The strongest association for adverse outcomes occurred with weekend ICU admissions (hospital LOS: +3.0 days, 95%CI 3.2-3.6; hospital mortality: OR 1.7, 95%CI 1.6-1.8). Clustering of adverse outcomes by hospitals was not observed in the generalised estimating equation analyses. Despite a greater clinical staff availability and higher monitoring levels, planned surgery requiring anticipated out-of-office-hours ICU admission was associated with a prolonged hospital LOS, reduced discharge directly home, and increased mortality compared with in-office-hours admissions. Our findings have potential clinical, economic and health policy implications on how complex planned surgery should be planned and managed. Copyright © 2018 British Journal of Anaesthesia. All rights reserved.

The Association of Fever with Total Mechanical Ventilation Time in Critically Ill Patients.

PubMed

Park, Dong Won; Egi, Moritoki; Nishimura, Masaji; Chang, Youjin; Suh, Gee Young; Lim, Chae Man; Kim, Jae Yeol; Tada, Keiichi; Matsuo, Koichi; Takeda, Shinhiro; Tsuruta, Ryosuke; Yokoyama, Takeshi; Kim, Seon Ok; Koh, Younsuck

2016-12-01

This research aims to investigate the impact of fever on total mechanical ventilation time (TVT) in critically ill patients. Subgroup analysis was conducted using a previous prospective, multicenter observational study. We included mechanically ventilated patients for more than 24 hours from 10 Korean and 15 Japanese intensive care units (ICU), and recorded maximal body temperature under the support of mechanical ventilation (MAX(MV)). To assess the independent association of MAX(MV) with TVT, we used propensity-matched analysis in a total of 769 survived patients with medical or surgical admission, separately. Together with multiple linear regression analysis to evaluate the association between the severity of fever and TVT, the effect of MAX(MV) on ventilator-free days was also observed by quantile regression analysis in all subjects including non-survivors. After propensity score matching, a MAX(MV) ≥ 37.5°C was significantly associated with longer mean TVT by 5.4 days in medical admission, and by 1.2 days in surgical admission, compared to those with MAX(MV) of 36.5°C to 37.4°C. In multivariate linear regression analysis, patients with three categories of fever (MAX(MV) of 37.5°C to 38.4°C, 38.5°C to 39.4°C, and ≥ 39.5°C) sustained a significantly longer duration of TVT than those with normal range of MAX(MV) in both categories of ICU admission. A significant association between MAX(MV) and mechanical ventilator-free days was also observed in all enrolled subjects. Fever may be a detrimental factor to prolong TVT in mechanically ventilated patients. These findings suggest that fever in mechanically ventilated patients might be associated with worse mechanical ventilation outcome.

Symbolic interactionism and nurse-mother communication in the neonatal intensive care unit.

PubMed

Cleveland, Lisa Marie

2009-01-01

The admission of an infant to the neonatal intensive care unit (NICU) has the potential to cause significant stress for the mothers of these infants. Researchers have found that nurse-mother communication has the potential to either aid or hinder the mother's adaptation to the NICU environment. These communication patterns are relatively complex in nature and therefore warrant further investigation. Symbolic interactionism (SI) is a theoretical framework that offers the potential to direct such an investigation. The purpose of this article is to examine nurse-mother communication patterns in the NICU through the theoretical lens of SI.

32 CFR 575.6 - Catalogue, United States Military Academy.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 32 National Defense 3 2013-07-01 2013-07-01 false Catalogue, United States Military Academy. 575.6... ADMISSION TO THE UNITED STATES MILITARY ACADEMY § 575.6 Catalogue, United States Military Academy. The latest edition of the catalogue, United States Military Academy, contains additional information...

32 CFR 575.6 - Catalogue, United States Military Academy.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 32 National Defense 3 2011-07-01 2009-07-01 true Catalogue, United States Military Academy. 575.6... ADMISSION TO THE UNITED STATES MILITARY ACADEMY § 575.6 Catalogue, United States Military Academy. The latest edition of the catalogue, United States Military Academy, contains additional information...

32 CFR 575.6 - Catalogue, United States Military Academy.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 32 National Defense 3 2010-07-01 2010-07-01 true Catalogue, United States Military Academy. 575.6... ADMISSION TO THE UNITED STATES MILITARY ACADEMY § 575.6 Catalogue, United States Military Academy. The latest edition of the catalogue, United States Military Academy, contains additional information...

Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy

PubMed Central

Selewski, David T.; Cornell, Timothy T.; Lombel, Rebecca M.; Blatt, Neal B.; Han, Yong Y.; Mottes, Theresa; Kommareddi, Mallika; Kershaw, David B.; Shanley, Thomas P.; Heung, Michael

2012-01-01

Purpose In pediatric intensive care unit (PICU) patients, fluid overload (FO) at initiation of continuous renal replacement therapy (CRRT) has been reported to be an independent risk factor for mortality. Previous studies have calculated FO based on daily fluid balance during ICU admission, which is labor intensive and error prone. We hypothesized that a weight-based definition of FO at CRRT initiation would correlate with the fluid balance method and prove predictive of outcome. Methods This is a retrospective single-center review of PICU patients requiring CRRT from July 2006 through February 2010 (n = 113). We compared the degree of FO at CRRT initiation using the standard fluid balance method versus methods based on patient weight changes assessed by both univariate and multivariate analyses. Results The degree of fluid overload at CRRT initiation was significantly greater in nonsurvivors, irrespective of which method was used. The univariate odds ratio for PICU mortality per 1% increase in FO was 1.056 [95% confidence interval (CI) 1.025, 1.087] by the fluid balance method, 1.044 (95% CI 1.019, 1.069) by the weight-based method using PICU admission weight, and 1.045 (95% CI 1.022, 1.07) by the weight-based method using hospital admission weight. On multivariate analyses, all three methods approached significance in predicting PICU survival. Conclusions Our findings suggest that weight-based definitions of FO are useful in defining FO at CRRT initiation and are associated with increased mortality in a broad PICU patient population. This study provides evidence for a more practical weight-based definition of FO that can be used at the bedside. PMID:21533569

Outcome of older persons admitted to intensive care unit, mortality, prognosis factors, dependency scores and ability trajectory within 1 year: a prospective cohort study.

PubMed

Level, Claude; Tellier, Eric; Dezou, Patrick; Chaoui, Karim; Kherchache, Aissa; Sejourné, Philippe; Rullion-Pac Soo, Anne Marie

2017-12-06

The outcome and functional trajectory of older persons admitted to intensive care (ICU) unit remain a true question for critical care physicians and geriatricians, due to the heterogeneity of geriatric population, heterogeneity of practices and absence of guidelines. To describe the 1-year outcome, prognosis factors and functional trajectory for older people admitted to ICU. In a prospective 1-year cohort study, all patients aged 75 years and over admitted to our ICU were included according to a global comprehensive geriatric assessment. Follow-up was conducted for 1 year survivors, in particular, ability scores and living conditions. Of 188 patients included [aged 82.3 ± 4.7 years, 46% of admissions, median SAPS II 53.5 (43-74), ADL of Katz's score 4.2 ± 1.6, median Barthel's index 71 (55-90), AGGIR scale 4.5 ± 1.5], the ICU, hospital and 1-year mortality were, respectively, 34, 42.5 and 65.5%. Prognosis factors were: SAPS 2, mechanical ventilation, comorbidity (Lee's and Mc Cabe's scores), disability scores (ADL of Katz's score, Barthel's index and AGGIR scale), admission creatinin, hypoalbuminemia, malignant haemopathy, cognitive impairment. One-year survivors lived in their own home for 83%, with a preserved physical ability, without significant variation of the three ability assessed scores compared to prior ICU admission. The mortality of older people admitted to ICU is high, with a significant impact of disabilty scores, and preserved 1-year survivor independency. Other studies, including a better comprehensive geriatric assessment, seem necessary to determine a predictive "phenotype" of survival with a "satisfactory" level of autonomy.

PREP: Outreach to Online Learners through Admissions

ERIC Educational Resources Information Center

Gupton, Preeti

2016-01-01

Librarians have collaborated with academic departments within their institutions for decades now, working with professors and administrators to bring information literacy skills to students. The librarians at National American University decided to extend this collaboration to a non-academic unit, the admissions department of the university. The…

Islamic Republic of Pakistan: A Study of the Educational System of Pakistan and a Guide to the Academic Placement of Students from Pakistan in Educational Institutions of the United States.

ERIC Educational Resources Information Center

Sweeney, Leo J.

Written as a guide to be used in the admission and placement of students from Pakistan in U.S. institutions of higher education, this study discusses the education system of Pakistan. The first four chapters contain a summary of the development of Pakistan. These are followed by guidelines and suggestions for admissions officers and admissions and…

Outcomes of nighttime refusal of admission to the intensive care unit: The role of the intensivist in triage.

PubMed

Hinds, Nicholas; Borah, Amit; Yoo, Erika J

2017-06-01

To compare outcomes of patients refused medical intensive care unit (MICU) admission overnight to those refused during the day and to examine the impact of the intensivist in triage. Retrospective, observational study of patients refused MICU admission at an urban university hospital. Of 294 patients, 186 (63.3%) were refused admission overnight compared to 108 (36.7%) refused during the day. Severity-of-illness by the Mortality Probability Model was similar between the two groups (P=.20). Daytime triage refusals were more likely to be staffed by an intensivist (P=.01). After risk-adjustment, daytime refusals had a lower odds of subsequent ICU admission (OR 0.46, 95% CI 0.22-0.95, P=.04) than patients triaged at night. There was no evidence for interaction between time of triage and intensivist staffing of the patient (P=.99). Patients refused MICU admission overnight are more likely to be later admitted to an ICU than patients refused during the day. However, the mechanism for this observation does not appear to depend on the intensivist's direct evaluation of the patient. Further investigation into the clinician-specific effects of ICU triage and identification of potentially modifiable hospital triage practices will help to improve both ICU utilization and patient safety. Copyright © 2017 Elsevier Inc. All rights reserved.

Factors and trade-offs with rehabilitation effectiveness and efficiency in newly disabled older persons.

PubMed

Chow, Patsy; Chen, Cynthia; Cheong, Angela; Fong, Ngan Phoon; Chan, Kin Ming; Tan, Boon Yeow; Menon, Edward; Ee, Chye Hua; Lee, Kok Keng; Koh, David; Koh, Gerald C

2014-08-01

To determine the factors for rehabilitation effectiveness (REs) and rehabilitation efficiency (REy) among newly disabled older persons and if there is any trade-off between REs and REy. Retrospective cohort study. Rehabilitation hospitals. Patients (N=8828) aged ≥65 years admitted for inpatient rehabilitation from 1996 to 2005. Not applicable. Independent factors affecting REs and REy were determined. The median rank ratios of REs to REy for each admission Barthel Index (BI) unit and number of days of stay were generated. The ideal ranges of admission BI score and length of stay (LOS) that corresponded to the REs to REy median rank ratio of 1 (both REs and REy optimized) were identified. Factors associated with poorer REs and REy were older age, Malay ethnicity, delayed admission, admission diagnosis of amputation, and comorbidities of dementia and stroke. An increase of 10 in admission BI score was associated with an increase of 3.47% in REs but a decrease of 1.1 per 30 days in REy; and an increase in LOS of 2.7 days was associated with an increase of 28% in REs but a decrease of 5.2 per 30 days in REy. A trade-off relation between REs and REy with respect to admission functional status and LOS was observed. The range, which optimized both REs and REy, was 50 to 59 units for admission BI score and 37 to 46 days for LOS. There are trade-offs between REs and REy with respect to admission functional status and LOS. Clinicians, policymakers, patients, and other stakeholders should be aware of such trade-offs when they make joint policy decisions about rehabilitation services. Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Association of primary care factors with hospital admissions for epilepsy in England, 2004-2010: National observational study.

PubMed

Calderón-Larrañaga, Amaia; Soljak, Michael; Cowling, Thomas E; Gaitatzis, Athanasios; Majeed, Azeem

2014-09-01

There has been little research on the accessibility and quality of primary care services for epilepsy and emergency hospital admissions for epilepsy. We examined time trends in admissions for epilepsy in England between 2004-2005 and 2010, and the association of admission rates with population and primary care factors. The units of analysis were the registered populations of 8622 general practices. We used negative binomial regression to model indicators from the Quality and Outcomes Framework, the UK's primary care pay for performance scheme, to measure the accessibility and quality of care for epilepsy, and supply of general practitioners, after adjustment for population factors. The mean indirectly standardised admission rate decreased from 122.9 to 102.6 (-16.5%; P<0.001) over the study period, while the mean percentage of patients seizure free increased from 65.3% to 74.9% (P<0.001). In the multivariable analysis, a one unit increase in the percentage of seizure free adult patients on epilepsy drugs predicted a 0.20% decrease (IRR=0.9980; 95% CI: 0.9974-0.9986) in admission rate. The percentage of patients who were able to book a GP appointment over two days ahead predicted a 0.12% decrease (IRR=0.9988; 95% CI: 0.9982-0.9994). The deprivation score of practice populations (IRR=1.0179; P<0.001) and general practitioner supply (IRR=1.0022; P<0.001) were both positively associated with admission rates. Patient access to primary care appointments and percentage of patients who have been recorded as seizure free for 12 months were associated with lower admission rates. However the effect sizes are small relative to that of population deprivation. Copyright © 2014 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

Prognostic Usefulness of Eosinopenia in the Pediatric Intensive Care Unit

PubMed Central

Kim, Yoon Hee; Park, Hyun Bin; Kim, Min Jung; Kim, Hwan Soo; Lee, Hee Seon; Han, Yoon Ki; Sohn, Myung Hyun; Kim, Kyu-Earn

2013-01-01

Eosinopenia, a biomarker for infection, has recently been shown to be a predictor of adult mortality in the intensive care unit (ICU). Our study assessed the usefulness of eosinopenia as a mortality and an infection biomarker in the pediatric ICU (PICU). We compared the PICU mortality scores, eosinophil count and percentage at ICU admission between children who survived and those who did not survive and between children with infection and those without infection. A total of 150 patients were evaluated. The initial eosinophil count and percentage were significantly lower in the group that did not survive when compared to those that did survive (P < 0.001; P < 0.001). However, there was no significant difference in the eosinophil count and percentage seen in patients with and without infection. Eosinopenia, defined as an eosinophil count < 15 cells/µL and an eosinophil percentage < 0.25%, (hazard ratio [HR]: 2.96; P = 0.008) along with a Pediatric Index of Mortality (PIM) 2 (HR: 1.03; P = 0.004) were both determined to be independent predictors of mortality in the PICU. The presence of eosinopenia at the ICU admission can be a useful biomarker for mortality in children, but is not useful as a biomarker for infection. PMID:23341721

Discharge Outcomes and Survival of Patients with Advanced Cancer Admitted to an Acute Palliative Care Unit at a Comprehensive Cancer Center

PubMed Central

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

Development and validation of a risk model for identification of non-neutropenic, critically ill adult patients at high risk of invasive Candida infection: the Fungal Infection Risk Evaluation (FIRE) Study.

PubMed

Harrison, D; Muskett, H; Harvey, S; Grieve, R; Shahin, J; Patel, K; Sadique, Z; Allen, E; Dybowski, R; Jit, M; Edgeworth, J; Kibbler, C; Barnes, R; Soni, N; Rowan, K

2013-02-01

There is increasing evidence that invasive fungal disease (IFD) is more likely to occur in non-neutropenic patients in critical care units. A number of randomised controlled trials (RCTs) have evaluated antifungal prophylaxis in non-neutropenic, critically ill patients, demonstrating a reduction in the risk of proven IFD and suggesting a reduction in mortality. It is necessary to establish a method to identify and target antifungal prophylaxis at those patients at highest risk of IFD, who stand to benefit most from any antifungal prophylaxis strategy. To develop and validate risk models to identify non-neutropenic, critically ill adult patients at high risk of invasive Candida infection, who would benefit from antifungal prophylaxis, and to assess the cost-effectiveness of targeting antifungal prophylaxis to high-risk patients based on these models. Systematic review, prospective data collection, statistical modelling, economic decision modelling and value of information analysis. Ninety-six UK adult general critical care units. Consecutive admissions to participating critical care units. None. Invasive fungal disease, defined as a blood culture or sample from a normally sterile site showing yeast/mould cells in a microbiological or histopathological report. For statistical and economic modelling, the primary outcome was invasive Candida infection, defined as IFD-positive for Candida species. Systematic review: Thirteen articles exploring risk factors, risk models or clinical decision rules for IFD in critically ill adult patients were identified. Risk factors reported to be significantly associated with IFD were included in the final data set for the prospective data collection. Data were collected on 60,778 admissions between July 2009 and March 2011. Overall, 383 patients (0.6%) were admitted with or developed IFD. The majority of IFD patients (94%) were positive for Candida species. The most common site of infection was blood (55%). The incidence of IFD identified in unit was 4.7 cases per 1000 admissions, and for unit-acquired IFD was 3.2 cases per 1000 admissions. Statistical modelling: Risk models were developed at admission to the critical care unit, 24 hours and the end of calendar day 3. The risk model at admission had fair discrimination (c-index 0.705). Discrimination improved at 24 hours (c-index 0.823) and this was maintained at the end of calendar day 3 (c-index 0.835). There was a drop in model performance in the validation sample. Economic decision model: Irrespective of risk threshold, incremental quality-adjusted life-years of prophylaxis strategies compared with current practice were positive but small compared with the incremental costs. Incremental net benefits of each prophylaxis strategy compared with current practice were all negative. Cost-effectiveness acceptability curves showed that current practice was the strategy most likely to be cost-effective. Across all parameters in the decision model, results indicated that the value of further research for the whole population of interest might be high relative to the research costs. The results of the Fungal Infection Risk Evaluation (FIRE) Study, derived from a highly representative sample of adult general critical care units across the UK, indicated a low incidence of IFD among non-neutropenic, critically ill adult patients. IFD was associated with substantially higher mortality, more intensive organ support and longer length of stay. Risk modelling produced simple risk models that provided acceptable discrimination for identifying patients at 'high risk' of invasive Candida infection. Results of the economic model suggested that the current most cost-effective treatment strategy for prophylactic use of systemic antifungal agents among non-neutropenic, critically ill adult patients admitted to NHS adult general critical care units is a strategy of no risk assessment and no antifungal prophylaxis. Funding for this study was provided by the Health Technology Assessment programme of the National Institute for Health Research.

Implementation of dextrose gel in the management of neonatal hypoglycaemia.

PubMed

Ter, Marene; Halibullah, Ikhwan; Leung, Laura; Jacobs, Susan

2017-04-01

The aim of this study was to evaluate dextrose gel in the management of neonatal hypoglycaemia in the postnatal wards at an Australian tertiary level perinatal centre. An audit was performed before and after implementation of dextrose gel. Pre-implementation, neonatal hypoglycaemia was managed with feed supplementation alone, and dextrose gel was used in addition to feed supplementation in the post-implementation phase. Outcomes included admission to neonatal intensive care unit (NICU) for management of hypoglycaemia, proportion of neonates who achieved normoglycaemia (defined as blood glucose ≥2.6 mmol/L, with no clinical signs after one or two treatment attempts) and proportion of neonates with hypoglycaemia recurrence after normoglycaemia and one or two treatment attempts. NICU admission for treatment of hypoglycaemia reduced significantly post-implementation of dextrose gel (29/100 (29%) vs. 14/100 (14%), P = 0.01). No significant difference was seen in the proportion of neonates achieving normoglycaemia (71/100 (71%) vs. 75/100 (75%), P = 0.52), but hypoglycaemia recurrence was higher in the post-implementation group (22/71 (31%) vs. 37/75 (49%), P = 0.02). Dextrose gel is effective in the management of neonatal hypoglycaemia in the postnatal ward setting, reducing admission to NICU and mother-infant separation. © 2016 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

Impact of case volume on survival of septic shock in patients with malignancies.

PubMed

Zuber, Benjamin; Tran, Thi-Chien; Aegerter, Philippe; Grimaldi, David; Charpentier, Julien; Guidet, Bertrand; Mira, Jean-Paul; Pène, Frédéric

2012-01-01

Septic shock is a frequent and severe complication in the course of malignancies. In a large multicenter cohort of septic shock patients with hematologic malignancies and solid tumors, we assessed the temporal trend in survival and the prognostic factors, with particular emphasis on case volume. A 12-yr multicenter retrospective cohort study of prospectively collected data. Cancer patients with septic shock were selected over a 12-yr period (1997-2008) from a French regional database (CUB-Réa). The following variables were extracted: demographic characteristics, type of malignancy, characteristics of infection, severity-of-illness score (Simplified Acute Physiology Score II), organ failure supports, and vital status. For each unit, a running mean annual volume of admissions was calculated for the purpose of categorization into volume tertiles. Prognostic factors were analyzed by a conditional multivariate logistic model after matching on a propensity score of being admitted to a high-volume unit and on the year of admission. None. A total of 3,437 patients were included in the study. The intensive care unit mortality rate dramatically dropped over time (from 70.4% in 1997 to 52.5% in 2008, relative decrease 25.4%, p < .001). Participating units were distributed into low-volume (< five patients per year), medium-volume (five to 12 patients per year), and high-volume (≥ 13 patients per year) tertiles. A medical cause for intensive care unit admission, Simplified Acute Physiology Score II, invasive mechanical ventilation, renal replacement therapy, fungal infections, and unknown microorganism were identified as poor prognostic factors. Case volume demonstrated a strong influence on survival, admission in a high-volume unit being associated with a marked decrease in mortality as compared to low-volume units (adjusted odds ratio 0.63; 95% confidence interval [0.46-0.87], p = .002). Survival of septic shock patients with malignancies markedly increased over the recent years. Furthermore, we identified case volume as a major prognostic factor in this setting.

Admissions Standards and the Use of Key Marketing Techniques by United States' Colleges and Universities.

ERIC Educational Resources Information Center

Goldgehn, Leslie A.

1989-01-01

A survey of admissions deans and directors investigated the use and perceived effectiveness of 15 well-known marketing techniques: advertising, advertising research, a marketing plan, market positioning, market segmentation, marketing audit, marketing research, pricing, program and service accessibility, program development, publicity, target…

Trends in U.S. Engineering and Engineering Technology: A Comparative Study of Admissions, Curricula, and Employment.

ERIC Educational Resources Information Center

Lebold, W. K.; Lebold, D. J.

1985-01-01

Discusses the admissions selection practices, educational programs, quality standards, and employment characteristics of engineering and engineering technology in the United States. The importance of these two occupations as part of technical teams (which include scientists and technicians) is documented and stressed. (JN)

Intensive Care Unit Admission and Death Rates of Infants Admitted With Respiratory Syncytial Virus Lower Respiratory Tract Infection in Mexico.

PubMed

Vizcarra-Ugalde, Sergio; Rico-Hernández, Montserrat; Monjarás-Ávila, César; Bernal-Silva, Sofía; Garrocho-Rangel, Maria E; Ochoa-Pérez, Uciel R; Noyola, Daniel E

2016-11-01

Respiratory syncytial virus (RSV) is the most common etiology for acute respiratory infection hospital admissions in young children. Case fatality rates for hospitalized patients range between 0% and 3.4%. Recent reports indicate that deaths associated with RSV are uncommon in developed countries. However, the role of this virus as a current cause of mortality in other countries requires further examination. Children with RSV infection admitted between May 2003 and December 2014 to a level 2 specialty hospital in Mexico were included in this analysis. Underlying risk factors, admission to the intensive care unit (ICU) and condition on discharge were assessed to determine the ICU admission and death rates associated to RSV infection. We analyzed data of 1153 patients with RSV infection in whom information regarding underlying illnesses and discharge status was available. Sixty patients (5.2 %) were admitted to the ICU and 12 (1.04 %) died. Relevant underlying conditions were present in 320 (27.7%) patients. Infants with underlying respiratory disorders (excluding asthma) and a history of prematurity had high ICU admission rates (17.1% and 13.8%, respectively). Mortality rates were highest for infants with respiratory disease (excluding asthma) (7.3%), cardiovascular diseases (5.9%) and neurologic disorders (5.3%). The ICU admission and death rates were higher in infants <6 months of age than in other age groups. The ICU admission rate and mortality rate in Mexican infants hospitalized with RSV infection were 5.2% and 1%, respectively. Mortality rates were high in infants with respiratory, cardiovascular and neurologic disorders.

Appropriateness of red blood cell transfusion in Australasian intensive care practice.

PubMed

French, Craig J; Bellomo, Rinaldo; Finfer, Simon R; Lipman, Jeffery; Chapman, Marianne; Boyce, Neil W

2002-11-18

To determine the incidence and appropriateness of use of allogenic packed red blood cell (RBC) transfusion in Australian and New Zealand intensive care practice. Intensive care units of 18 Australian and New Zealand hospitals: March 2001. Prospective, observational, multicentre study. All admissions to participating intensive care units were screened and all patients who received a transfusion of RBC were enrolled. The indications for transfusion were recorded and compared with Australian National Health and Medical Research Council guidelines. Transfusions conforming to these guidelines were deemed appropriate. RBC transfusion in intensive care and transfusion appropriateness. 1808 admissions to intensive care units were screened: 357 (19.8%) admissions (350 patients) received an RBC transfusion while in intensive care. Overall, 1464 RBC units were administered in intensive care on 576 transfusion days. The most common indications for transfusion were acute bleeding (60.1%; 880/1464) and diminished physiological reserve (28.9%; 423/1464). The rate of inappropriate transfusion was 3.0% (44/1464). Diminished physiological reserve with haemogloblin level > or = 100 g/L was the indication in 50% (22/44) of inappropriate transfusions; no indication was provided for 31% (15/44). The rate of inappropriate transfusion in Australian and New Zealand intensive care units in 2001 was remarkably low.

Day case management of sickle pain: 3 years experience in a UK sickle cell unit.

PubMed

Wright, J; Bareford, D; Wright, C; Augustine, G; Olley, K; Musamadi, L; Dhanda, C; Knight, C

2004-09-01

A day centre was established to determine whether an alternative approach to the management of uncomplicated sickle pain would improve the quality of care and reduce hospital admissions in patients with sickle cell disease. Since the centre opened there has been a 43% decrease in hospital admissions and 49% decrease in occupied bed days. In the third year, 84% of patients treated for severe sickle pain were managed without the need for hospital admission. A centre offering day case management of painful crisis reduced unnecessary hospital admissions for uncomplicated pain. This approach is safe and cost-effective.

A Longitudinal Investigation of Alcohol Use over the Course of the Year Following Medical-Surgical Intensive Care Unit Admission

PubMed Central

Davydow, Dimitry S.; Zatzick, Douglas; Hough, Catherine L.; Katon, Wayne J.

2013-01-01

Background There have been no studies describing post-intensive care unit (ICU) alcohol use among medical-surgical ICU survivors. Objective To examine alcohol use and identify potentially modifiable risk factors, such as in-hospital probable acute stress disorder, for increased alcohol use following medical-surgical ICU admission. Method This longitudinal investigation included 150 medical-surgical ICU survivors. In-hospital interviews obtained baseline characteristics including pre-ICU alcohol use with the Alcohol Use Disorders Identification Test (AUDIT) and in-hospital probable acute stress disorder with the Posttraumatic Stress Disorder Checklist-civilian version. Clinical factors were obtained from medical records. Post-ICU alcohol use was ascertained via telephone interviews at 3 and 12 months post-discharge using the AUDIT. Mixed-model linear regression was used to examine potential risk factors for increased post-ICU alcohol use. Results There was a significant decline in the mean AUDIT score from baseline (3.9, 95%Confidence Interval [95%CI]: 2.9, 5.0) to 3 months post-ICU (1.5, 95%CI: 1.0, 2.1) (P < 0.001 by one-way analysis of variance [ANOVA]), with a significant increase between 3 and 12 months post-ICU (2.7, 95%CI: 1.8, 3.5) (P < 0.001 by one-way ANOVA). After adjusting for patient and clinical factors, in-hospital probable acute stress disorder (beta: 3.0, 95%CI: 0.9, 5.0) and pre-ICU unhealthy alcohol use (beta: 5.4, 95%CI: 3.4, 7.4) were independently associated with increased post-ICU alcohol use. Conclusions Alcohol use decreases in the early aftermath of medical-surgical ICU admission and then increases significantly by one year post-ICU. Interventions for unhealthy alcohol use among medical-surgical ICU survivors that take into account comorbid psychiatric symptoms are needed. PMID:23414847

The Structured Interview and Interviewer Training in the Admissions Process

PubMed Central

Cox, Wendy C.; White-Harris, Carla; Blalock, Susan J.

2007-01-01

Objectives To determine the extent to which the structured interview is used in the PharmD admissions process in US colleges and schools of pharmacy, and the prevalence and content of interviewer training. Methods A survey instrument consisting of 7 questions regarding interviews and interviewer training was sent to 92 colleges and schools of pharmacy in the United States that were accredited or seeking accreditation. Results Sixty survey instruments (65% response rate) were returned. The majority of the schools that responded (80%) used interviews as part of the PharmD admissions process. Of the schools that used an interview as part of the admissions process, 86% provided some type of interviewer training and 13% used a set of predefined questions in admissions interviews. Conclusions Most colleges and schools of pharmacy use some components of the structured interview in the PharmD admissions process; however, training for interviewers varies widely among colleges and schools of pharmacy. PMID:17998980

Stroke mimic diagnoses presenting to a hyperacute stroke unit.

PubMed

Dawson, Ang; Cloud, Geoffrey C; Pereira, Anthony C; Moynihan, Barry J

2016-10-01

Stroke services have been centralised in several countries in recent years. Diagnosing acute stroke is challenging and a high proportion of patients admitted to stroke units are diagnosed as a non-stroke condition (stroke mimics). This study aims to describe the stroke mimic patient group, including their impact on stroke services. We analysed routine clinical data from 2,305 consecutive admissions to a stroke unit at St George's Hospital, London. Mimic groupings were derived from 335 individual codes into 17 groupings. From 2,305 admissions, 555 stroke mimic diagnoses were identified (24.2%) and 72% of stroke mimics had at least one stroke risk factor. Common mimic diagnoses were headache, seizure and syncope. Medically unexplained symptoms and decompensation of underlying conditions were also common. Median length of stay was 1 day; a diagnosis of dementia (p=0.028) or needing MRI (p=0.006) was associated with a longer stay. Despite emergency department assessment by specialist clinicians and computed tomography brain, one in four suspected stroke patients admitted to hospital had a non-stroke diagnosis. Stroke mimics represent a heterogeneous patient group with significant impacts on stroke services. Co-location of stroke and acute neurology services may offer advantages where service reorganisation is being considered. © Royal College of Physicians 2016. All rights reserved.

Priority Queuing Models for Hospital Intensive Care Units and Impacts to Severe Case Patients

PubMed Central

Hagen, Matthew S.; Jopling, Jeffrey K; Buchman, Timothy G; Lee, Eva K.

2013-01-01

This paper examines several different queuing models for intensive care units (ICU) and the effects on wait times, utilization, return rates, mortalities, and number of patients served. Five separate intensive care units at an urban hospital are analyzed and distributions are fitted for arrivals and service durations. A system-based simulation model is built to capture all possible cases of patient flow after ICU admission. These include mortalities and returns before and after hospital exits. Patients are grouped into 9 different classes that are categorized by severity and length of stay (LOS). Each queuing model varies by the policies that are permitted and by the order the patients are admitted. The first set of models does not prioritize patients, but examines the advantages of smoothing the operating schedule for elective surgeries. The second set analyzes the differences between prioritizing admissions by expected LOS or patient severity. The last set permits early ICU discharges and conservative and aggressive bumping policies are contrasted. It was found that prioritizing patients by severity considerably reduced delays for critical cases, but also increased the average waiting time for all patients. Aggressive bumping significantly raised the return and mortality rates, but more conservative methods balance quality and efficiency with lowered wait times without serious consequences. PMID:24551379

Enrollment Management in Academic Units

ERIC Educational Resources Information Center

DeBiaso, Nick

2012-01-01

This study provides an understanding of how administrative leaders make decisions regarding enrollment management within academic units at a major research university in the southwestern United States. Key enrollment management functions of recruiting, admissions, marketing, orientation, financial aid/scholarships, academic advising, student…

The patterns and causes of neonatal mortality at a tertiary hospital in oman.

PubMed

Abdellatif, Mohamed; Ahmed, Masood; Bataclan, Maria Flordeliz; Khan, Ashfaq Ahmed; Al Battashi, Abeer; Al Maniri, Abdullah

2013-11-01

To report the patterns and causes of neonatal death from a tertiary care neonatal intensive care unit over a period of four years. This is a retrospective cohort study where four years data (January 2006 - December 2009) of all inborn neonatal admissions and deaths were collected from the neonatal intensive care unit at Sultan Qaboos University hospital on predesigned forms. All out born admissions and deaths were excluded. The causes of neonatal death were classified using Wigglesworth's classification. The number of inborn live births during the study period was 10064 and the total number of inborn neonatal admissions was 1475. The total deaths (neonatal and post neonatal) at the neonatal intensive care unit was 73 (63 inborn and 10 out born). Among the inborn, five deaths were post neonatal deaths and hence, excluded from analysis. Among the remaining inborn neonatal deaths (n=58), 34 (59%) were males and 24 (41%) were females. The number of neonatal admissions increased over the years during the study period from 248 to 356, while the number of deaths also increased from 10 deaths in 2006, to 20 deaths in 2009. The primary causes of neonatal deaths were prematurity and its complications 52% (n=30). Lethal congenital malformations lead to 17 (29%) newborn deaths, specific diagnosis in 7 newborns (12%), and birth asphyxia in four (7%) of cases. There was an increasing trend of neonatal admissions and deaths among inborn babies. Prematurity, with sepsis as its major complication and congenital malformations were the leading cause of neonatal mortality.

The Patterns and Causes of Neonatal Mortality at a Tertiary Hospital in Oman

PubMed Central

Abdellatif, Mohamed; Ahmed, Masood; Bataclan, Maria Flordeliz; Khan, Ashfaq Ahmed; Al Battashi, Abeer; Al Maniri, Abdullah

2013-01-01

Objective To report the patterns and causes of neonatal death from a tertiary care neonatal intensive care unit over a period of four years. Methods This is a retrospective cohort study where four years data (January 2006 - December 2009) of all inborn neonatal admissions and deaths were collected from the neonatal intensive care unit at Sultan Qaboos University hospital on predesigned forms. All out born admissions and deaths were excluded. The causes of neonatal death were classified using Wigglesworth's classification. Results The number of inborn live births during the study period was 10064 and the total number of inborn neonatal admissions was 1475. The total deaths (neonatal and post neonatal) at the neonatal intensive care unit was 73 (63 inborn and 10 out born). Among the inborn, five deaths were post neonatal deaths and hence, excluded from analysis. Among the remaining inborn neonatal deaths (n=58), 34 (59%) were males and 24 (41%) were females. The number of neonatal admissions increased over the years during the study period from 248 to 356, while the number of deaths also increased from 10 deaths in 2006, to 20 deaths in 2009. The primary causes of neonatal deaths were prematurity and its complications 52% (n=30). Lethal congenital malformations lead to 17 (29%) newborn deaths, specific diagnosis in 7 newborns (12%), and birth asphyxia in four (7%) of cases. Conclusion There was an increasing trend of neonatal admissions and deaths among inborn babies. Prematurity, with sepsis as its major complication and congenital malformations were the leading cause of neonatal mortality. PMID:24223246

Predictors of intensive care unit refusal in French intensive care units: a multiple-center study.

PubMed

Garrouste-Orgeas, Maité; Montuclard, Luc; Timsit, Jean-François; Reignier, Jean; Desmettre, Thibault; Karoubi, Philippe; Moreau, Delphine; Montesino, Laurent; Duguet, Alexandre; Boussat, Sandrine; Ede, Christophe; Monseau, Yannick; Paule, Thierry; Misset, Benoit; Carlet, Jean

2005-04-01

To identify factors associated with granting or refusing intensive care unit (ICU) admission, to analyze ICU characteristics and triage decisions, and to describe mortality in admitted and refused patients. Observational, prospective, multiple-center study. Four university hospitals and seven primary-care hospitals in France. None. Age, underlying diseases (McCabe score and Knaus class), dependency, hospital mortality, and ICU characteristics were recorded. The crude ICU refusal rate was 23.8% (137/574), with variations from 7.1% to 63.1%. The reasons for refusal were too well to benefit (76/137, 55.4%), too sick to benefit (51/137, 37.2%), unit too busy (9/137, 6.5%), and refusal by the family (1/137). In logistic regression analyses, two patient-related factors were associated with ICU refusal: dependency (odds ratio [OR], 14.20; 95% confidence interval [CI], 5.27-38.25; p < .0001) and metastatic cancer (OR, 5.82; 95% CI, 2.22-15.28). Other risk factors were organizational, namely, full unit (OR, 3.16; 95% CI, 1.88-5.31), center (OR, 3.81; 95% CI, 2.27-6.39), phone admission (OR, 0.23; 95% CI, 0.14-0.40), and daytime admission (OR, 0.52; 95% CI, 0.32-0.84). The Standardized Mortality Ratio was 1.41 (95% CI, 1.19-1.69) for immediately admitted patients, 1.75 (95% CI, 1.60-1.84) for refused patients, and 1.03 (95% CI, 0.28-1.75) for later-admitted patients. ICU refusal rates varied greatly across ICUs and were dependent on both patient and organizational factors. Efforts to define ethically optimal ICU admission policies might lead to greater homogeneity in refusal rates, although case-mix variations would be expected to leave an irreducible amount of variation across ICUs.

[Predictive factors of all-cause mortality in patients attending the medical emergency unit of Kinshasa University Hospital].

PubMed

Mbutiwi Ikwa Ndol, F; Dramaix-Wilmet, M; Meert, P; Lepira Bompeka, F; Nseka Mangani, N; Malengreau, M; Makaula, P

2014-02-01

The management of medical emergencies is poorly organized in the Democratic Republic of Congo. In addition, the mortality of patients attending the medical emergency unit of Kinshasa University Hospital is relatively high, with death of patients occurring rather early. To date, factors associated with this mortality have been poorly elucidated. This study aimed to identify predictive factors of all-cause mortality in patients admitted to the medical emergency unit of the Kinshasa University Hospital. Analytical prospective study of all patients admitted from 15th January to 15th February 2011 in the emergency unit of the internal medicine department of Kinshasa University Hospital (427 patients). Among these patients, 13 were dead at arrival and were excluded from this study. The 414 patients included were followed until discharge from the hospital. Demographic, clinical, biological, diagnostic, therapeutical and evolutive data were collected. Four multivariate logistic regression models were used to identify risk factors associated with mortality. Patients' median age was 40 years (interquartile range, 28-58 years), 54.5% were male, and 15.9% had a life-threatening pathological condition on admission. The overall mortality was 12.3%. According to multivariate analyses, transfer from other health care structures (OR: 3.5; 95% CI: 1.7-7.1), Glasgow Coma Scale score less than 14 on admission (OR: 11.1; 95% CI: 4.7-26.3), high creatinine level (OR: 4.2; 95% CI: 1.8-9.7), presence of cardiovascular (OR: 2.9; 95% CI: 1.5-5.7), renal (OR: 7.4; 95% CI: 3.2-17.3), hematologic and/or respiratory (OR: 6.1; 95% CI: 1.7-21.4) diseases, presence of sepsis and/or meningitis and encephalitis (OR: 5.2; 95% CI: 1.6-17.0) were significantly associated with a high risk of death. However, the Glasgow Coma Scale score less than 14 on admission and renal disease were the only predictive factors of mortality remaining after including demographic, clinical, diagnostic and therapeutical variables in the logistic regression model. Our study showed that transfer from another health care structure, low Glasgow Coma Scale score on admission, high creatinine level, cardiovascular, renal, hematologic and/or respiratory diseases, sepsis and/or meningitis and encephalitis were associated with an increased risk of death in Kinshasa University Hospital patients admitted in the medical emergency unit. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

8 CFR 233.4 - Preinspection outside the United States.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 8 Aliens and Nationality 1 2014-01-01 2014-01-01 false Preinspection outside the United States... CONTRACTS WITH TRANSPORTATION LINES § 233.4 Preinspection outside the United States. (a) Form I-425 agreements. A transportation line bringing applicants for admission to the United States through...

8 CFR 233.4 - Preinspection outside the United States.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 8 Aliens and Nationality 1 2011-01-01 2011-01-01 false Preinspection outside the United States... CONTRACTS WITH TRANSPORTATION LINES § 233.4 Preinspection outside the United States. (a) Form I-425 agreements. A transportation line bringing applicants for admission to the United States through...

Medical status of adolescents at time of admission to a juvenile detention center.

PubMed

Feinstein, R A; Lampkin, A; Lorish, C D; Klerman, L V; Maisiak, R; Oh, M K

1998-03-01

To examine the medical status and history of health care utilization of adolescents at the time of their admission to a juvenile detention facility. Data were collected over an 18-month period on all detainees admitted for the first time to a juvenile detention facility in a major southeastern city in the United States. Information was gathered through a private, confidential interview completed by a medical social worker and a physical examination by a physician. Information was obtained regarding past medical history, complaints at the time of admission, health care utilization, and physical examination. Approximately 10% of teenagers admitted to a detention facility have a significant medical problem (excluding drug/alcohol abuse, or uncomplicated sexually transmitted diseases) that requires medical follow-up. The majority of these conditions were known to the adolescent at the time of admission. Only a third of adolescents admitted to the detention facility reported a regular source of medical care, and only about 20% reported having a private physician. A majority of all the detainees had already fallen behind in or dropped out of school. More than half of the families of the adolescents with a medical problem appeared to be unable or unwilling to assist in ensuring proper medical follow-up. A significant percentage of adolescents entering a detention facility have a medical problem requiring health care services. Detention facilities offer an opportunity to deliver and coordinate medical care to high-risk adolescents. Programs linking public and private health care providers with the correctional care system may provide juveniles with an acceptable option for obtaining needed health care services.

Regional variation in rates of pediatric perforated appendicitis.

PubMed

Sarda, Samir; Short, Heather L; Hockenberry, Jason M; McCarthy, Ian; Raval, Mehul V

2017-09-01

While trends in perforated appendicitis (PA) rates have been studied, regional variability in pediatric admissions for PA remains unknown. A retrospective, cross-sectional analysis of the 2006-2012 Kids' Inpatient Database was conducted to examine variation in PA admission rates by region of the United States and insurance status. PA rates were calculated and reported as per 1000 admissions in accordance with national quality measure specifications. National PA rates per 1000 admissions for 2006, 2009, and 2012 were 313.9, 279.2, and 309.1, respectively. Similarly, all regions demonstrated a statistically significant decrease in PA rates between 2006 and 2009 (p<0.001), where the increase in rates between 2009 and 2012 was only statistically significant in the Midwest [Odds Ratio (OR) 1.07; 95% Confidence Interval (95%CI) 1.03-1.12] and West (OR 1.10; 95% CI 1.07-1.14). The Northeast consistently experienced the lowest PA rates. The odds of PA were highest among uninsured patients (OR 1.35; 95% CI 1.31-1.29). The South had the highest proportion of uninsured children, and these patients had the highest odds of perforation (OR 1.57; 95% CI 1.21-2.02). For children with appendicitis, geographic region and insurance status appear to be associated with perforation upon presentation. Understanding regional variation in pediatric PA rates may inform health policymakers in the constantly evolving insurance coverage landscape. Level III Treatment Study - Retrospective comparative study of appendicitis presentation in children by region of the country. Copyright © 2017 Elsevier Inc. All rights reserved.

Systematic Review of Economic Evaluations of Units Dedicated to Acute Coronary Syndromes.

PubMed

Azeredo-Da-Silva, André Luis Ferreira; Perini, Silvana; Rigotti Soares, Pedro Henrique; Polaczyk, Carisi Anne

2016-01-01

Dedicated units for the care of acute coronary syndrome (ACS) have been submitted to economic evaluations; however, the results have not been systematically presented. To identify and summarize economic outcomes of studies on hospital units dedicated to the initial care of patients with suspected or confirmed ACS. A systematic review of literature to identify economic evaluations of chest pain unit (CPU), coronary care unit (CCU), or equivalent units was done. Two search strategies were used: the first one to identify economic evaluations irrespective of study design, and the second one to identify randomized clinical trials that reported economic outcomes. The following databases were searched: MEDLINE, EMBASE, CENTRAL, and National Health Service (NHS)Economic Evaluation Database. Data extraction was performed by two independent reviewers. Costs were inflated to 2012 values. Search strategies retrieved five partial economic evaluations based on observational studies, six randomized clinical trials that reported economic outcomes, and five model-based economic evaluations. Overall, cost estimates based on observational studies and randomized clinical trials reported statistically significant cost savings of more than 50% with the adoption of CPU care instead of routine hospitalization or CCU care for suspected low-to-intermediate risk patients with ACS (median per-patient cost US $1,969.89; range US $1,002.12-13,799.15). Model-based economic evaluations reported incremental cost-effectiveness ratios below US $ 50,000/quality-adjusted life-year for all comparisons between intermediate care unit, CPU, or CCU with routine hospital admissions. This finding was sensible to myocardial infarction probability. Published economic evaluations indicate that more intensive care is likely to be cost-effective in comparison to routine hospital admission for patients with suspected ACS. Copyright © 2016. Published by Elsevier Inc.

Acute Respiratory Failure in Cardiac Transplant Recipients.

PubMed

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 developed sepsis and hypotension, suggesting a poorer prognosis.

Effect of osteopathic manipulative treatment on gastrointestinal function and length of stay of preterm infants: an exploratory study

PubMed Central

2011-01-01

Background Organizational improvement of neonatal intensive care units requires strict monitoring of preterm infants, including routine assessment of physiological functions of the gastrointestinal system and optimized procedures for the definition of appropriate discharge timing. Methods We conducted a prospective study on the effect of osteopathic manipulative treatment in a cohort of N = 350 consecutive premature infants admitted to a neonatal intensive care unit without any major complication between 2005 and 2008. In addition to ordinary care, N = 162 subjects received osteopathic treatment. Endpoints of the study were differences between study and control groups in terms of excessive length of stay and gastrointestinal symptoms, defined as the upper quartiles in the distribution of the overall population. Statistical analysis was based on crude and adjusted odds ratios from multivariate logistic regression. Results Baseline characteristics were evenly distributed across treated/control groups, except for the rate of infants unable to be oral fed at admission, significantly higher among those undergoing osteopathic care (p = .03). Osteopathic treatment was significantly associated with a reduced risk of an average daily occurrence of gut symptoms per subject above .44 (OR = 0.45; 0.26-0.74). Gestational age lower or equal to 32 weeks, birth weight lower or equal to 1700 grams and no milk consumption at admission were associated with higher rates of length of stay in the unit of at least 28 days, while osteopathic treatment significantly reduced such risk (OR = 0.22;0.09-0.51). Conclusions In a population of premature infants, osteopathic manipulative treatment showed to reduce a high occurrence of gastrointestinal symptoms and an excessive length of stay in the NICU. Randomized control studies are needed to generalize these results to a broad population of high risk newborns. PMID:21711535

Comparison of web-based and face-to-face interviews for application to an anesthesiology training program: a pilot study

PubMed Central

Malkin, Mathew R.; Lenart, John; Stier, Gary R.; Gatling, Jason W.; Applegate II, Richard L.

2016-01-01

Objectives This study compared admission rates to a United States anesthesiology residency program for applicants completing face-to-face versus web-based interviews during the admissions process. We also explored factors driving applicants to select each interview type. Methods The 211 applicants invited to interview for admission to our anesthesiology residency program during the 2014-2015 application cycle were participants in this pilot observational study. Of these, 141 applicants selected face-to-face interviews, 53 applicants selected web-based interviews, and 17 applicants declined to interview. Data regarding applicants' reasons for selecting a particular interview type were gathered using an anonymous online survey after interview completion. Residency program admission rates and survey answers were compared between applicants completing face-to-face versus web-based interviews. Results One hundred twenty-seven (75.1%) applicants completed face-to-face and 42 (24.9%) completed web-based interviews. The admission rate to our residency program was not significantly different between applicants completing face-to-face versus web-based interviews. One hundred eleven applicants completed post-interview surveys. The most common reasons for selecting web-based interviews were conflict of interview dates between programs, travel concerns, or financial limitations. Applicants selected face-to-face interviews due to a desire to interact with current residents, or geographic proximity to the residency program. Conclusions These results suggest that completion of web-based interviews is a viable alternative to completion of face-to-face interviews, and that choice of interview type does not affect the rate of applicant admission to the residency program. Web-based interviews may be of particular interest to applicants applying to a large number of programs, or with financial limitations. PMID:27039029

Severe vitamin D deficiency upon admission in critically ill patients is related to acute kidney injury and a poor prognosis.

PubMed

Zapatero, A; Dot, I; Diaz, Y; Gracia, M P; Pérez-Terán, P; Climent, C; Masclans, J R; Nolla, J

2018-05-01

To evaluate the prevalence of vitamin D deficiency in critically ill patients upon admission to an Intensive Care Unit (ICU) and its prognostic implications. A single-center, prospective observational study was carried out from January to November 2015. Patients were followed-up on until death or hospital discharge. The department of Critical Care Medicine of a university hospital. All adults admitted to the ICU during the study period, without known factors capable of altering serum 25(OH)D concentration. Determination of serum 25(OH)D levels within the first 24h following admission to the ICU. Prevalence and mortality at 28 days. The study included 135 patients, of which 74% presented deficient serum 25(OH)D levels upon admission to the ICU. Non-survivors showed significantly lower levels than survivors (8.14ng/ml [6.17-11.53] vs. 12ng/ml [7.1-20.30]; P=.04], and the serum 25(OH)D levels were independently associated to mortality (OR 2.86; 95% CI 1.05-7.86; P=.04]. The area under the ROC curve was 0.61 (95% CI 0.51-0.75), and the best cut-off point for predicting mortality was 10.9ng/ml. Patients with serum 25(OH)D<10.9ng/ml also showed higher acute kidney injury rates (13 vs. 29%; P=.02). Vitamin D deficiency is highly prevalent upon admission to the ICU. Severe Vitamin D deficiency (25[OH]D<10.9ng/ml) upon admission to the ICU is associated to acute kidney injury and mortality. Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

Diagnostic accuracy of heart fatty acid binding protein (H-FABP) and glycogen phosphorylase isoenzyme BB (GPBB) in diagnosis of acute myocardial infarction in patients with acute coronary syndrome.

PubMed

Cubranic, Zlatko; Madzar, Zeljko; Matijevic, Sanja; Dvornik, Stefica; Fisic, Elizabeta; Tomulic, Vjekoslav; Kunisek, Juraj; Laskarin, Gordana; Kardum, Igor; Zaputovic, Luka

2012-01-01

This study aimed to assess whether heart fatty acid-binding protein (H-FABP) and glycogen phosphorylase isoenzyme BB (GPBB) could be used for the accurate diagnosis of acute myocardial infarction (AMI) in acute coronary syndrome (ACS) patients. The study included 108 ACS patients admitted to a coronary unit within 3 h after chest pain onset. AMI was distinguished from unstable angina (UA) using a classical cardiac troponin I (cTnI) assay. H-FABP and GPBB were measured by ELISA on admission (0 h) and at 3, 6, 12, and 24 h after admission; their accuracy to diagnose AMI was assessed using statistical methods. From 92 patients with ACS; 71 had AMI. H-FABP and GPBB had higher peak value after 3 h from admission than cTnI (P = 0.001). Both markers normalized at 24 h. The area under the receiver operating characteristic curves was significantly greater for both markers in AMI patients than in UA patients at all time points tested, including admission (P < 0.001). At admission, the H-FABP (37%) and GPBB (40%) sensitivities were relatively low. They increased at 3 and 6 h after admission for both markers and decreased again after 24 h. It was 40% for H-FABP and approximately 2-times lower for GPBB (P < 0.01). In AMI patients, both biomarkers had similar specificities, positive- and negative-predictive values, positive and negative likelihood ratios, and risk ratios for AIM. H-FABP and GPBB can contribute to early AMI diagnosis and can distinguish AMI from UA.

Medication reconciliation by a pharmacy technician in a mental health assessment unit.

PubMed

Brownlie, Kay; Schneider, Carl; Culliford, Roger; Fox, Chris; Boukouvalas, Alexis; Willan, Cathy; Maidment, Ian D

2014-04-01

Medication discrepancies are common when patients cross organisational boundaries. However, little is known about the frequency of discrepancies within mental health and the efficacy of interventions to reduce discrepancies. To evaluate the impact of a pharmacy-led reconciliation service on medication discrepancies on admissions to a secondary care mental health trust. In-patient mental health services. Prospective evaluation of pharmacy technician led medication reconciliation for admissions to a UK Mental Health NHS Trust. From March to June 2012 information on any unintentional discrepancies (dose, frequency and name of medication); patient demographics;and type and cause of the discrepancy was collected. The potential for harm was assessed based on two scenarios; the discrepancy was continued into primary care, and the discrepancy was corrected during admission. Logistic regression identified factors associated with discrepancies. Mean number of discrepancies per admission corrected by the pharmacy technician. Unintentional medication discrepancies occurred in 212 of 377 admissions (56.2 %). Discrepancies involving 569 medicines (mean 1.5 medicines per admission) were corrected.The most common discrepancy was omission(n = 464). Severity was assessed for 114 discrepancies. If the discrepancy was corrected within 16 days the potential harm was minor in 71 (62.3 %) cases and moderate in 43(37.7 %) cases whereas if the discrepancy was not corrected the potential harm was minor in 27 (23.7 %) cases and moderate in 87 (76.3 %) cases. Discrepancies were associated with both age and number of medications; the stronger association was age. Medication discrepancies are common within mental health services with potentially significant consequences for patients.Trained pharmacy technicians are able to reduce the frequency of discrepancies, improving safety.

The Utility of the Systemic Inflammatory Respsonse Syndrome Score on Admission in Children With Acute Pancreatitis.

PubMed

Grover, Amit S; Kadiyala, Vivek; Banks, Peter A; Grand, Richard J; Conwell, Darwin L; Lightdale, Jenifer R

2017-01-01

Pediatric patients with acute pancreatitis (AP) may meet criteria at admission for the systemic inflammatory response syndrome (SIRS). Early SIRS in adults with AP is associated with severe disease. Our aim was to evaluate the importance of SIRS in children presenting with AP on various outcomes. This is a retrospective cohort study of children hospitalized with AP at Boston Children's Hospital in 2010. Increased length of stay (LOS) and/or admission to the intensive care unit (ICU) served as the primary outcomes. Statistical analyses of measures studied included the presence of SIRS, demographic, and clinical information present on admission. Fifty encounters, in which AP was the primary admitting diagnosis, were documented. Patients had a median LOS of 4.5 (interquartile range, 2-9) days. Systemic inflammatory response syndrome was present in 22 (44%) of 50 patients at admission. Systemic inflammatory response syndrome at admission was an independent predictor of increased LOS (odds ratio, 7.99; P = 0.045) as well as admission to the ICU (odds ratio, 12.06; P = 0.027). The presence of SIRS criteria on admission serves as a useful and easy-to-calculate predictor of increased LOS and admission to ICU in children with AP.

Predicting academic performance and clinical competency for international dental students: seeking the most efficient and effective measures.

PubMed

Stacey, D Graham; Whittaker, John M

2005-02-01

Measures used in the selection of international dental students to a U.S. D.D.S. program were examined to identify the grouping that most effectively and efficiently predicted academic performance and clinical competency. Archival records from the International Dental Program (IDP) at Loma Linda University provided data on 171 students who had trained in countries outside the United States. The students sought admission to the D.D.S. degree program, successful completion of which qualified them to sit for U.S. licensure. As with most dental schools, competition is high for admission to the D.D.S. program. The study's goal was to identify what measures contributed to a fair and accurate selection process for dental school applicants from other nations. Multiple regression analyses identified National Board Part II and dexterity measures as significant predictors of academic performance and clinical competency. National Board Part I, TOEFL, and faculty interviews added no significant additional help in predicting eventual academic performance and clinical competency.

The clinical relevance of the Waterlow pressure sore risk scale in the ICU.

PubMed

Weststrate, J T; Hop, W C; Aalbers, A G; Vreeling, A W; Bruining, H A

1998-08-01

To evaluate whether the Waterlow pressure sore risk (PSR) scale has prognostic significance for intensive care patients. A prospective study. The surgical intensive care unit (ICU) of the University Hospital Rotterdam. Data were evaluated from 594 patients who had been admitted to the ICU during the year 1994. Each patient was assessed daily with respect to their Waterlow PSR score and the development of pressure sores in the sacral region. Actuarial statistical methods were used to analyse the predictive value of the risk score. When a patient had a Waterlow PSR score > 25 on admission, the risk of developing a pressure sore was significantly increased compared to patients with a PSR score < 25. After admission, the daily Waterlow PSR scores obtained were significantly associated with the risk of developing a pressure sore. For each additional point this risk increased by 23% (95% confidence interval 17 to 28%). The Waterlow PSR scale provides the medical and nursing staff at an early stage with reliable information about the risk patients have in developing a pressure sore.

Lactate clearance as a marker of mortality in pediatric intensive care unit.

PubMed

Munde, A; Kumar, N; Beri, R S; Puliyel, J M

2014-07-01

To correlate lactate clearance with Pediatric Intensive Care Unit (PICU) mortality. 45 (mean age 40.15 mo, 60% males) consecutive admissions in the PICU were enrolled between May 2012 to June 2013. Lactate clearance (Lactate level at admission - level 6 hr later x 100 / lactate level at admission) in first 6 hours of hospitalization was correlated to in-hospital mortality and PRISM score. Twelve out of 45 patients died. 90% died among those with delayed/poor clearance (clearance <30%) compared to 8.5% in those with good clearance (clearance >30%) (P<0.001). Lactate clearance <30% predicted mortality with sensitivity of 75%, specificity of 97%, positive predictive value of 90%, and negative predictive value of 91.42%. Predictability was comparable to PRISM score >30. Lactate clearance at six hours correlates with mortality in the PICU.

Predictors of Hospitalization and Admission to Intensive Care Units of Influenza Patients in Serbia through Four Influenza Seasons from 2010/2011 to 2013/2014.

PubMed

Dimitrijević, Dragana; Ilić, Dragan; Rakić Adrović, Slavica; Šuljagić, Vesna; Pelemiš, Mijomir; Stevanović, Goran; Milinković, Milunka; Šipetić Grujićić, Sandra

2017-05-24

A retrospective analysis of the surveillance data on laboratory confirmed cases of influenza in 4 post pandemic seasons in Serbia was performed to evaluate predictors of hospitalization and admission to intensive care units (ICU). The specimens, including nasal and throat swabs were tested for influenza. Univariate and multivariate logistic regression analyses were performed. Data of a total of 777 confirmed influenza cases were analyzed. Age > 65 years, the presence of any co-morbidity or the presence of ≥ 2 comorbidities, infection with influenza virus subtype A (H1) pdm09, and an interval greater than 3 days between symptom onset and the first physician visit, were independently associated with hospital admission. These variables, as well as infection with non-subtype influenza virus A, were predictors for ICU admission. Obesity and chronic neurological disease were independent predictors for ICU admission but not hospitalization. Overall, 41.7% of patients with influenza had at least one co-morbidity, but only 3% of all patients were vaccinated against influenza. Identification of high risk groups and education of these groups regarding their increased susceptibility to severe forms of influenza, and in particular regarding the importance of influenza vaccination, is essential.

Psychosocial resiliency is associated with lower emotional distress among dyads of patients and their informal caregivers in the neuroscience intensive care unit.

PubMed

Shaffer, Kelly M; Riklin, Eric; Jacobs, Jamie M; Rosand, Jonathan; Vranceanu, Ana-Maria

2016-12-01

The purpose of the study is to examine the associations of patients' and their informal caregivers' psychosocial resiliency factors with their own and their partners' emotion domains (distress, anxiety, depression, and anger) after admission to the neuroscience intensive care unit (Neuro-ICU). Eighty-three dyads of patients (total n = 87) and their informal caregivers (total n = 99) participated in this observational, cross-sectional study by self-reporting demographics and measures of resiliency factors (mindfulness [Cognitive and Affective Mindfulness Scale Revised], coping [Measure of Coping Status-A], intimate bond [Intimate Bond Measure], self-efficacy [patients: General Self-Efficacy Scale; caregivers: Revised Caregiver Self-Efficacy Scale]) and emotion domains (Emotion Thermometers) within 2 weeks of Neuro-ICU admission. There were no differences between patients' and caregivers' levels of psychosocial resiliency, distress, or anxiety. Patients reported greater depression and anger relative to their caregivers. Overall, roughly half of patients (50.6%) and caregivers (42.4%) reported clinically significant emotional distress. Patients' and caregivers' own psychosocial resiliency factors were associated with their own, but not their partner's, emotion domains. Findings of high distress among both patients and caregivers at admission emphasize the importance of attending to the mental health of both patients and caregivers in the Neuro-ICU. As modifiable psychosocial resiliency factors were associated with emotion domains for both patients and caregivers, interventions to enhance these factors may ameliorate emotional distress among these vulnerable populations. Copyright © 2016 Elsevier Inc. All rights reserved.

Evaluating the validity of an integrity-based situational judgement test for medical school admissions.

PubMed

Husbands, Adrian; Rodgerson, Mark J; Dowell, Jon; Patterson, Fiona

2015-09-02

While the construct of integrity has emerged as a front-runner amongst the desirable attributes to select for in medical school admissions, it is less clear how best to assess this characteristic. A potential solution lies in the use of Situational Judgement Tests (SJTs) which have gained popularity due to robust psychometric evidence and potential for large-scale administration. This study aims to explore the psychometric properties of an SJT designed to measure the construct of integrity. Ten SJT scenarios, each with five response stems were developed from critical incident interviews with academic and clinical staff. 200 of 520 (38.5 %) Multiple Mini Interview candidates at Dundee Medical School participated in the study during the 2012-2013 admissions cycle. Participants were asked to rate the appropriateness of each SJT response on a 4-point likert scale as well as complete the HEXACO personality inventory and a face validity questionnaire. Pearson's correlations and descriptive statistics were used to examine the associations between SJT score, HEXACO personality traits, pre-admissions measures namely academic and United Kingdom Clinical Aptitude Test (UKCAT) scores, as well as acceptability. Cronbach's alpha reliability for the SJT was .64. Statistically significant correlations ranging from .16 to .36 (.22 to .53 disattenuated) were observed between SJT score and the honesty-humility (integrity), conscientiousness, extraversion and agreeableness dimensions of the HEXACO inventory. A significant correlation of .32 (.47 disattenuated) was observed between SJT and MMI scores and no significant relationship with the UKCAT. Participant reactions to the SJTs were generally positive. Initial findings are encouraging regarding the psychometric robustness of an integrity-based SJT for medical student selection, with significant associations found between the SJTs, integrity, other desirable personality traits and the MMI. The SJTs showed little or no redundancy with cognitive ability. Results suggest that carefully-designed SJTs may augment more costly MMIs.

Availability of Pre-Admission Information to Prospective Graduate Students in Speech-Language Pathology

ERIC Educational Resources Information Center

Tekieli Koay, Mary Ellen; Lass, Norman J.; Parrill, Madaline; Naeser, Danielle; Babin, Kelly; Bayer, Olivia; Cook, Megan; Elmore, Madeline; Frye, Rachel; Kerwood, Samantha

2016-01-01

An extensive Internet search was conducted to obtain pre-admission information and acceptance statistics from 260 graduate programmes in speech-language pathology accredited by the American Speech-Language-Hearing Association (ASHA) in the United States. ASHA is the national professional, scientific and credentialing association for members and…

The Assessment of Prior Experiential Learning in Universities' Admissions Procedures.

ERIC Educational Resources Information Center

West, Linden; Fraser, Wilma

A project studied use of assessment of prior experiential learning (APEL) in admissions to part-time degrees and diplomas at the University of Kent at Canterbury (England, United Kingdom). The APEL course was highlighted in brochures advertising part-time degree, diploma, and Access courses. Interviews with 40 applicants explained APEL and…

78 FR 62415 - Refugee Admissions for Fiscal Year 2014

Federal Register 2010, 2011, 2012, 2013, 2014

2013-10-21

... number of admissions allocated to the East Asia region shall include persons admitted to the United...) of Public Law 100-202 (Amerasian immigrants and their family members): Africa 15,000 East Asia 14,000 Europe and Central Asia........ 1,000 Latin America/Caribbean........ 5,000 Near East/South Asia 33,000...

Coupling Admissions and Curricular Data to Predict Medical Student Outcomes

ERIC Educational Resources Information Center

Sesate, Diana B.; Milem, Jeffrey F.; McIntosh, Kadian L.; Bryan, W. Patrick

2017-01-01

The relative impact of admissions factors and curricular measures on the first medical licensing exam (United States Medical Licensing Exam [USMLE] Step 1) scores is examined. The inclusion of first-year and second-year curricular measures nearly doubled the variance explained in Step 1 scores from the amount explained by the combination of…

Speaking in Tongues: Can International Graduate Students Read International Graduate Admissions Materials?

ERIC Educational Resources Information Center

Taylor, Zachary W.

2017-01-01

A recent Educational Testing Services report (2016) found that international graduate students with a TOEFL score of 80--the minimum average TOEFL score for graduate admission in the United States--usually possess reading subscores of 20, equating to a 12th-grade reading comprehension level. However, one public flagship university's international…

Fairness and Fate in Elite College Admissions

ERIC Educational Resources Information Center

Handel, Stephen J.

2017-01-01

The University of California (UC) is a research-intensive institution that is widely considered to be the best public university system in the United States. A total of 147 years of sustained academic distinction has made admission to UC's nine undergraduate campuses among the most competitive in the nation. More students apply to UC than any…

A new risk prediction model for critical care: the Intensive Care National Audit & Research Centre (ICNARC) model.

PubMed

Harrison, David A; Parry, Gareth J; Carpenter, James R; Short, Alasdair; Rowan, Kathy

2007-04-01

To develop a new model to improve risk prediction for admissions to adult critical care units in the UK. Prospective cohort study. The setting was 163 adult, general critical care units in England, Wales, and Northern Ireland, December 1995 to August 2003. Patients were 216,626 critical care admissions. None. The performance of different approaches to modeling physiologic measurements was evaluated, and the best methods were selected to produce a new physiology score. This physiology score was combined with other information relating to the critical care admission-age, diagnostic category, source of admission, and cardiopulmonary resuscitation before admission-to develop a risk prediction model. Modeling interactions between diagnostic category and physiology score enabled the inclusion of groups of admissions that are frequently excluded from risk prediction models. The new model showed good discrimination (mean c index 0.870) and fit (mean Shapiro's R 0.665, mean Brier's score 0.132) in 200 repeated validation samples and performed well when compared with recalibrated versions of existing published risk prediction models in the cohort of patients eligible for all models. The hypothesis of perfect fit was rejected for all models, including the Intensive Care National Audit & Research Centre (ICNARC) model, as is to be expected in such a large cohort. The ICNARC model demonstrated better discrimination and overall fit than existing risk prediction models, even following recalibration of these models. We recommend it be used to replace previously published models for risk adjustment in the UK.

Imperfect physician assistant and physical therapist admissions processes in the United States

PubMed Central

2014-01-01

We compared and contrasted physician assistant and physical therapy profession admissions processes based on the similar number of accredited programs in the United States and the co-existence of many programs in the same school of health professions, because both professions conduct similar centralized application procedures administered by the same organization. Many studies are critical of the fallibility and inadequate scientific rigor of the high-stakes nature of health professions admissions decisions, yet typical admission processes remain very similar. Cognitive variables, most notably undergraduate grade point averages, have been shown to be the best predictors of academic achievement in the health professions. The variability of non-cognitive attributes assessed and the methods used to measure them have come under increasing scrutiny in the literature. The variance in health professions students’ performance in the classroom and on certifying examinations remains unexplained, and cognitive considerations vary considerably between and among programs that describe them. One uncertainty resulting from this review is whether or not desired candidate attributes highly sought after by individual programs are more student-centered or graduate-centered. Based on the findings from the literature, we suggest that student success in the classroom versus the clinic is based on a different set of variables. Given the range of positions and general lack of reliability and validity in studies of non-cognitive admissions attributes, we think that health professions admissions processes remain imperfect works in progress. PMID:24810020

[Medical short stay unit for geriatric patients in the emergency department: clinical and healthcare benefits].

PubMed

Pareja, Teresa; Hornillos, Mercedes; Rodríguez, Miriam; Martínez, Javier; Madrigal, María; Mauleón, Coro; Alvarez, Bárbara

2009-01-01

To evaluate the impact of comprehensive geriatric assessment and management of high-risk elders in a medical short stay unit located in the emergency department of a general hospital. We performed a descriptive, prospective study of patients admitted to the medical short stay unit for geriatric patients of the emergency department in 2006. A total of 749 patients were evaluated, with a mean (standard deviation) stay in the unit of 37 (16) h. The mean age was 86 (7) years; 57% were women, and 50% had moderate-severe physical impairment and dementia. Thirty-five percent lived in a nursing home. The most frequent reason for admission was exacerbation of chronic cardiopulmonary disease. Multiple geriatric syndromes were identified. The most frequent were immobility, pressure sores and behavioral disorders related to dementia. Seventy percent of the patients were discharged to home after being stabilized and were followed-up by the geriatric clinic and day hospital (39%), the home care medical team (11%), or the nursing home or primary care physician (20%). During the month after discharge, 17% were readmitted and 7.7% died, especially patients with more advanced age or functional impairment. After the unit was opened, admissions to the acute geriatric unit fell by 18.2%. Medical short stay units for geriatric patients in emergency departments may be useful for geriatric assessment and treatment of exacerbations of chronic diseases. These units can help to reduce the number of admissions and optimize the care provided in other ambulatory and domiciliary geriatric settings.

Stressors in the relatives of patients admitted to an intensive care unit.

PubMed

Barth, Angélica Adam; Weigel, Bruna Dorfey; Dummer, Claus Dieter; Machado, Kelly Campara; Tisott, Taís Montagner

2016-09-01

To identify and stratify the main stressors for the relatives of patients admitted to the adult intensive care unit of a teaching hospital. Cross-sectional descriptive study conducted with relatives of patients admitted to an intensive care unit from April to October 2014. The following materials were used: a questionnaire containing identification information and demographic data of the relatives, clinical data of the patients, and 25 stressors adapted from the Intensive Care Unit Environmental Stressor Scale. The degree of stress caused by each factor was determined on a scale of values from 1 to 4. The stressors were ranked based on the average score obtained. The main cause of admission to the intensive care unit was clinical in 36 (52.2%) cases. The main stressors were the patient being in a state of coma (3.15 ± 1.23), the patient being unable to speak (3.15 ± 1.20), and the reason for admission (3.00 ± 1.27). After removing the 27 (39.1%) coma patients from the analysis, the main stressors for the relatives were the reason for admission (2.75 ± 1.354), seeing the patient in the intensive care unit (2.51 ± 1.227), and the patient being unable to speak (2.50 ± 1.269). Difficulties in communication and in the relationship with the patient admitted to the intensive care unit were identified as the main stressors by their relatives, with the state of coma being predominant. By contrast, the environment, work routines, and relationship between the relatives and intensive care unit team had the least impact as stressors.

Care in specialist medical and mental health unit compared with standard care for older people with cognitive impairment admitted to general hospital: randomised controlled trial (NIHR TEAM trial)

PubMed Central

Goldberg, Sarah E; Bradshaw, Lucy E; Kearney, Fiona C; Russell, Catherine; Whittamore, Kathy H; Foster, Pippa E R; Mamza, Jil; Gladman, John R F; Jones, Rob G; Lewis, Sarah A; Porock, Davina

2013-01-01

Objective To develop and evaluate a best practice model of general hospital acute medical care for older people with cognitive impairment. Design Randomised controlled trial, adapted to take account of constraints imposed by a busy acute medical admission system. Setting Large acute general hospital in the United Kingdom. Participants 600 patients aged over 65 admitted for acute medical care, identified as “confused” on admission. Interventions Participants were randomised to a specialist medical and mental health unit, designed to deliver best practice care for people with delirium or dementia, or to standard care (acute geriatric or general medical wards). Features of the specialist unit included joint staffing by medical and mental health professionals; enhanced staff training in delirium, dementia, and person centred dementia care; provision of organised purposeful activity; environmental modification to meet the needs of those with cognitive impairment; delirium prevention; and a proactive and inclusive approach to family carers. Main outcome measures Primary outcome: number of days spent at home over the 90 days after randomisation. Secondary outcomes: structured non-participant observations to ascertain patients’ experiences; satisfaction of family carers with hospital care. When possible, outcome assessment was blind to allocation. Results There was no significant difference in days spent at home between the specialist unit and standard care groups (median 51 v 45 days, 95% confidence interval for difference −12 to 24; P=0.3). Median index hospital stay was 11 versus 11 days, mortality 22% versus 25% (−9% to 4%), readmission 32% versus 35% (−10% to 5%), and new admission to care home 20% versus 28% (−16% to 0) for the specialist unit and standard care groups, respectively. Patients returning home spent a median of 70.5 versus 71.0 days at home (−6.0 to 6.5). Patients on the specialist unit spent significantly more time with positive mood or engagement (79% v 68%, 2% to 20%; P=0.03) and experienced more staff interactions that met emotional and psychological needs (median 4 v 1 per observation; P<0.001). More family carers were satisfied with care (overall 91% v 83%, 2% to 15%; P=0.004), and severe dissatisfaction was reduced (5% v 10%, −10% to 0%; P=0.05). Conclusions Specialist care for people with delirium and dementia improved the experience of patients and satisfaction of carers, but there were no convincing benefits in health status or service use. Patients’ experience and carers’ satisfaction might be more appropriate measures of success for frail older people approaching the end of life. Trial registration Clinical Trials NCT01136148 PMID:23819964

Assessment of Communications-related Admissions Criteria in a Three-year Pharmacy Program

PubMed Central

Tejada, Frederick R.; Lang, Lynn A.; Purnell, Miriam; Acedera, Lisa; Ngonga, Ferdinand

2015-01-01

Objective. To determine if there is a correlation between TOEFL and other admissions criteria that assess communications skills (ie, PCAT variables: verbal, reading, essay, and composite), interview, and observational scores and to evaluate TOEFL and these admissions criteria as predictors of academic performance. Methods. Statistical analyses included two sample t tests, multiple regression and Pearson’s correlations for parametric variables, and Mann-Whitney U for nonparametric variables, which were conducted on the retrospective data of 162 students, 57 of whom were foreign-born. Results. The multiple regression model of the other admissions criteria on TOEFL was significant. There was no significant correlation between TOEFL scores and academic performance. However, significant correlations were found between the other admissions criteria and academic performance. Conclusion. Since TOEFL is not a significant predictor of either communication skills or academic success of foreign-born PharmD students in the program, it may be eliminated as an admissions criterion. PMID:26430273

Assessment of Communications-related Admissions Criteria in a Three-year Pharmacy Program.

PubMed

Parmar, Jayesh R; Tejada, Frederick R; Lang, Lynn A; Purnell, Miriam; Acedera, Lisa; Ngonga, Ferdinand

2015-08-25

To determine if there is a correlation between TOEFL and other admissions criteria that assess communications skills (ie, PCAT variables: verbal, reading, essay, and composite), interview, and observational scores and to evaluate TOEFL and these admissions criteria as predictors of academic performance. Statistical analyses included two sample t tests, multiple regression and Pearson's correlations for parametric variables, and Mann-Whitney U for nonparametric variables, which were conducted on the retrospective data of 162 students, 57 of whom were foreign-born. The multiple regression model of the other admissions criteria on TOEFL was significant. There was no significant correlation between TOEFL scores and academic performance. However, significant correlations were found between the other admissions criteria and academic performance. Since TOEFL is not a significant predictor of either communication skills or academic success of foreign-born PharmD students in the program, it may be eliminated as an admissions criterion.

Variation in critical care services across North America and Western Europe.

PubMed

Wunsch, Hannah; Angus, Derek C; Harrison, David A; Collange, Olivier; Fowler, Robert; Hoste, Eric A J; de Keizer, Nicolette F; Kersten, Alexander; Linde-Zwirble, Walter T; Sandiumenge, Alberto; Rowan, Kathryn M

2008-10-01

Critical care represents a large percentage of healthcare spending in developed countries. Yet, little is known regarding international variation in critical care services. We sought to understand differences in critical care delivery by comparing data on the distribution of services in eight countries. Retrospective review of existing national administrative data. We identified sources of data in each country to provide information on acute care hospitals and beds, intensive care units and beds, intensive care admissions, and definitions of intensive care beds. Data were all referenced and from as close to 2005 as possible. United States, France, United Kingdom, Canada, Belgium, Germany, The Netherlands, and Spain. Not available. None. No standard definition existed for acute care hospital or intensive care unit beds across countries. Hospital beds varied three-fold from 221/100,000 population in the United States to 593/100,000 in Germany. Adult intensive care unit beds also ranged seven-fold from 3.3/100,000 population in the United Kingdom to 24.0/100,000 in Germany. Volume of intensive care unit admissions per year varied ten-fold from 216/100,000 population in the United Kingdom to 2353/100,000 in Germany. The ratio of intensive care unit beds to hospital beds was highly correlated across all countries except the United States (r = .90). There was minimal correlation between the number of intensive care unit beds per capita and health care spending per capita (r = .45), but high inverse correlation between intensive care unit beds and hospital mortality for intensive care unit patients across countries (r = -.82). Absolute critical care services vary dramatically between countries with wide differences in both numbers of beds and volume of admissions. The number of intensive care unit beds per capita is not strongly correlated with overall health expenditure, but does correlate strongly with mortality. These findings demonstrate the need for critical care data from all countries, as they are essential for interpretation of studies, and policy decisions regarding critical care services.

Variability in the organisation and management of hospital care for COPD exacerbations in the UK.

PubMed

Hosker, Harold; Anstey, Katharine; Lowe, Derek; Pearson, Michael; Roberts, C Michael

2007-04-01

Previous smaller UK audits have demonstrated wide variation in organisation, resources, and process of care for acute chronic obstructive pulmonary disease (COPD) admissions. Smallest units appeared to do less well. UK acute hospitals supplied information on (1) resources and organisation of care, (2) clinical data on process of care and outcomes for up to 40 consecutive COPD admissions. Comparisons were made against national recommendations. Eight thousand and thirteen admissions involved 7529 patients from 233 units (93% of UK acute Trusts). Twenty-six percent of units had at most one whole-time equivalent respiratory consultant while 12% had at least four. Thirty percent patients were admitted under a respiratory specialist and 48% discharged under their care whilst 28% had no specialist input at all. Variation in care provision was wide across all hospitals but patients in smaller hospitals had less access to specialist respiratory or admission wards, pulmonary rehabilitation programs, specialty triage or an early discharge scheme. Six percent of units did not have access to NIV and 18% to invasive ventilatory support. There remains wide variation in all aspects of acute hospital COPD care in the UK, with smaller hospitals offering fewest services. Those receiving specialist input are more likely to be offered interventions of proven effect. Management guidelines alone are insufficient to address inequalities of care and a clear statement of minimum national standards for resource provision and organisation of COPD care are required. This study provides a unique insight into the current state of care for patients admitted with COPD exacerbations in the UK.

Black Clouds vs Random Variation in Hospital Admissions.

PubMed

Ong, Luei Wern; Dawson, Jeffrey D; Ely, John W

2018-06-01

Physicians often accuse their peers of being "black clouds" if they repeatedly have more than the average number of hospital admissions while on call. Our purpose was to determine whether the black-cloud phenomenon is real or explainable by random variation. We analyzed hospital admissions to the University of Iowa family medicine service from July 1, 2010 to June 30, 2015. Analyses were stratified by peer group (eg, night shift attending physicians, day shift senior residents). We analyzed admission numbers to find evidence of black-cloud physicians (those with significantly more admissions than their peers) and white-cloud physicians (those with significantly fewer admissions). The statistical significance of whether there were actual differences across physicians was tested with mixed-effects negative binomial regression. The 5-year study included 96 physicians and 6,194 admissions. The number of daytime admissions ranged from 0 to 10 (mean 2.17, SD 1.63). Night admissions ranged from 0 to 11 (mean 1.23, SD 1.22). Admissions increased from 1,016 in the first year to 1,523 in the fifth year. We found 18 white-cloud and 16 black-cloud physicians in simple regression models that did not control for this upward trend. After including study year and other potential confounding variables in the regression models, there were no significant associations between physicians and admission numbers and therefore no true black or white clouds. In this study, apparent black-cloud and white-cloud physicians could be explained by random variation in hospital admissions. However, this randomness incorporated a wide range in workload among physicians, with potential impact on resident education at the low end and patient safety at the high end.

Temperature changes, temperature extremes, and their relationship to emergency department visits and hospitalizations for sickle cell crisis.

PubMed

Smith, Wally R; Coyne, Patrick; Smith, Virginia S; Mercier, Bruce

2003-09-01

Weather changes are among the proposed precursors of painful sickle cell crises. However, epidemiologic data are mixed regarding the relationship between ambient temperature and crisis frequency. To study this relationship among a local sickle cell disease population, emergency department (ED) visits and admissions were evaluated in adults with sickle cell crisis as the primary diagnosis at a major teaching hospital in a temperate climate. Official daily ambient temperatures (average for that day) were obtained from the National Climate Data Center for the days patients visited the ED or were hospitalized, and for 24 or 48 hours prior. Daily ED visit counts and admission counts were correlated with the visit/admission day's ambient temperature, with the ambient temperature 24 hours before admission, and with the magnitude of change in daily ambient temperature over the prior 24 or 48 hours. For all correlations, statistical significance was defined as a p value of <0.01 and clinical significance was defined as a moderate or greater correlation, absolute value of r >/= 0.30. ED visits or admissions correlated statistically, but not clinically, with daily temperatures. On days when temperatures were <32 degrees F or >80 degrees F, these correlations were statistically significant, but clinical significance was variable. ED visits or admissions correlated only statistically with temperatures 24 hours prior, even on days when temperatures were <32 degrees F. When temperatures were >80 degrees F, the correlations were statistically significant, but there was a reverse, clinically significant correlation between admissions and temperatures. Finally, only statistically significant correlations were found between ED visits or admissions and change in temperature over the prior 24 or 48 hours. Weak or inconsistent confirmation of a relationship was found between daily ambient temperatures and ED visits or hospital admissions for sickle cell crises.

[Involuntary admission of addict during early pregnancy].

PubMed

Hondius, Adger J K; Stikker, Tineke E; Wennink, J M B Hanneke; Honig, Adriaan

2012-01-01

A 30-year-old cocaine-dependent woman was 16 weeks pregnant. Because of possible endangerment of the fetus, an involuntary provisional admission was authorized. Of particular interest is the application of the Dutch Act on Formal Admissions to Psychiatric Hospitals for the primary diagnosis 'addiction' and the fact that the fetus was regarded as a legal 'other'. In severe cases of addiction combined with pregnancy an earlier intervention is needed and arrangement of accelerated legal custody of the newborn before birth should be considered. For the protection of the unborn, we advocate a stricter application of the United Nations Convention on the Rights of the Child. Information for addicted women with preconception counselling can help prevent a compulsory admission.

Validating use of a critical thinking test for the dental admission test.

PubMed

Tsai, Tsung-Hsun

2014-04-01

The purpose of this study was to validate the use of a test to assess dental school applicants' critical thinking abilities. The intent was to include this test on the Dental Admission Test (DAT) if it was shown to enhance the DAT's validity. Correlation and regression analyses of undergraduate and dental school performance with scores on each of the tests on the DAT battery and the California Critical Thinking Skills Test (CCTST) were performed. Data were collected from 439 third- and fourth-year dental students who consented to participate and were enrolled at one of the ten accredited dental schools included in the study. These ten dental schools were from most regions of the United States. This study concluded that including the CCTST on the DAT did not significantly enhance the DAT's validity.

A medium-term follow-up study of a cohort of Chinese patients after first hospitalisation in a gazetted hospital for mania.

PubMed

Cheung, K Y; Dunn, E L W

2010-03-01

To study the characteristics of a cohort of first-episode manic patients treated in a regional psychiatric unit in Hong Kong, to explore the predictors of re-admission, and to investigate their functional outcomes 4 years after first hospitalisation. This was a medium-term follow-up study, using retrospective review of hospital records and clinical interviews at follow-up. Forty-four Chinese patients diagnosed as having their first-episode mania were discharged from a gazetted psychiatric ward in Hong Kong between January 1999 and June 2002. Their clinical characteristics on admission and prescribed medications on discharge were investigated. Their re-admission status was charted. The patients were contacted for follow-up assessment of their functional outcome at 4 years after their first hospitalisation. In our cohort of 44 patients, their first-episode mania mostly presented in young adulthood, as significantly disturbed behaviour deemed to require compulsory admission. Nineteen (43%) of the patients were re-admitted at least once within 4 years of being discharged, 6 of whom were re-admitted more than once. Compulsory admission at the first-episode mania predicted future re-admission. Alcohol and substance abuse were associated with earlier re-admission after the first-episode mania. None of the patients died. For those who were reassessed (28 patients), most lived with family members. In all, 21 patients were able to sustain open employment at 4 years after discharge. About half (n = 14) of the traceable patients were able to continue in full-time employment at 4 years, while 7 were doing part-time work. The median Global Assessment of Functioning score of the traceable group was 88. The results of this local study on patients with their first-episode of hospitalisation for mania were comparable to findings reported in western studies.

Is there a weekend effect in hip fracture patients presenting to a United Kingdom teaching hospital?

PubMed Central

Mathews, John Abraham; Vindlacheruvu, Madhavi; Khanduja, Vikas

2016-01-01

AIM To compare mortality and time-to-surgery of patients admitted with hip fracture to our teaching hospital on weekdays vs weekends. METHODS Data was prospectively collected and retrospectively analysed for 816 hip fracture patients. Multivariate logistic regression was carried out on 3 binary outcomes (time-to-surgery < 36 h; 30-d mortality; 120-d mortality), using the explanatory variables time-of-admission; age; gender; American Society of Anesthesiologist (ASA) grade; abbreviated mental test score (AMTS); fracture type; accommodation admitted from; walking ability outdoors; accompaniment outdoors and season. RESULTS Baseline characteristics were not statistically different between those admitted on weekdays vs weekends. Weekend admission was not associated with an increased time-to-surgery (P = 0.975), 30-d mortality (P = 0.842) or 120-d mortality (P = 0.425). Gender (P = 0.028), ASA grade (P < 0.001), AMTS (P = 0.041) and accompaniment outdoors (P = 0.033) were significant co-variates for 30-d mortality. Furthermore, age (P < 0.001), gender (P = 0.011), ASA grade (P < 0.001), AMTS (P < 0.001) and accompaniment outdoors (P = 0.033) all significantly influenced mortality at 120 d. ASA (P < 0.001) and season (P = 0.014) had significant effect on the odds of undergoing surgery in under 36 h. CONCLUSION Weekend admission was not associated with increased time-to-surgery or mortality in hip fracture patients. Demographic factors affect mortality in accordance with previous published reports. PMID:27795950

Blood glucose control for patients with acute coronary syndromes in Qatar.

PubMed

Wilby, Kyle John; Elmekaty, Eman; Abdallah, Ibtihal; Habra, Masa; Al-Siyabi, Khalid

2016-01-01

Blood glucose is known to be elevated in patients presenting with acute coronary syndromes. However a gap in knowledge exists regarding effective management strategies once admitted to acute care units. It is also unknown what factors (if any) predict elevated glucose values during initial presentation. OBJECTIVES of the study were to characterize blood glucose control in patients admitted to the cardiac care unit (CCU) in Qatar and to determine predictive factors associated with high glucose levels (>10 mmol/l) on admission to the CCU. All data for this study were obtained from the CCU at Heart Hospital in Doha, Qatar. A retrospective chart review was completed for patients admitted to the CCU in Qatar from October 1st, 2012 to March 31st, 2013, of which 283 were included. Baseline characteristics (age, gender, nationality, medical history, smoking status, type of acute coronary syndrome), capillary and lab blood glucose measurements, and use of insulin were extracted. Time spent in glucose ranges of <4, 4 to <8, 8 to <10, and >10 mmol/1 was calculated manually. Univariate and multivariate logistic regression were performed to assess factors associated with high glucose on admission. The primary analysis was completed with capillary data and a sensitivity analysis was completed using laboratory data. Blood glucose values measured on admission and throughout length of stay in the CCU. Capillary blood glucose data showed majority of time was spent in the range of >10 mmol/l (41.95%), followed by 4-8 mmol/l (35.44%), then 8-10 mmol/l (21.45%), and finally <4 mmol/l (1.16%). As a sensitivity analysis, laboratory data showed very similar findings. Diabetes, hypertension, and non-smoker status predicted glucose values >10 mmol/l on admission (p < 0.05) in a univariate analysis but only diabetes remained significant in a multivariate model (OR 23.3; 95% CI, 11.5-47.3). Diabetes predicts high glucose values on hospital admission for patients with ACS and patients are not being adequately controlled throughout CCU stay.

Rhabdomyolysis and acute kidney injury: creatine kinase as a prognostic marker and validation of the McMahon Score in a 10-year cohort: A retrospective observational evaluation.

PubMed

Simpson, Joanna P; Taylor, Andrew; Sudhan, Nazneen; Menon, David K; Lavinio, Andrea

2016-12-01

High-volume fluid resuscitation and the administration of sodium bicarbonate and diuretics have a theoretical renoprotective role in patients at high risk of acute kidney injury (AKI) following rhabdomyolysis. Abnormally elevated creatine kinase has previously been used as a biological marker for the identification of patients at high risk of AKI following rhabdomyolysis. To assess the sensitivity and specificity of plasma creatine kinase (admission and peak values) for the prediction of AKI requiring renal replacement therapy (RRT) or of death in patients with confirmed rhabdomyolysis. To compare the diagnostic performance of creatine kinase with the McMahon score. Retrospective observational study. Data collection included McMahon and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores; daily creatine kinase; daily creatinine and electrolytes; ICU length of stay and mortality. Neurosciences and Trauma Critical Care Unit (Cambridge, UK). In total, 232 adults with confirmed rhabdomyolysis (creatine kinase > 1000 Ul) admitted to Neurosciences and Trauma Critical Care Unit between 2002 and 2012. AKI, RRT and mortality. Forty-five (19%) patients developed AKI and 29 (12.5%) patients required RRT. Mortality was significantly higher in patients who developed AKI (62 vs. 18%, P < 0.001). Average creatine kinase on admission was 5009 (range 69-157 860) Ul. Creatine kinase peaked between the day of admission and day 3 in 91% of cases. PEAK creatine kinase of at least 5000 Ul is 55% specific and 83% sensitive for the prediction of AKI requiring RRT. A McMahon Score of at least 6 calculated on admission is 68% specific and 86% sensitive for RRT. Creatine kinase is not a specific or early predictor of AKI in patients with rhabdomyolysis. Although a PEAK creatine kinase of at least 5000 Ul has sensitivity acceptable for screening purposes, this is often a delayed finding. A McMahon score of at least 6 calculated on admission allows for a more sensitive, specific and timely identification of patients who may benefit from high-volume fluid resuscitation.

Use of technology as an evaluation tool of clinical care in preterm newborns.

PubMed

Mendes, Izabel; Carvalho, Manoel de; Almeida, Rosimary Terezinha; Moreira, Maria Elizabeth

2006-01-01

To assess the use of the Neonatal Therapeutic Intervention Scoring System (NTISS) as a tool to quantify the use of technology in neonatal intensive care units, in order to detect discrepancies in the care provided to high-risk newborn infants. Prospective, descriptive, observational study about the use of technology in two neonatal intensive care units (one public and one private). The NTISS was calculated on a daily basis up to the discharge or death of preterm newborns with gestational age equal to or less than 32 weeks. We gathered data about prenatal clinical conditions, birth characteristics, and conditions on admission to the intensive care unit, as well as about the morbidities developed during the hospital stay. The risks of preterm newborns were adjusted by means of the Score for Neonatal Acute Physiology, Perinatal Extension, Version II (SNAPPE-II). Student's t test, chi-square test, Fisher's exact test, and the Mann-Whitney/Wilcoxon's test were used for the descriptive analysis. The study was approved by the local Research and Ethics Committee. We assessed 44 newborn infants from the public intensive care unit and 52 from the private one. On admission, the severity score (SNAPPE-II) and the overall NTISS were statistically similar in both care units. The curve for the use of technology showed a gradual and progressive decreasing pattern in both care units up to the 31st day. Thereafter, there was a continuous downward trend in the private care unit, but a significant increase in the overall NTISS in the public care unit. The patients from the public care unit developed more morbidities than those from the private unit. Patients with similar clinical pictures can be treated with different levels of technological resources. This may have a direct impact on morbidities and on healthcare costs. The NTISS allowed monitoring healthcare and proved efficient in detecting discrepancies in practices that could influence clinical outcomes and operating costs.

A single-centre cohort study of National Early Warning Score (NEWS) and near patient testing in acute medical admissions.

PubMed

Abbott, Tom E F; Torrance, Hew D T; Cron, Nicholas; Vaid, Nidhi; Emmanuel, Julian

2016-11-01

The utility of an early warning score may be improved when used with near patient testing. However, this has not yet been investigated for National Early Warning Score (NEWS). We hypothesised that the combination of NEWS and blood gas variables (lactate, glucose or base-excess) was more strongly associated with clinical outcome compared to NEWS alone. This was a prospective cohort study of adult medical admissions to a single-centre over 20days. Blood gas results and physiological observations were recorded at admission. NEWS was calculated retrospectively and combined with the biomarkers in multivariable logistic regression models. The primary outcome was a composite of mortality or critical care escalation within 2days of hospital admission. The secondary outcome was hospital length of stay. After accounting for missing data, 15 patients out of 322 (4.7%) died or were escalated to the critical care unit. The median length of stay was 4 (IQR 7) days. When combined with lactate or base excess, NEWS was associated with the primary outcome (OR 1.18, p=0.01 and OR 1.13, p=0.03). However, NEWS alone was more strongly associated with the primary outcome measure (OR 1.46, p<0.01). The combination of NEWS with glucose was not associated with the primary outcome. Neither NEWS nor any combination of NEWS and a biomarker were associated with hospital length of stay. Admission NEWS is more strongly associated with death or critical care unit admission within 2days of hospital admission, compared to combinations of NEWS and blood-gas derived biomarkers. Copyright © 2016 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Addition of adjuvant progesterone to physical-exam-indicated cervical cerclage to prevent preterm birth.

PubMed

Jung, Eun Young; Oh, Kyung Joon; Hong, Joon-Seok; Han, Bo Ryoung; Joo, Jung Kyung

2016-12-01

The aim of this study was to assess the effect of vaginal progesterone as an adjuvant therapy to physical-exam-indicated cervical cerclage (PEICC). This retrospective cohort study included 53 consecutive singleton women who underwent PEICC because of acute cervical insufficiency at 17-24 gestational weeks. The study population was divided into two groups: the adjuvant progesterone group (n = 18) and the non-adjuvant group (n = 35). A 200-mg dose of vaginal micronized natural progesterone was administered after cerclage in the adjuvant progesterone group. Primary outcome measure was spontaneous preterm birth (SPTB) at <36 weeks. The SPTB rate at <36 weeks in the adjuvant group was significantly lower than in the non-adjuvant group (17% vs 51%, P < 0.05). Adjuvant progesterone therapy was significantly associated with a reduction in SPTB at <36 weeks (adjusted odds ratio, 0.12; 95% confidence interval, 0.02-0.69, P < 0.05) even after adjusting for known covariates, including a visible membrane size of ≥4 cm, gestational age, prior SPTB, and use of amnioreduction. The frequency of SPTB at <32 weeks, birthweight < 2500 g, and neonatal intensive care unit admission was significantly lower in the adjuvant progesterone group than in the non-adjuvant group (P < 0.05 for all). Adjuvant vaginal progesterone therapy with PEICC was associated with reductions in SPTB, low birthweight, and neonatal intensive care unit admission. © 2016 Japan Society of Obstetrics and Gynecology.

Effects of anticoagulant therapy on pregnancy outcomes in patients with thrombophilia and previous poor obstetric history.

PubMed

Mutlu, Ilknur; Mutlu, Mehmet Firat; Biri, Aydan; Bulut, Berk; Erdem, Mehmet; Erdem, Ahmet

2015-04-01

This study investigates the effects of anticoagulant therapy on pregnancy outcomes in 204 patients with thrombophilia and previous poor obstetric outcomes. Patients with poor obstetric history (pre-eclampsia, intrauterine growth retardation, fetal death, placental abruption, recurrent pregnancy loss) and having hereditary thrombophilia were included in this study. Poor obstetric outcomes were observed more frequently in patients who had not taken anticogulant therapy compared with treated group. Live birth rate, gestational age at birth and Apgar scores were significantly higher in the treated group when compared with the untreated group. There were no significant differences in terms of birthweight, mode of delivery and admission rates to the neonatal intensive care unit (NICU). Low-molecular-weight heparin (LMWH) plus acetylsalicylic acid (ASA) had higher gestational age at birth, Apgar scores, live birth rate and a lower abortion rates when compared with controls; in contrast, no significant difference was observed in terms of birthweight, mode of delivery, obstetric complications and admission rates to NICU. There were no significant differences between control group and both LMWH only and ASA only groups in terms of gestational age at birth, Apgar scores, birthweight, mode of delivery, obstetric complications and admission rates to NICU. Only LMWH group had higher live birth rate as compared with control group. The use of only ASA did not seem to affect the perinatal complication rates and outcomes. In conclusion, anticoagulant therapy with both LMWH and ASA seems to provide better obstetric outcomes in pregnant women with thrombophilia and previous poor obstetric outcomes.

Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge.

PubMed

Rodehaver, Claire; Fearing, Deb

2005-07-01

Several factors contribute to the potential for patient confusion regarding his or her medication regimen, including multiple names for a single drug and formulary variations when the patient receives medications from more than one pharmacy. A 68-year-old woman was discharged from the hospital on a HMG-CoA reductase inhibitor (statin) and resumed her home statin. Eleven days later she returned to the hospital with a diagnosis of severe rhabdomyolysis due to statin overdose. IMPLEMENTING SOLUTIONS: Miami Valley Hospital, Dayton, Ohio, implemented a reconciliation process and order form at admission and discharge to reduce the likelihood that this miscommunication would recur. Initial efforts were trialed on a 44-bed orthopedic unit, with spread of the initiative to the cardiac units and finally to the remaining 22 nursing units. The team successfully implemented initiation of the order sheet, yet audits indicated the need for improvement in reconciling the medications within 24 hours of admission and in reconciling the home medications at the point of discharge. Successful implementation of the order sheet to drive reconciliation takes communication, perseverance, and a multidisciplinary team approach.

Character and temporal evolution of apoptosis in acetaminophen-induced acute liver failure*.

PubMed

Possamai, Lucia A; McPhail, Mark J W; Quaglia, Alberto; Zingarelli, Valentina; Abeles, R Daniel; Tidswell, Robert; Puthucheary, Zudin; Rawal, Jakirty; Karvellas, Constantine J; Leslie, Elaine M; Hughes, Robin D; Ma, Yun; Jassem, Wayel; Shawcross, Debbie L; Bernal, William; Dharwan, Anil; Heaton, Nigel D; Thursz, Mark; Wendon, Julia A; Mitry, Ragai R; Antoniades, Charalambos G

2013-11-01

To evaluate the role of hepatocellular and extrahepatic apoptosis during the evolution of acetaminophen-induced acute liver failure. A prospective observational study in two tertiary liver transplant units. Eighty-eight patients with acetaminophen-induced acute liver failure were recruited. Control groups included patients with nonacetaminophen-induced acute liver failure (n = 13), nonhepatic multiple organ failure (n = 28), chronic liver disease (n = 19), and healthy controls (n = 11). Total and caspase-cleaved cytokeratin-18 (M65 and M30) measured at admission and sequentially on days 3, 7, and 10 following admission. Levels were also determined from hepatic vein, portal vein, and systemic arterial blood in seven patients undergoing transplantation. Protein arrays of liver homogenates from patients with acetaminophen-induced acute liver failure were assessed for apoptosis-associated proteins, and histological assessment of liver tissue was performed. Admission M30 levels were significantly elevated in acetaminophen-induced acute liver failure and non-acetaminophen induced acute liver failure patients compared with multiple organ failure, chronic liver disease, and healthy controls. Admission M30 levels correlated with outcome with area under receiver operating characteristic of 0.755 (0.639-0.885, p < 0.001). Peak levels in patients with acute liver failure were seen at admission then fell significantly but did not normalize over 10 days. A negative gradient of M30 from the portal to hepatic vein was demonstrated in patients with acetaminophen-induced acute liver failure (p = 0.042) at the time of liver transplant. Analysis of protein array data demonstrated lower apoptosis-associated protein and higher catalase concentrations in acetaminophen-induced acute liver failure compared with controls (p < 0.05). Explant histological analysis revealed evidence of cellular proliferation with an absence of histological evidence of apoptosis. Hepatocellular apoptosis occurs in the early phases of human acetaminophen-induced acute liver failure, peaking on day 1 of hospital admission, and correlates strongly with poor outcome. Hepatic regenerative/tissue repair responses prevail during the later stages of acute liver failure where elevated levels of M30 are likely to reflect epithelial cell death in extrahepatic organs.

Admission to a psychiatric unit and changes in tobacco smoking.

PubMed

Ker, Suzy; Owens, David

2008-05-06

Smoking and withdrawal from smoking complicates the assessment and treatment of mental illness. We aimed to establish whether psychiatric inpatients smoke different amounts after admission than beforehand and, if so, to find out why. Forty-three inpatients on a working age adult psychiatry ward completed self-report questionnaires about smoking habits. Those who smoked a different amount after admission had a follow-up interview to find out why they thought this had occurred. The interview incorporated qualitative and quantitative aspects which were analysed accordingly.Fifty-six percent of participants were smokers before admission, rising to 70% afterwards. Of the smokers, 17% smoked less after admission, and 63% smoked more. The average number of cigarettes smoked per person per day increased from five to thirteen. The main reasons for smoking more were boredom, stress and the wish to socialise.

Mobility decline in patients hospitalized in an intensive care unit

PubMed Central

de Jesus, Fábio Santos; Paim, Daniel de Macedo; Brito, Juliana de Oliveira; Barros, Idiel de Araujo; Nogueira, Thiago Barbosa; Martinez, Bruno Prata; Pires, Thiago Queiroz

2016-01-01

Objective To evaluate the variation in mobility during hospitalization in an intensive care unit and its association with hospital mortality. Methods This prospective study was conducted in an intensive care unit. The inclusion criteria included patients admitted with an independence score of ≥ 4 for both bed-chair transfer and locomotion, with the score based on the Functional Independence Measure. Patients with cardiac arrest and/or those who died during hospitalization were excluded. To measure the loss of mobility, the value obtained at discharge was calculated and subtracted from the value obtained on admission, which was then divided by the admission score and recorded as a percentage. Results The comparison of these two variables indicated that the loss of mobility during hospitalization was 14.3% (p < 0.001). Loss of mobility was greater in patients hospitalized for more than 48 hours in the intensive care unit (p < 0.02) and in patients who used vasopressor drugs (p = 0.041). However, the comparison between subjects aged 60 years or older and those younger than 60 years indicated no significant differences in the loss of mobility (p = 0.332), reason for hospitalization (p = 0.265), SAPS 3 score (p = 0.224), use of mechanical ventilation (p = 0.117), or hospital mortality (p = 0.063). Conclusion There was loss of mobility during hospitalization in the intensive care unit. This loss was greater in patients who were hospitalized for more than 48 hours and in those who used vasopressors; however, the causal and prognostic factors associated with this decline need to be elucidated. PMID:27410406

Acute Surgical Unit: a new model of care.

PubMed

Cox, Michael R; Cook, Lyn; Dobson, Jennifer; Lambrakis, Paul; Ganesh, Shanthan; Cregan, Patrick

2010-06-01

The traditional on-call system for the management of acute general surgical admissions is inefficient and outdated. A new model, Acute Surgical Unit (ASU), was developed at Nepean Hospital in 2006. The ASU is a consultant-driven, independent unit that manages all acute general surgical admissions. The team has the same make up 7 days a week and functions the same every day, including weekends and public holidays. The consultant does a 24-h period of on-call, from 7 pm to 7 pm. They are on remote call from 7 pm to 7 am and are in the hospital from 7 am to 7 pm with their sole responsibility being to the ASU. The ASU has a day team with two registrars, two residents and a nurse practitioner. All patients are admitted and stay in the ASU until discharge or transfer to other units. Handover of the patients at the end of each day is facilitated by a comprehensive ASU database. The implementation of the ASU at Nepean Hospital has improved the timing of assessment by the surgical unit. There has been significant improvement in the timing of operative management, with an increased number and proportion of cases being done during daylight hours, with an associated reduction in the proportion of cases performed afterhours. There is greater trainee supervision with regard to patient assessment, management and operative procedures. There has been an improvement in the consultants' work conditions. The ASU provides an excellent training opportunity for surgical trainees, residents and interns in the assessment and management of acute surgical conditions.

[Trends in the prevalence of pressure ulcers in an acute care tertiary hospital (2006-2013)].

PubMed

Alonso-Lorente, C; Barrasa-Villar, J I; Aibar-Remón, C

2015-01-01

To analyse the trends in pressure ulcer prevalence from 2006 to 2013. To determine the main risk factors associated with pressure ulcers. A descriptive study analysing the prevalence in a series of pressure ulcers collected in the study on the prevalence of nosocomial infections in Spain from 2006 to 2013 in the Clinical University Hospital of Zaragoza. The mean prevalence among the 5,354 patients included over the period of study was 4.5% (95% CI=3.9-5.0%). No significant difference in its trend or distribution of pressure ulcers was observed over the several years of the study. Prevalence increased up to 5.0% (95% CI=4.4-5.6%) when short-stay patients (less than 24 hours) and those admitted into low risk units (Paediatrics, Psychiatry and Obstetrics) were removed from the study, but there was still no significant differences in its yearly trend or distribution (p>0.05). Age, length of stay, presence of coma, in-dwelling urethral catheters, malnutrition, infection, and admission unit were risk factors associated with pressure ulcer prevalence in the logistic regression. Age, length of stay, coma, in-dwelling urethral catheters, malnutrition, infection, and admission unit were independent risk markers for patients with pressure ulcers. No particular trend of pressure ulcer prevalence could be determined to demonstrate any effects from the different strategies of improvement implemented during the period of study, although this fact could be due to the limitations of data used in the study. Copyright © 2014 SECA. Published by Elsevier Espana. All rights reserved.

A crossover randomized prospective pilot study evaluating a central venous catheter team in reducing catheter-related bloodstream infections in pediatric oncology patients.

PubMed

Secola, Rita; Azen, Colleen; Lewis, Mary Ann; Pike, Nancy; Needleman, Jack; Sposto, Richard; Doering, Lynn

2012-01-01

Treatment for most children with cancer includes the use of a central venous catheter (CVC). CVCs provide reliable venous access for delivery of chemotherapy and supportive care. This advantage is mitigated by an increased risk of bloodstream infections (BSIs). Despite the ubiquitous use of CVCs, few prospective studies have been conducted to address infection prevention strategies in pediatric oncology patients. Prospective, crossover pilot study of a CVC team intervention versus standard care. Two inpatient oncology units in a metropolitan children's hospital. A total of 41 patients/135 admissions for the experimental unit (EU) and 41/129 admissions for the control unit (CU). Patients received a CVC blood draw bundle procedure by a CVC registered nurse (RN) team member (experimental intervention: EU) for 6 months and by the assigned bedside RN (standard care: CU) for 6 months. Feasibility of implementing a CVC RN team; a significant difference in CVC-related BSIs between the team intervention versus standard care and risk factors associated in the development of CVC-related BSIs were determined. There were 7 CVC-related BSIs/1238 catheter days in the EU group (5.7/1000 catheter days) versus 3 CVC-related BSIs/1419 catheter days in the CU group (2.1/1000 catheter days; P = .97). Selected risk factors were not significantly associated with the development of a CVC-related BSI. A CVC team in the care of pediatric oncology patients is feasible; however, a larger cohort will be required to adequately determine the effectiveness of the team reducing CVC-related BSIs.

Maternal outcomes of term breech presentation delivery: impact of successful external cephalic version in a nationwide sample of delivery admissions in the United States.

PubMed

Weiniger, Carolyn F; Lyell, Deirdre J; Tsen, Lawrence C; Butwick, Alexander J; Shachar, BatZion; Callaghan, William M; Creanga, Andreea A; Bateman, Brian T

2016-07-08

We aimed to define the frequency and predictors of successful external cephalic version in a nationally-representative cohort of women with breech presentations and to compare maternal outcomes associated with successful external cephalic version versus persistent breech presentation. Using the Nationwide Inpatient Sample, a United States healthcare utilization database, we identified delivery admissions between 1998 and 2011 for women who had successful external cephalic version or persistent breech presentation (including unsuccessful or no external cephalic version attempt) at term. Multivariable logistic regression identified patient and hospital-level factors associated with successful external cephalic version. Maternal outcomes were compared between women who had successful external cephalic version versus persistent breech. Our study cohort comprised 1,079,576 delivery admissions with breech presentation; 56,409 (5.2 %) women underwent successful external cephalic version and 1,023,167 (94.8 %) women had persistent breech presentation at the time of delivery. The rate of cesarean delivery was lower among women who had successful external cephalic version compared to those with persistent breech (20.2 % vs. 94.9 %; p < 0.001). Compared to women with persistent breech at the time of delivery, women with successful external cephalic version were also less likely to experience several measures of significant maternal morbidity including endometritis (adjusted Odds Ratio (aOR) = 0.36, 95 % Confidence Interval (CI) 0.24-0.52), sepsis (aOR = 0.35, 95 % CI 0.24-0.51) and length of stay > 7 days (aOR = 0.53, 95 % CI 0.40-0.70), but had a higher risk of chorioamnionitis (aOR = 1.83, 95 % CI 1.54-2.17). Overall a low proportion of women with breech presentation undergo successful external cephalic version, and it is associated with significant reduction in the frequency of cesarean delivery and a number of measures of maternal morbidity. Increased external cephalic version use may be an important approach to mitigate the high rate of cesarean delivery observed in the United States.

Anxiety, depression and PTSD-related symptoms in spouses and close relatives of burn survivors: When the supporter needs to be supported.

PubMed

Bond, Suzie; Gourlay, Catherine; Desjardins, Alexandra; Bodson-Clermont, Paule; Boucher, Marie-Ève

2017-05-01

The aim of the study was to assess the prevalence of anxiety, depression and PTSD-related symptoms reported by spouses and close relatives of adult burn survivors. Potential associations between these symptoms and variables such as the severity of the burn were also explored. Participants were spouses (n=31) and close relatives (n=25) of hospitalized patients with acute burns. Anxiety and depression symptoms were assessed by the Hospital Distress Anxiety and Depression Scale and PTSD-related symptoms by the Modified PTSD Symptom Scale at both admission to and discharge from the burn unit. At admission, 77% of spouses and 56% of close relatives of burn patients reported anxiety, depression or PTSD-related symptoms in the clinical range. While spouses had higher scores than close relatives on symptom measures, significant differences were only established for anxiety symptoms (p<.02). A significant effect was found for gender, with women reporting more anxiety (p=.01) and depression (p=.02) symptoms than men. Results also showed a main effect for time, with anxiety (p<.0001), depression (p<.0001) and PTSD-related (p<.0001) symptoms being higher at admission than at discharge. Variables associated with the index patient, such as total body surface area burned, length of stay, number of ventilated days, facial burns, or level of care at admission, were not associated with outcome measures. Spouses and close relatives of burn survivors showed high levels of psychological distress in the first few days following admission, and more than a quarter still reported symptoms in the clinical range at discharge. Our analysis points to the need to offer psychological support and guidance to family members so that they can in turn provide effective support to the burn survivor. Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.

77 FR 76352 - Adjustment of Status of Refugees and Aliens Granted Asylum

Federal Register 2010, 2011, 2012, 2013, 2014

2012-12-28

... is not admissible to the United States as described in 8 CFR 209.2(a)(1)(v), may, under section 209(c..., shall be eligible for adjustment without regard to the foreign residence requirement if otherwise... admission for lawful permanent residence as of the date one year before the date of the approval of the...

Profile of Neonatal Sepsis due to Burkholderia capacia Complex.

PubMed

Chandrasekaran, Aparna; Subburaju, Nivedhana; Mustafa, Muzamil; Putlibai, Sulochana

2016-12-15

We report the result of retrospective record review of the clinical profile of 59 neonates who presented to a tertiary-care extramural neonatal unit with Burkholderia cepacia complex infection. Among the 3265 admissions over 45 months, incidence of Burkholderia sepsis was 18 per 1000 admissions. Case fatality rate was 17%. Most (95%) isolates were sensitive to cotrimoxazole.

Cape Verde. A Country Guide Series Report from the AACRAO-AID Project.

ERIC Educational Resources Information Center

Sevigny, Joseph A.

This report provides information on the education system of Cape Verde, and is designed to assist college admissions officers and registrars in the United States with the admission and placement of students from that country. The report contains general information on the geography, history, and people of Cape Verde, as well as more specific…

Perceptions of Nursing Education Administrators Regarding the Relationship of Admission Criteria to Student Graduation

ERIC Educational Resources Information Center

Cline, Joy F.

2013-01-01

This research investigated admission criteria of baccalaureate nursing students related to their success in a multi-state sample of peer universities in the United States. The researcher used mixed methods to collect data that were analyzed using descriptive and phenomenological approaches. The sample of the study was chairpersons from peer…

Central venous catheter-associated bloodstream infections in a pediatric intensive care unit: effect of the location of catheter insertion.

PubMed

Krishnaiah, Anil; Soothill, James; Wade, Angie; Mok, Quen Q; Ramnarayan, Padmanabhan

2012-05-01

To compare the rate of central venous catheter-associated bloodstream infections between pediatric intensive care unit admissions where central venous catheters were inserted within the same hospital (internal central venous catheters) and those where central venous catheters were inserted before transfer from other hospitals (external central venous catheters). Retrospective analysis of prospectively collected data. A tertiary care pediatric intensive care unit in London, UK. Consecutive pediatric intensive care unit admissions between May 2007 and March 2009. None. Catheter-associated bloodstream infections were identified using a widely accepted surveillance definition. The rate and time to occurrence of catheter-associated bloodstream infection were compared between internal and external nontunneled central venous catheters. A multilevel Cox-regression model was used to study the association between location of central venous catheter insertion and time to catheter-associated bloodstream infection. In total, 382 central venous catheters were studied (245 internal; 137 external) accounting for a total of 1,737 central venous catheter days. There was a higher catheter-associated bloodstream infection incidence density among external central venous catheters (23.1 [95% confidence interval 11.0-35.2] vs. 9.7 [95% confidence interval 3.9-15.5] per 1,000 catheter-days). Multivariable analyses demonstrated higher infection risk with external central venous catheters (hazard ratio 2.65 [95% confidence interval 1.18-5.96]) despite adjustment for confounding variables. The rate of catheter-associated bloodstream infections in the pediatric intensive care unit is significantly affected by external insertion of the central venous catheter. Future interventions to reduce nosocomial infections on pediatric intensive care units will need to be specifically targeted at this high-risk patient group.

Age of red blood cells and outcome in acute kidney injury

PubMed Central

2013-01-01

Introduction Transfusion of red blood cells (RBCs) and, in particular, older RBCs has been associated with increased short-term mortality in critically ill patients. We evaluated the association between age of transfused RBCs and acute kidney injury (AKI), hospital, and 90-day mortality in critically ill patients. Methods We conducted a prospective, observational, predefined sub-study within the FINNish Acute Kidney Injury (FINNAKI) study. This study included all elective ICU admissions with expected ICU stay of more than 24 hours and all emergency admissions from September to November 2011. To study the age of RBCs, we classified transfused patients into quartiles according to the age of oldest transfused RBC unit in the ICU. AKI was defined according to KDIGO (Kidney Disease: Improving Global Outcomes) criteria. Results Out of 1798 patients, 652 received at least one RBC unit. The median [interquartile range] age of the oldest RBC unit transfused was 12 [11-13] days in the freshest quartile and 21 [17-27] days in the quartiles 2 to 4. On logistic regression, RBC age was not associated with the development of KDIGO stage 3 AKI. Patients in the quartile of freshest RBCs had lower crude hospital and 90-day mortality rates compared to those in the quartiles of older blood. After adjustments, older RBC age was associated with significantly increased risk for hospital mortality. Age, Simplified Acute Physiology Score II (SAPS II)-score without age points, maximum Sequental Organ Failure Assessment (SOFA) score and the total number of transfused RBC units were independently associated with 90-day mortality. Conclusions The age of transfused RBC units was independently associated with hospital mortality but not with 90-day mortality or KDIGO stage 3 AKI. The number of transfused RBC units was an independent risk factor for 90-day mortality. PMID:24093554

Edinburgh Emergency Asthma Admission Service: report on 10 years' experience.

PubMed Central

Crompton, G K; Grant, I W; Bloomfield, P

1979-01-01

In December 1968 an emergency service was begun in Edinburgh to expedite admission to hospital of patients with severe acute asthma. During the first 10 years requests were made to admit 112 patients to a respiratory unit with provision for intensive care on 360 occasions. Four of the patients died of their disease, one in hospital and three before admission. It was thought that the death rate would have been much higher had conventional admission procedures been observed. Owing to ethical objections to a controlled trial it was not possible to obtain substantive proof that the service reduced deaths from asthma. Nevertheless, there was strong circumstantial evidence that organised facilities for the immediate admission to hospital of patients with a history of life-threatening attacks would result in fewer deaths at home. Earlier admission also apparently reduced hospital mortality and the number of patients requiring tracheal intubation and mechanical ventilation. It is concluded that there is a prima facie case for an emergency asthma admission serivce similar to that operating in Edinburgh to be established in all cities and large towns. PMID:519358

Prior Work and Educational Experience Are Not Associated With Successful Completion of a Master's-Level, Distance Education Midwifery Program.

PubMed

Niemczyk, Nancy A; Cutts, Alison; Perlman, Dana B

2018-03-01

In order to increase and diversify the midwifery workforce, admissions criteria for midwifery education programs must not contain unnecessary barriers to entry. Once accepted, students need to successfully complete the program. Many admissions criteria commonly used in midwifery education programs in the United States are not evidence based and could be unnecessary barriers to education. The primary objective of this study was to identify factors known during the admission process that were related to successful completion or failure to complete a midwifery program educating both student nurse-midwives (SNMs) and student midwives (SMs); a secondary objective was to quantify reasons for program noncompletion. This master's-level, distance education program educates a diverse group of both SNMs and SMs. A pilot, retrospective cohort study examined all students matriculating at the program from fall 2012 on and scheduled to graduate by summer 2016 (N = 58). Demographic information, admissions information, academic records, and advising notes were reviewed. Reasons for noncompletion were identified, and characteristics were compared between students who did and did not complete the program. Program completion was not significantly associated with students' status as nurses prior to admission, labor and delivery nursing experience, length of nursing experience, nursing degree held, presence of children at home, working while in school, or undergraduate grade point average. Being a nurse, years of nursing experience, type of nursing degree, or labor and delivery nursing experience were not associated with completion of this midwifery program. © 2018 by the American College of Nurse-Midwives.

Scrub Typhus - A Major Cause of Pediatric Intensive Care Admission and Multiple Organ Dysfunction Syndrome: A Single-Center Experience from India.

PubMed

Giri, Prabahs Prasun; Roy, Joydeb; Saha, Agnisekhar

2018-02-01

Scrub typhus has been globally recognized as an emerging infectious disease contributing significantly to pyrexia of unknown origin (PUO) and a potential cause of multiorgan dysfunction syndrome (MODS). We studied the incidence of scrub typhus as a cause of pediatric intensive care unit (PICU) admission and MODS in our hospital and its clinical and laboratory characteristics to measure the incidence of MODS caused by scrub typhus. This study was done in a pediatric teaching hospital in Kolkata, India. Records of patients admitted with PUO from March 2012 to December 2015 were reviewed. Rathi-Goodman-Aghai scoring system was used to identify potential ST patients and confirmed by serological testing. Clinical characteristics, laboratory findings, and treatment response were noted of those needing PICU admissions. Ninety-seven cases of scrub typhus have been identified during that period. PICU admission was needed in 30 of them (31%) which contributed 8.43% of total PICU admissions. Among these 30 patients, 16 (53%) developed MODS which contributed 18.29% of total MODS admitted in PICU. Septic shock was the most common manifestation in as many as 18 (60%) patients followed by encephalopathy in 13 (43%). Patients were treated with either doxycycline alone or in combination with azithromycin. Mean time to complete defervescence was 32 h after first dose of doxycycline. The outcome was excellent without a single mortality. Scrub typhus is an important cause of MODS in this part of the world, especially in fevers associated with features as identified and not responding to conventional antibiotics.

A prospective multicenter study of factors associated with hospital admission among adults with acute asthma.

PubMed

Weber, Ellen J; Silverman, Robert A; Callaham, Michael L; Pollack, Charles V; Woodruff, Prescott G; Clark, Sunday; Camargo, Carlos A

2002-10-01

We sought to determine patient characteristics associated with hospital admission after emergency treatment for asthma, and whether disposition guidelines are followed. We performed a prospective multicenter cohort study involving 64 emergency departments in the United States and Canada. Consecutive adult patients with asthma exacerbations were interviewed, and their charts were reviewed using standardized protocols. Telephone follow-up at 2 weeks determined relapse. Of 1805 patients, 363 (20%; 95% confidence interval [CI]: 18% to 22%) were hospitalized. Among patients with severe exacerbations (final peak flow <50% of predicted), 122 (49%; 95% CI: 43% to 55%) were hospitalized. Admission was associated with final peak flow, female sex, nonwhite race, severity of chronic illness, and severity of exacerbation. Admission predictors were similar regardless of hospital funding, region, or size. Among patients with mild or moderate exacerbations of asthma (peak flow >or=50% predicted), the likelihood of admission was associated significantly with the number of predefined risk factors for death from asthma. Of patients who were discharged from the emergency department, 62 (5%; 95% CI: 4% to 6%) relapsed within 72 hours. Relapse was not associated with final peak flow (P = 0.39). Associations between patient characteristics and disposition were similar across sites. Despite guidelines to the contrary, half of patients with final peak flow <50% were discharged. After emergency department treatment and discharge, short-term relapse was uncommon among patients with asthma, suggesting that strict peak flow cutoffs may be unnecessary if risk factors in patients with mild or moderate exacerbations are considered.

Stroke patients admitted within normal working hours are more likely to achieve process standards and to have better outcomes

PubMed Central

Turner, Melanie; Barber, Mark; Dodds, Hazel; Dennis, Martin; Langhorne, Peter; Macleod, Mary-Joan

2016-01-01

Background The presence of a ‘weekend’ effect has been shown across a range of medical conditions, but has not been consistently observed for patients with stroke. Aims We investigated the impact of admission time on a range of process and outcome measures after stroke. Methods Using routine data from National Scottish data sets (2005–2013), time of admission was categorised into weekday, weeknight and weekend/public holidays. The main process measures were swallow screen on day of admission (day 0), brain scan (day 0 or 1), aspirin (day 0 or 1), admission to stroke unit (day 0 or 1), and thrombolysis administration. After case-mix adjustment, multivariable logistic regression was used to estimate the OR for mortality and discharge to home/usual place of residence. Results There were 52 276 index stroke events. Compared to weekday, the adjusted OR (95%CI) for early stroke unit admission was 0.81 (0.77 to 0.85) for weeknight admissions and 0.64 (0.61 to 0.67) for weekend/holiday admissions; early brain scan 1.30 (0.87 to 1.94) and 1.43 (0.95 to 2.18); same day swallow screen 0.86 (0.81 to 0.91) and 0.85 (0.81 to 0.90); thrombolysis 0.85 (0.75 to 0.97) and 0.85 (0.75 to 0.97), respectively. Seven-day mortality, 30-day mortality and 30-day discharge for weekend admission compared to weekday was 1.17 (1.05 to 1.30); 1.08 (1.00 to 1.17); and 0.90 (0.85 to 0.95), respectively. Conclusions Patients with stroke admitted out of hours and at weekends or public holidays are less likely to be managed according to current guidelines. They experience poorer short-term outcomes than those admitted during normal working hours, after correcting for known independent predictors of outcome and early mortality. PMID:26285585

Epidemiology of Obstetric-Related Intensive Care Unit Admissions in Maryland: 1999–2008

PubMed Central

Wanderer, Jonathan P.; Leffert, Lisa R.; Mhyre, Jill M.; Kuklina, Elena V.; Callaghan, William M.; Bateman, Brian T.

2013-01-01

Objective To define the incidence, indications, and temporal trends in obstetric-related intensive care unit (ICU) admissions Design Descriptive analysis of utilization patterns Setting All hospitals within the State of Maryland Patients All antepartum, delivery and postpartum patients who were hospitalized between 1999 and 2008 Interventions None Measurements and Main Results We identified 2,927 ICU admissions from 765,598 admissions for antepartum, delivery, or postpartum conditions using appropriate International Classification of Diseases, 9th revision-Clinical Modification (ICD-9 CM) codes. The overall rate of ICU utilization was 419.1 per 100,000 deliveries, with rates of 162.5, 202.6 and 54.0 per 100,000 deliveries for the antepartum, delivery and postpartum periods, respectively. The leading diagnoses associated with ICU admission were pregnancy-related hypertensive disease (present in 29.9% of admissions), hemorrhage (18.8%), cardiomyopathy or other cardiac disease (18.3%), genitourinary infection (11.5%), complications from ectopic pregnancies and abortions (10.3%), non-genitourinary infection (10.1%), sepsis (7.1%), cerebrovascular disease (5.8%) and pulmonary embolism (3.7%). We assessed for changes in the most common diagnoses in the ICU population over time and found rising rates of sepsis (10.1 per 100,000 deliveries to 16.6 per 100,000 deliveries, p=0.003) and trauma (9.2 per 100,000 deliveries to 13.6 per 100,000 deliveries, p=0.026) with decreasing rates of anesthetic complications (11.3 per 100,000 to 4.7 per 100,000, p=0.006). The overall frequency of obstetric-related ICU admission and the rates for other indications remained relatively stable. Conclusions Between 1999 and 2008, 419.1 per 100,000 deliveries in Maryland were complicated by ICU admission. Hospitals providing obstetric services should plan for appropriate critical care management and/or transfer of women with severe morbidities during pregnancy. PMID:23648568

Resource savings and outcomes associated with outpatient laparoscopic appendectomy for nonperforated appendicitis.

PubMed

Gurien, Lori A; Burford, Jeffrey M; Bonasso, Patrick C; Dassinger, Melvin S

2017-11-01

Postoperative admission for acute appendicitis utilizes health care system resources. We evaluated outcomes and hospital charges for children with nonperforated appendicitis who underwent outpatient laparoscopic appendectomy. A retrospective chart review was performed for patients ≤18years old who underwent laparoscopic appendectomy for acute appendicitis in 2015. Patients were categorized into discharge from postanesthesia care unit (PACU) (outpatient), admission for <24-h, and admission for >24-h. Continuous variables were compared using analysis of variance and categorical variables were compared using chi-square test, with p<0.05 considered significant. Of the 171 patients identified, 63 (37%) were discharged from the PACU, 94 (55%) were admitted <24-h, and 14 (8%) were admitted >24-h. There were no differences in postoperative emergency department/clinic visits, complications, or readmissions. Hospital charges for admission <24-h and >24-h were $1007 and $2237 more per patient than the PACU-discharge group, respectively. Outpatient laparoscopic appendectomies became more common over time, occurring in only 20% of patients with acute appendicitis in the first quarter of the year versus 49% of patients in the last quarter. Outpatient laparoscopic appendectomy for nonperforated appendicitis in children is a safe practice that decreases length of stay and hospital charges. Adoption of an outpatient strategy allows for better standardization of care and can lead to savings in health care resources. III (Treatment: retrospective comparative study). Copyright © 2017 Elsevier Inc. All rights reserved.

Risk assessment in ginecology and obstetrics in Sicily: an approach based on Wolff's Criteria.

PubMed

Matranga, D; Marsala, M G L; Vadalà, M; Morici, M; Restivo, V; Ferrara, C; Vitale, F; Firenze, A

2013-01-01

To apply Wolff's Criteria to hospital discharge records (HDR) in order to detect adverse events worthy of further study. Gynecology and Obstetrics Units of three Sicilian hospitals were considered and HDR regarding ordinary and day hospital admissions in 2008 were collected. A matched case-control study was designed, by random selection of 10 controls at maximum for each case. Matching was performed on the variables age and speciality of admission (gynecology or obstetrics). Out of a total of 7011 HDR examined, 114 cases were identified with Wolff's Criteria. Multivariate analysis confirmed a statistically significant association with the origin of admission, diagnosis at the acceptance and length of stay: there was a decreased risk of Wolff's event in patients having urgent admission compared to elective (OR = 0.47, 95% CI = [0.28-0.78]), an increased risk in patients reporting tumor (OR = 5:41, 95 % CI [1.89-15.47]) and other causes (OR = 2.16, 95% CI [1.10-4.24]) compared to delivery diagnosis at acceptance and in patients whose length of stay was more than 6 days (OR = 23.17, 95% CI = [12.56-42.7]) compared to less or equal than 3 days Wolff's Criteria can be applied for the analysis of clinical risk in hospitals with different structural characteristics, on condition that the HDR database is complete and good quality.

YKL-40, CCL18 and SP-D predict mortality in patients hospitalized with community-acquired pneumonia.

PubMed

Spoorenberg, Simone M C; Vestjens, Stefan M T; Rijkers, Ger T; Meek, Bob; van Moorsel, Coline H M; Grutters, Jan C; Bos, Willem Jan W

2017-04-01

The aim of this study was to investigate the prognostic value of four biomarkers, YKL-40, chemokine (C-C motif) ligand 18 (CCL18), surfactant protein-D (SP-D) and CA 15-3, in patients admitted with community-acquired pneumonia (CAP). These markers have been studied extensively in chronic pulmonary disease, but in acute pulmonary disease their prognostic value is unknown. A total of 289 adult patients who were hospitalized with CAP and participated in a randomized controlled trial were enrolled. Biomarker levels were measured on the day of admission. Intensive care unit admission, 30-day, 1-year and long-term mortality (median follow-up of 5.4 years, interquartile range (IQR): 4.7-6.1) were recorded as outcomes. Median YKL-40 and CCL18 levels were significantly higher and levels of SP-D were significantly lower in CAP patients compared to healthy controls. Significantly higher YKL-40, CCL18 and SP-D levels were found in patients classified in pneumonia severity index classes 4-5 and with a CURB-65 score ≥2 compared to patients with less severe pneumonia. Furthermore, these three markers were significant predictors for long-term mortality in multivariate analysis and compared with C-reactive protein and procalcitonin level on admission, area under the curves were higher for 30-day, 1-year and long-term mortality. CA 15-3 levels were less predictive. YKL-40, CCL18 and SP-D levels were higher in patients with more severe pneumonia, possibly reflecting the extent of pulmonary inflammation. Of these, YKL-40 most significantly predicts mortality for CAP. © 2016 Asian Pacific Society of Respirology.

Universal Pressure Ulcer Prevention Bundle With WOC Nurse Support.

PubMed

Anderson, Megan; Finch Guthrie, Patricia; Kraft, Wendy; Reicks, Patty; Skay, Carol; Beal, Alan L

2015-01-01

This study examined the effectiveness of a universal pressure ulcer prevention bundle (UPUPB) applied to intensive care unit (ICU) patients combined with proactive, semiweekly WOC nurse rounds. The UPUBP was compared to a standard guideline with referral-based WOC nurse involvement measuring adherence to 5 evidence-based prevention interventions and incidence of pressure ulcers. The study used a quasi-experimental, pre-, and postintervention design in which each phase included different subjects. Descriptive methods assisted in exploring the content of WOC nurse rounds. One hundred eighty-one pre- and 146 postintervention subjects who met inclusion criteria and were admitted to ICU for more than 24 hours participated in the study. The research setting was 3 ICUs located at North Memorial Medical Center in Minneapolis, Minnesota. Data collection included admission/discharge skin assessments, chart reviews for 5 evidence-based interventions and patient characteristics, and WOC nurse rounding logs. Study subjects with intact skin on admission identified with an initial skin assessment were enrolled in which prephase subjects received standard care and postphase subjects received the UPUPB. Skin assessments on ICU discharge and chart reviews throughout the stay determined the presence of unit-acquired pressure ulcers and skin care received. Analysis included description of WOC nurse rounds, t-tests for guideline adherence, and multivariate analysis for intervention effect on pressure ulcer incidence. Unit assignment, Braden Scale score, and ICU length of stay were covariates for a multivariate model based on bivariate logistic regression screening. The incidence of unit-acquired pressure ulcers decreased from 15.5% to 2.1%. WOC nurses logged 204 rounds over 6 months, focusing primarily on early detection of pressure sources. Data analysis revealed significantly increased adherence to heel elevation (t = -3.905, df = 325, P < .001) and repositioning (t = -2.441, df = 325, P < .015). Multivariate logistic regression modeling showed a significant reduction in unit-acquired pressure ulcers (P < .001). The intervention increased the Nagelkerke R-Square value by 0.099 (P < .001) more than 0.297 (P < .001) when including only covariates, for a final model value of 0.396 (P < .001). The UPUPB with WOC nurse rounds resulted in a statistically significant and clinically relevant reduction in the incidence of pressure ulcers.

Pediatric Admissions After Dental Care Under General Anesthesia: A Retrospective Study at a Tertiary Care Center.

PubMed

Lucy, Anna L; Gandhi, Roopa P; Gross, Lilyana; McNair, Bryan

2017-05-15

The purpose of this study was to identify factors associated with planned and unplanned pediatric hospital admissions following dental treatment under general anesthesia (DGA) in a tertiary care center. Dental and medical records of 100 subjects one to 20 years of age, with a known history of admission after DGA, were reviewed retrospectively for patient-, procedure-, and anesthesia-related factors as well as adverse events following DGA. During the review period (December 3, 2011 to June 30, 2015), 10,371 subjects underwent DGA, of which 100 subjects (less than one percent) required admission. A significant association was found between postoperative (PO) recovery time and unplanned admissions following DGA (P<0.001). Adverse post-operative events significantly associated with unplanned admissions included emesis (P=0.01) and hypoxia (P<0.001). Patients who were classified as having American Anesthesiology Association (ASA) III status were more frequently admitted following DGA. Adverse events such as emesis and hypoxia were significantly associated with patients with an unplanned admission.

Effect of Massachusetts healthcare reform on racial and ethnic disparities in admissions to hospital for ambulatory care sensitive conditions: retrospective analysis of hospital episode statistics.

PubMed

McCormick, Danny; Hanchate, Amresh D; Lasser, Karen E; Manze, Meredith G; Lin, Mengyun; Chu, Chieh; Kressin, Nancy R

2015-04-01

To examine the impact of Massachusetts healthcare reform on changes in rates of admission to hospital for ambulatory care sensitive conditions (ACSCs), which are potentially preventable with good access to outpatient medical care, and racial and ethnic disparities in such rates, using complete inpatient discharge data (hospital episode statistics) from Massachusetts and three control states. Difference in differences analysis to identify the change, overall and according to race/ethnicity, adjusted for secular changes unrelated to reform. Hospitals in Massachusetts, New York, New Jersey, and Pennsylvania, United States. Adults aged 18-64 (those most likely to have been affected by the reform) admitted for any of 12 ACSCs in the 21 months before and after the period during which reform was implemented (July 2006 to December 2007). Admission rates for a composite of all 12 ACSCs, and subgroup composites of acute and chronic ACSCs. After adjustment for potential confounders, including age, race and ethnicity, sex, and county income, unemployment rate and physician supply, we found no evidence of a change in the admission rate for overall composite ACSC (1.2%, 95% confidence interval -1.6% to 4.1%) or for subgroup composites of acute and chronic ACSCs. Nor did we find a change in disparities in admission rates between black and white people (-1.9%, -8.5% to 5.1%) or white and Hispanic people (2.0%, -7.5% to 12.4%) for overall composite ACSC that existed in Massachusetts before reform. In analyses limited to Massachusetts only, we found no evidence of a change in admission rate for overall composite ACSC between counties with higher and lower rates of uninsurance at baseline (1.4%, -2.3% to 5.3%). Massachusetts reform was not associated with significantly lower overall or racial and ethnic disparities in rates of admission to hospital for ACSCs. In the US, and Massachusetts in particular, additional efforts might be needed to improve access to outpatient care and reduce preventable admissions. © McCormick et al 2015.

Is patient-grouping on basis of condition on admission indicative for discharge destination in geriatric stroke patients after rehabilitation in skilled nursing facilities? The results of a cluster analysis.

PubMed

Buijck, Bianca I; Zuidema, Sytse U; Spruit-van Eijk, Monica; Bor, Hans; Gerritsen, Debby L; Koopmans, Raymond T C M

2012-12-04

Geriatric stroke patients are generally frail, have an advanced age and co-morbidity. It is yet unclear whether specific groups of patients might benefit differently from structured multidisciplinary rehabilitation programs. Therefore, the aims of our study are 1) to determine relevant patient characteristics to distinguish groups of patients based on their admission scores in skilled nursing facilities (SNFs), and (2) to study the course of these particular patient-groups in relation to their discharge destination. This is a longitudinal, multicenter, observational study. We collected data on patient characteristics, balance, walking ability, arm function, co-morbidity, activities of daily living (ADL), neuropsychiatric symptoms, and depressive complaints of 127 geriatric stroke patients admitted to skilled nursing facilities with specific units for geriatric rehabilitation after stroke. Cluster analyses revealed two groups: cluster 1 included patients in poor condition upon admission (n = 52), and cluster 2 included patients in fair/good condition upon admission (n = 75). Patients in both groups improved in balance, walking abilities, and arm function. Patients in cluster 1 also improved in ADL. Depressive complaints decreased significantly in patients in cluster 1 who were discharged to an independent- or assisted-living situation. Compared to 80% of the patients in cluster 2, a lower proportion (46%) of the patients in cluster 1 were discharged to an independent- or assisted-living situation. Stroke patients referred for rehabilitation to SNFs could be clustered on the basis of their condition upon admission. Although patients in poor condition on admission were more likely to be referred to a facility for long-term care, this was certainly not the case in all patients. Almost half of them could be discharged to an independent or assisted living situation, which implied that also in patients in poor condition on admission, discharge to an independent or assisted living situation was an attainable goal. It is important to put substantial effort into the rehabilitation of patients in poor condition at admission.

Hypernatremic Dehydration in Breastfed Term Infants: Retrospective Evaluation of 159 Cases.

PubMed

Ünver Korğalı, Elif; Cihan, Meriç Kaymak; Oğuzalp, Tahir; Şahinbaş, Ali; Ekici, Mahmut

The aim of this study was to reveal the frequency, presenting complaints, risk factors, complications, and ways for prevention of hypernatremic dehydration (HD) among term breastfed infants. The files of 159 breastfed term infants hospitalized because of HD between the years 2009 and 2014 were examined retrospectively in the Neonatal Intensive Care Unit of Sivas State Hospital, Turkey. The patients were classified according to serum sodium (Na) levels, group 1 (Na: 146-149 mEq/L, n = 68) and group 2 (Na ≥150 mEq/L, n = 91). The most common complaint was fever (67.9%), and the most common physical finding was oral mucosal dryness (76%). There were positive correlations between serum Na levels and weight loss, hospital stay, admission age, admission to neonatal unit after discharge, serum urea levels, and body temperature (p < 0.05). The normalization period of Na levels was significantly longer (21.7 ± 8.8 versus 29.3 ± 17.8 hours, p = 0.03), and Na reduction rate was faster in group 2 (0.41 ± 0.3 versus 0.50 ± 0.3 mEq/L/hour, p = 0.02). Bradycardia was seen more commonly in group 2 (1.5% versus 16.5%, p = 0.002). HD is a significant condition that should be treated appropriately to avoid serious complications.

Childhood motocross truncal injuries: high-velocity, focal force to the chest and abdomen

PubMed Central

Kennedy, Raelene D; Potter, D Dean; Osborn, John B; Zietlow, Scott; Zarroug, Abdalla E; Moir, Christopher R; Ishitani, Michael B; McIntosh, Amy

2012-01-01

Objectives To review the need for operative intervention and critical care services for motocross truncal injuries in children. Design cohort Retrospective review of patients identified via the hospital trauma registry. Setting Our Level 1 Pediatric Trauma Center serves five motocross tracks. These patients require frequent medical care for injuries. Participants All patients ≤17 years of age with truncal injuries sustained during motocross activities, between 2000 and 2011, were identified through the trauma registry. Primary and secondary outcome measures Operative intervention, intensive care unit (ICU) admission, length of stay, morbidity and demographics were reviewed. Results Motocross injured 162 children. Thirty (18.5%) were thoracic or abdominal injuries. Operative intervention was required in eight (27%) patients. Mean injury severity score (ISS) was 11.8. ICU admission was required in 50% and average hospital length of stay was 4.1 days. The most common injuries include pulmonary contusion, pneumothorax, spleen and liver lacerations. 13% of subjects suffered truncal injury from motocross on more than one occasion. Conclusions Paediatric motocross-related truncal injuries are significant. Surgical intervention is required in 27% of patients. The lower ISS incurred from motocross combined with high surgical and ICU admission rates suggests focal high-impact injuries to the chest and abdomen. Despite significant injury, 13% of motocross patients suffer recurrent injuries. Parents and children need injury prevention education. PMID:23166134

Cost-effectiveness of 'Program We Care' for patients with chronic obstructive pulmonary disease: A case-control study.

PubMed

Wong, Eliza Mi Ling; Lo, Shuk Man; Ng, Ying Chu; Lee, Larry Lap Yip; Yuen, T M Y; Chan, Jimmy Tak Shing; Chair, Sek Ying

2016-07-01

To evaluate the effectiveness of a discharge program for patients with chronic obstructive pulmonary disease (COPD) patients on discharge from an emergency medical ward on discharge home rate, hospital length of stay (LOS), inpatient admission rate and cost. Frequent visits to the emergency department (ED) and subsequent hospital admission are common among patients with COPD, which adds a burden to ED and hospital care. A discharge program was implemented in an ED emergency medical ward. The program consisted of multidisciplinary care, discharge planning, discharge health education on disease management, and continued support from the community nursing services. A retrospective case-control study was used. Data were retrieved and compared between 478 COPD program cases and 478 COPD non-program cases. No significant difference was found in age, gender, and triage category, LOS in ED, and readmission rate between the program and non-program groups. The program group demonstrated a significantly higher discharge home rate from the ED (33.89% vs. 20.08%) and fewer medical admissions (40.59% vs. 55.02%) compared with the non-program group, resulting in lower total medical costs after the program was implemented. The program provides insight on the strategic planning for discharge care in a short stay unit of emergency department. Copyright © 2015 Elsevier Ltd. All rights reserved.

Shock Index Values and Trends in Pediatric Sepsis: Predictors or Therapeutic Targets? A Retrospective Observational Study.

PubMed

Ray, Samiran; Cvetkovic, Mirjana; Brierley, Joe; Lutman, Daniel H; Pathan, Nazima; Ramnarayan, Padmanabhan; Inwald, David P; Peters, Mark J

2016-09-01

Shock index (SI) (heart rate [HR]/systolic blood pressure [SBP]) has been used to predict outcome in both adult and pediatric sepsis within the intensive care unit (ICU). We aimed to evaluate the utility of SI before pediatric ICU (PICU) admission. We conducted a retrospective observational study of children referred to a pediatric intensive care transport service (PICTS) between 2005 and 2011. The predictive value of SI, HR, and blood pressure at three prespecified time points (at referral to PICTS, at PICTS arrival at the referring hospital, and at PICU admission) and changes in SI between the time points were evaluated. Death within the first 48 h of ICU admission (early death) was the primary outcome variable. Over the 7-year period, 633 children with sepsis were referred to the PICTS. Thirty-nine children died before transport to a PICU, whereas 474 were transported alive. Adjusting for age, time points, and time duration in a multilevel regression analysis, SI was significantly higher in those who died early. There was a significant improvement in SI with the transport team in survivors but not in nonsurvivors. However, the predictive value of a change in SI for mortality was no better than either a change in HR or blood pressure. The absolute or change in SI does not predict early death any more than HR and SBP individually in children with sepsis.

Mortality factors in geriatric blunt trauma patients.

PubMed

Knudson, M M; Lieberman, J; Morris, J A; Cushing, B M; Stubbs, H A

1994-04-01

To examine various clinical factors for their ability to predict mortality in geriatric patients following blunt trauma. In this retrospective study, trauma registries and medical records from three trauma centers were reviewed for patients 65 years and older who had sustained blunt trauma. The following variables were extracted and examined independently and in combination for their ability to predict death: age, gender, mechanism of injury, admission blood pressure, and Glasgow Coma Scale score, respiratory status, Trauma Score, Revised Trauma Score, and Injury Severity Score. Three urban trauma centers. Geriatric trauma patients entering three trauma centers (Stanford [Calif] University Hospital, Vanderbilt University Medical Center, Nashville, Tenn, and Maryland Institute for Emergency Medical Services Systems, Baltimore) following blunt trauma during a 7-year period (1982 to 1989). The Injury Severity Score was the single variable that correlated most significantly with mortality. Mortality rates were higher for men than for women and were significantly higher in patients 75 years and older. Admission variables associated with the highest relative risks of death included a Trauma Score less than 7; hypotension (systolic blood pressure, < 90 mm Hg); hypoventilation (respiratory rate, < 10 breaths per minute); or a Glasgow Coma Scale score equal to 3. Admission variables in geriatric trauma patients can be used to predict outcome and may also be useful in making decisions about triage, quality assurance, and use of intensive care unit beds.

Outcome and prognostic factors in critically ill patients with systemic lupus erythematosus: a retrospective study.

PubMed

Hsu, Chia-Lin; Chen, Kuan-Yu; Yeh, Pu-Sheng; Hsu, Yeong-Long; Chang, Hou-Tai; Shau, Wen-Yi; Yu, Chia-Li; Yang, Pan-Chyr

2005-06-01

Systemic lupus erythematosus (SLE) is an archetypal autoimmune disease, involving multiple organ systems with varying course and prognosis. However, there is a paucity of clinical data regarding prognostic factors in SLE patients admitted to the intensive care unit (ICU). From January 1992 to December 2000, all patients admitted to the ICU with a diagnosis of SLE were included. Patients were excluded if the diagnosis of SLE was established at or after ICU admission. A multivariate logistic regression model was applied using Acute Physiology and Chronic Health Evaluation II scores and variables that were at least moderately associated (P < 0.2) with survival in the univariate analysis. A total of 51 patients meeting the criteria were included. The mortality rate was 47%. The most common cause of admission was pneumonia with acute respiratory distress syndrome. Multivariate logistic regression analysis showed that intracranial haemorrhage occurring while the patient was in the ICU (relative risk = 18.68), complicating gastrointestinal bleeding (relative risk = 6.97) and concurrent septic shock (relative risk = 77.06) were associated with greater risk of dying, whereas causes of ICU admission and Acute Physiology and Chronic Health Evaluation II score were not significantly associated with death. The mortality rate in critically ill SLE patients was high. Gastrointestinal bleeding, intracranial haemorrhage and septic shock were significant prognostic factors in SLE patients admitted to the ICU.

Predicting Appropriate Admission of Bronchiolitis Patients in the Emergency Department: Rationale and Methods.

PubMed

Luo, Gang; Stone, Bryan L; Johnson, Michael D; Nkoy, Flory L

2016-03-07

In young children, bronchiolitis is the most common illness resulting in hospitalization. For children less than age 2, bronchiolitis incurs an annual total inpatient cost of $1.73 billion. Each year in the United States, 287,000 emergency department (ED) visits occur because of bronchiolitis, with a hospital admission rate of 32%-40%. Due to a lack of evidence and objective criteria for managing bronchiolitis, ED disposition decisions (hospital admission or discharge to home) are often made subjectively, resulting in significant practice variation. Studies reviewing admission need suggest that up to 29% of admissions from the ED are unnecessary. About 6% of ED discharges for bronchiolitis result in ED returns with admission. These inappropriate dispositions waste limited health care resources, increase patient and parental distress, expose patients to iatrogenic risks, and worsen outcomes. Existing clinical guidelines for bronchiolitis offer limited improvement in patient outcomes. Methodological shortcomings include that the guidelines provide no specific thresholds for ED decisions to admit or to discharge, have an insufficient level of detail, and do not account for differences in patient and illness characteristics including co-morbidities. Predictive models are frequently used to complement clinical guidelines, reduce practice variation, and improve clinicians' decision making. Used in real time, predictive models can present objective criteria supported by historical data for an individualized disease management plan and guide admission decisions. However, existing predictive models for ED patients with bronchiolitis have limitations, including low accuracy and the assumption that the actual ED disposition decision was appropriate. To date, no operational definition of appropriate admission exists. No model has been built based on appropriate admissions, which include both actual admissions that were necessary and actual ED discharges that were unsafe. The goal of this study is to develop a predictive model to guide appropriate hospital admission for ED patients with bronchiolitis. This study will: (1) develop an operational definition of appropriate hospital admission for ED patients with bronchiolitis, (2) develop and test the accuracy of a new model to predict appropriate hospital admission for an ED patient with bronchiolitis, and (3) conduct simulations to estimate the impact of using the model on bronchiolitis outcomes. We are currently extracting administrative and clinical data from the enterprise data warehouse of an integrated health care system. Our goal is to finish this study by the end of 2019. This study will produce a new predictive model that can be operationalized to guide and improve disposition decisions for ED patients with bronchiolitis. Broad use of the model would reduce iatrogenic risk, patient and parental distress, health care use, and costs and improve outcomes for bronchiolitis patients.

Estimating the impact of newly arrived foreign-born persons on tuberculosis in the United States.

PubMed

Liu, Yecai; Painter, John A; Posey, Drew L; Cain, Kevin P; Weinberg, Michelle S; Maloney, Susan A; Ortega, Luis S; Cetron, Martin S

2012-01-01

Among approximately 163.5 million foreign-born persons admitted to the United States annually, only 500,000 immigrants and refugees are required to undergo overseas tuberculosis (TB) screening. It is unclear what extent of the unscreened nonimmigrant visitors contributes to the burden of foreign-born TB in the United States. We defined foreign-born persons within 1 year after arrival in the United States as "newly arrived", and utilized data from U.S. Department of Homeland Security, U.S. Centers for Disease Control and Prevention, and World Health Organization to estimate the incidence of TB among newly arrived foreign-born persons in the United States. During 2001 through 2008, 11,500 TB incident cases, including 291 multidrug-resistant TB incident cases, were estimated to occur among 20,989,738 person-years for the 1,479,542,654 newly arrived foreign-born persons in the United States. Of the 11,500 estimated TB incident cases, 41.6% (4,783) occurred among immigrants and refugees, 36.6% (4,211) among students/exchange visitors and temporary workers, 13.8% (1,589) among tourists and business travelers, and 7.3% (834) among Canadian and Mexican nonimmigrant visitors without an I-94 form (e.g., arrival-departure record). The top 3 newly arrived foreign-born populations with the largest estimated TB incident cases per 100,000 admissions were immigrants and refugees from high-incidence countries (e.g., 2008 WHO-estimated TB incidence rate of ≥100 cases/100,000 population/year; 235.8 cases/100,000 admissions, 95% confidence interval [CI], 228.3 to 243.3), students/exchange visitors and temporary workers from high-incidence countries (60.9 cases/100,000 admissions, 95% CI, 58.5 to 63.3), and immigrants and refugees from medium-incidence countries (e.g., 2008 WHO-estimated TB incidence rate of 15-99 cases/100,000 population/year; 55.2 cases/100,000 admissions, 95% CI, 51.6 to 58.8). Newly arrived nonimmigrant visitors contribute substantially to the burden of foreign-born TB in the United States. To achieve the goals of TB elimination, direct investment in global TB control and strategies to target nonimmigrant visitors should be considered.

The Association between Anticholinergic Drug Use and Rehabilitation Outcome in Post-Acute Hip Fractured Patients: A Retrospective Cohort Study.

PubMed

Hershkovitz, Avital; Angel, Corina; Brill, Shai; Nissan, Ran

2018-04-01

Anticholinergic (AC) drugs are associated with significant impairment in cognitive and physical function which may affect rehabilitation in older people. We aimed to evaluate whether AC burden is associated with rehabilitation achievement in post-acute hip-fractured patients. A retrospective cohort study carried out in a post-acute geriatric rehabilitation center on 1019 hip-fractured patients admitted from January 2011 to October 2015. The Anticholinergic Cognitive Burden Scale (ACB) was used to quantify the AC burden. Main outcome measures included the Functional Independence Measure (FIM) instrument, motor FIM (mFIM), Montebello Rehabilitation Factor Score (MRFS) on the mFIM, and length of stay (LOS). The study population was divided into two groups: individuals with low admission AC burden (ACB ≤ 1) and those with high admission AC burden (ACB ≥ 2). The relationship between the admission AC burden and clinical, demographic and comorbidity variables was assessed using the Mann-Whitney and Chi square tests. A multiple linear regression model was used to estimate the association between admission AC burden and discharge FIM score after controlling for sociodemographic characteristics and chronic diseases. Patients with a high admission AC burden had a significantly higher rate of high education, a significantly lower rate reside at home, they waited a longer period of time from surgery to rehabilitation, were less independent pre-fracture, and presented with a higher rate of vascular disorders and depression compared with patients with a lower admission AC burden. These patients also exhibited a significantly lower FIM score on admission and at discharge, a lower FIM score change, and a lower achievement on the MRFS compared with patients with a lower admission AC burden. A multiple linear regression analysis showed that admission AC burden was significantly associated with the discharge FIM score after adjustment for confounding variables. High admission AC drug burden is significantly associated with less favorable discharge functional status in post-acute hip-fractured patients, independent of relevant risk factors.

Early resuscitation intensity as a surrogate for bleeding severity and early mortality in the PRospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study

PubMed Central

Rahbar, Elaheh; Fox, Erin E.; del Junco, Deborah J.; Harvin, John A.; Holcomb, John B.; Wade, Charles E.; Schreiber, Martin A.; Rahbar, Mohammad H.; Bulger, Eileen M.; Phelan, Herb A.; Brasel, Karen J.; Alarcon, Louis H.; Myers, John G.; Cohen, Mitchell J.; Muskat, Peter; Cotton, Bryan A.

2013-01-01

Background The classic definition of MT, ≥10 units red blood cells (RBCs) in 24 hours, has never been demonstrated as a valid surrogate for severe hemorrhage and can introduce survival bias. In addition, the definition fails to capture other products that the clinician may have immediately available during the initial resuscitation. Assuming that units of resuscitative fluids reflect patient illness, our objective was to identify a rate of resuscitation intensity (RI) that could serve as an early surrogate of sickness for patients with substantial bleeding post-injury. Methods Adult patients surviving at least 30 minutes post-admission and receiving ≥1 RBC within 6 hours of admission from ten US Level 1 trauma centers were enrolled in the PRospective Observational Multicenter Major Trauma Transfusion study. Total fluid units were calculated as the sum of the number of crystalloid units (1 L=1 unit), colloids (0.5 L=1 unit) and blood products (1 RBC=1 unit, 1 plasma=1 unit, 6 pack platelets=1 unit). Univariable and multivariable logistic regressions were used to evaluate associations between RI and 6-hour mortality, adjusting for age, center, penetrating injury, weighted Revised Trauma Score, and Injury Severity Score. Results 1096 eligible patients received resuscitative fluids within 30 minutes, including 620 transfused with blood products. Despite varying products utilized, the total fluid RI was similar across all sites (3.2±2.5 units). Patients who received ≥4 units of any resuscitative fluid had a 6-hour mortality rate of 14.4% vs. 4.5% in patients who received <4 units. The adjusted odds ratio of 6-hour mortality for patients receiving ≥4 units within 30 minutes was 2.1 (95% Confidence Interval: 1.2–3.5). Conclusions Resuscitation with ≥4 units of any fluid was significantly associated with 6-hour mortality. This study suggests that early RI regardless of fluid type can be used as a surrogate for sickness and mortality in severely bleeding patients. Level of Evidence PROMMTT is a prospective observational study, Level II. PMID:23778506

Identifying patient-level health and social care costs for older adults discharged from acute medical units in England.

PubMed

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.

Stressors in the relatives of patients admitted to an intensive care unit

PubMed Central

Barth, Angélica Adam; Weigel, Bruna Dorfey; Dummer, Claus Dieter; Machado, Kelly Campara; Tisott, Taís Montagner

2016-01-01

Objective To identify and stratify the main stressors for the relatives of patients admitted to the adult intensive care unit of a teaching hospital. Methods Cross-sectional descriptive study conducted with relatives of patients admitted to an intensive care unit from April to October 2014. The following materials were used: a questionnaire containing identification information and demographic data of the relatives, clinical data of the patients, and 25 stressors adapted from the Intensive Care Unit Environmental Stressor Scale. The degree of stress caused by each factor was determined on a scale of values from 1 to 4. The stressors were ranked based on the average score obtained. Results The main cause of admission to the intensive care unit was clinical in 36 (52.2%) cases. The main stressors were the patient being in a state of coma (3.15 ± 1.23), the patient being unable to speak (3.15 ± 1.20), and the reason for admission (3.00 ± 1.27). After removing the 27 (39.1%) coma patients from the analysis, the main stressors for the relatives were the reason for admission (2.75 ± 1.354), seeing the patient in the intensive care unit (2.51 ± 1.227), and the patient being unable to speak (2.50 ± 1.269). Conclusion Difficulties in communication and in the relationship with the patient admitted to the intensive care unit were identified as the main stressors by their relatives, with the state of coma being predominant. By contrast, the environment, work routines, and relationship between the relatives and intensive care unit team had the least impact as stressors. PMID:27737424

Subjects hospitalized with the 2009 pandemic influenza A (H1N1) virus in a respiratory infection unit: clinical factors correlating with ICU admission.

PubMed

Rovina, Nikoletta; Erifaki, Magdalini; Katsaounou, Paraskevi; Lyxi, Georgia; Koutsoukou, Antonia; Koulouris, Nikolaos G; Alchanatis, Manos

2014-10-01

The 2009 pandemic influenza A (H1N1) virus was accompanied by high morbidity and mortality. The aim of this study was to describe the clinical characteristics of patients with documented 2009 influenza A (H1N1) virus admitted to a reference chest hospital, the disease outcome, and risk factors associated with ICU admission. We assessed 109 subjects admitted to the respiratory infection unit of a hospital for chest disease with signs and symptoms of the 2009 influenza A (H1N1) virus between April 2009 and December 2010. Demographic data, comorbidities, clinical signs and symptoms, laboratory tests, radiographic findings, treatment, and final outcomes were all recorded. Factors associated with severe disease requiring ICU admission were determined. Ninety subjects (82.5%) had laboratory-confirmed 2009 influenza A (H1N1). Sixty-four percent of these subjects had pneumonia on admission, 26% had respiratory failure, and 11% required care in the ICU. Dyspnea and the presence of infiltrates on chest x-rays were the most common signs among the subjects with H1N1. All subjects were treated with antiviral therapy, and 75% received antibiotic treatment based on their clinical and laboratory findings. The predictive factors of ICU admission were severe hypoxemia and lymphocytosis. The outcome of subjects with influenza A (H1N1) virus infection was influenced by the severity of the disease on admission, the subjects' underlying conditions, and complications during hospitalization. Copyright © 2014 by Daedalus Enterprises.

Coarse Particulate Air Pollution Associated with Increased Risk of Hospital Admissions for Respiratory Diseases in a Tropical City, Kaohsiung, Taiwan.

PubMed

Cheng, Meng-Hsuan; Chiu, Hui-Fen; Yang, Chun-Yuh

2015-10-16

This study was undertaken to determine whether there was an association between coarse particles (PM₂.₅-₁₀) levels and frequency of hospital admissions for respiratory diseases (RD) in Kaohsiung, Taiwan. Hospital admissions for RD including chronic obstructive pulmonary disease (COPD), asthma, and pneumonia, and ambient air pollution data levels for Kaohsiung were obtained for the period from 2006 to 2010. The relative risk of hospital admissions for RD was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. For the single pollutant model (without adjustment for other pollutants), increased rate of admissions for RD were significantly associated with higher coarse PM levels only on cool days (<25 °C), with a 10 µg/m³ elevation in PM₂.₅-₁₀ concentrations associated with a 3% (95% CI = 1%-5%) rise in COPD admissions, 4% (95% CI = 1%-7%) increase in asthma admissions, and 3% (95% CI = 2%-4%) rise in pneumonia admissions. No significant associations were found between coarse particle levels and the number of hospital admissions for RD on warm days. In the two-pollutant models, PM₂.₅-₁₀ levels remained significantly correlated with higher rate of RD admissions even controlling for sulfur dioxide, nitrogen dioxide, carbon monoxide, or ozone on cool days. This study provides evidence that higher levels of PM₂.₅-₁₀ enhance the risk of hospital admissions for RD on cool days.

Changes in the outcomes of severe trauma patients from 15-year experience in a Western European trauma ICU of Emilia Romagna region (1996-2010). A population cross-sectional survey study.

PubMed

Di Saverio, Salomone; Gambale, Giorgio; Coccolini, Federico; Catena, Fausto; Giorgini, Eleonora; Ansaloni, Luca; Amadori, Niki; Coniglio, Carlo; Giugni, Aimone; Biscardi, Andrea; Magnone, Stefano; Filicori, Filippo; Cavallo, Piergiorgio; Villani, Silvia; Cinquantini, Francesco; Annicchiarico, Massimo; Gordini, Giovanni; Tugnoli, Gregorio

2014-01-01

Our experience in trauma center management increased over time and improved with development of better logistics, optimization of structural and technical resources. In addition recent Government policy in safety regulations for road traffic accident (RTA) prevention, such compulsory helmet use (2000) and seatbelt restraint (2003) were issued with aim of decreasing mortality rate for trauma. The evaluation of their influence on mortality during the last 15 years can lead to further improvements. In our level I trauma center, 60,247 trauma admissions have been recorded between 1996 and 2010, with 2183 deaths (overall mortality 3.6 %). A total of 2,935 trauma patients with ISS >16 have been admitted to Trauma ICU and recorded in a prospectively collected database (1996-2010). Blunt trauma occurred in 97.1 % of the cases, whilst only 2.5 % were penetrating. A retrospective review of the outcomes was carried out, including mortality, cause of death, morbidity and length of stay (LOS) in the intensive care unit (ICU), with stratification of the outcome changes through the years. Age, sex, mechanism, glasgow coma scale (GCS), systolic blood pressure (SBP), respiratory rate (RR), revised trauma score (RTS), injury severity score (ISS), pH, base excess (BE), as well as therapeutic interventions (i.e., angioembolization and number of blood units transfused in the first 24 h), were included in univariate and multivariate analyses by logistic regression of mortality predictive value. Overall mortality through the whole period was 17.2 %, and major respiratory morbidity in the ICU was 23.3 %. A significant increase of trauma admissions has been observed (before and after 2001, p < 0.01). Mean GCS (10.2) increased during the period (test trend p < 0.05). Mean age, ISS (24.83) and mechanism did not change significantly, whereas mortality rate decreased showing two marked drops, from 25.8 % in 1996, to 18.3 % in 2000 and again down to 10.3 % in 2004 (test trend p < 0.01). Traumatic brain injury (TBI) accounted for 58.4 % of the causes of death; hemorrhagic shock was the death cause in 28.4 % and multiple organ failure (MOF)/sepsis in 13.2 % of the patients. However, the distribution of causes of death changed during the period showing a reduction of TBI-related and increase of MOF/sepsis (CTR test trend p < 0.05). Significant predictors of mortality in the whole group were year of admission (p < 0.05), age, hemorrhagic shock and SBP at admission, ISS and GCS, pH and BE (all p < 0.01). In the subgroup of patients that underwent emergency surgery, the same factors confirmed their prognostic value and remained significant as well as the adjunctive parameter of total amount of blood units transfused (p < 0.05). Surgical time (mean 71 min) showed a significant trend towards reduction but did not show significant association with mortality (p = 0.06). Mortality of severe trauma decreased significantly during the last 15 years as well as mean GCS improved whereas mean ISS remained stable. The new safety regulations positively influenced incidence and severity of TBI and seemed to improve the outcomes. ISS seems to be a better predictor of outcome than RTS.

Symptoms associated with adverse dengue fever prognoses at the time of reporting in the 2015 dengue outbreak in Taiwan.

PubMed

Yeh, Chun-Yin; Chen, Po-Lin; Chuang, Kun-Ta; Shu, Yu-Chen; Chien, Yu-Wen; Perng, Guey Chuen; Ko, Wen-Chien; Ko, Nai-Ying

2017-12-01

Tainan experienced the most severe dengue epidemic in Taiwan in 2015. This study investigates the association between the signs and symptoms at the time of reporting with the adverse dengue prognoses. A descriptive study was conducted using secondary data from the Dengue Disease Reporting System in Tainan, Taiwan, between January 1 and December 31, 2015. A multivariate stepwise logistic regression was used to identify the risk factors for the adverse prognoses: ICU admissions and mortality. There were 22,777 laboratory-confirmed reported cases (mean age 45.6 ± 21.2 years), of which 3.7% were admitted to intensive care units (ICU), and 0.8% were fatal. The most common symptoms were fever (92.8%), myalgia (26.6%), and headache (22.4%). The prevalence of respiratory distress, altered consciousness, shock, bleeding, and thrombocytopenia increased with age. The multivariate analysis indicated that being in 65-89 years old age group [Adjusted Odds Ratio (aOR):4.95], or the 90 years old and above age group (aOR: 9.06), and presenting with shock (aOR: 8.90) and respiratory distress (aOR: 5.31) were significantly associated with the risk of ICU admission. While old age (aOR: 1.11), respiratory distress (aOR: 9.66), altered consciousness (aOR: 7.06), and thrombocytopenia (aOR: 2.55) were significantly associated with the risk of mortality. Dengue patients older than 65 and those with severe and non-specific signs and symptoms at the time of reporting were at a higher risk of ICU admission and mortality. First-line healthcare providers need to be aware of the varied presentations between the different age groups to allow early diagnosis and in-time management, which would prevent ICU admissions and fatalities in dengue patients.

The characteristics of patients frequently admitted to academic medical centers in the United States

PubMed Central

Williams, Mark V.; Carrier, Danielle; Hensley, Laurie; Thomas, Stephen; Cerese, Julie

2015-01-01

BACKGROUND The recent intense attention to hospital readmissions and their implications for quality, safety, and reimbursement necessitates understanding specific subsets of readmitted patients. Frequently admitted patients, defined as patients who are admitted 5 or more times within 1 year, may have some distinguishing characteristics that require novel solutions. METHODS A comprehensive administrative database (University HealthSystem Consortium's Clinical Data Base/Resource Manager™) was analyzed to identify demographic, social, and clinical characteristics of frequently admitted patients in 101 US academic medical centers. RESULTS We studied 28,291 frequently admitted patients with 180,185 admissions over a 1‐year period (2011–2012). These patients comprise 1.6% of all patients, but account for 8% of all admissions and 7% of direct costs. Their admissions are driven by multiple chronic conditions; compared to other hospitalized patients, they have significantly more comorbidities (an average of 7.1 vs 2.5), and 84% of their admissions are to medical services. A minority, but significantly more than other patients, have comorbidities of psychosis or substance abuse. Moreover, although they are slightly more likely than other patients to be on Medicaid or to be uninsured (27.6% vs 21.6%), nearly three‐quarters have private or Medicare coverage. CONCLUSIONS Patients who are frequently admitted to US academic medical centers are likely to have multiple complex chronic conditions and may have behavioral comorbidities that mediate their health behaviors, resulting in acute episodes requiring hospitalization. This information can be used to identify solutions for preventing repeat hospitalization for this small group of patients who consume a highly disproportionate share of healthcare resources. Journal of Hospital Medicine 2015;10:563–568. © 2015 The Authors Journal of Hospital Medicine published by Wiley Periodicals, Inc. on behalf of Society of Hospital Medicine PMID:26018340

Prognostic value of severity by various visceral proteins in critically ill patients with SIRS during 7 days of stay.

PubMed

Bouharras-El Idrissi, Hicham; Molina-López, Jorge; Herrera-Quintana, Lourdes; Domínguez-García, Álvaro; Lobo-Támer, Gabriela; Pérez-Moreno, Irene; Pérez-de la Cruz, Antonio; Planells-Del Pozo, Elena

2016-11-29

Critically ill patients typically develop a catabolic stress state as a result of a systemic inflammatory response (SIRS) that alters clinical-nutritional biomarkers, increasing energy demands and nutritional requirements. To evaluate the status of albumin, prealbumin and transferrin in critically ill patients and the association between these clinical-nutritional parameters with the severity during a seven day stay in intensive care unit (ICU). Multicenter, prospective, observational and analytical follow-up study. A total of 115 subjects in critical condition were included in this study. Clinical and nutritional parameters and severity were monitored at admission and at the seventh day of the ICU stay. A significant decrease in APACHE II and SOFA (p < 0.05) throughout the evolution of critically ill patients in ICU. In general, patients showed an alteration of most of the parameters analyzed. The status of albumin, prealbumin and transferrin were below reference levels both at admission and the 7th day in ICU. A high percentage of patients presented an unbalanced status of albumin (71.3%), prealbumin (84.3%) and transferrin (69.0%). At admission, 27% to 47% of patients with altered protein parameters had APACHE II above 18. The number of patients with altered protein parameters and APACHE II below 18 were significantly higher than severe ones throughout the ICU stay (p < 0.01). Regarding the multivariate analysis, low prealbumin status was the best predictor of severity critical (p < 0.05) both at admission and 7th day of the ICU stay. The results of the present study support the idea of including low prealbumin status as a severity predictor in APACHE II scale, due to the association found between severity and poor status of prealbumin.

Cost analysis of inpatient treatment of anorexia nervosa in adolescents: hospital and caregiver perspectives

PubMed Central

Wong, Matthew; Katzman, Debra K.; Akseer, Nadia; Steinegger, Cathleen; Hancock-Howard, Rebecca L.; Coyte, Peter C.

2015-01-01

Background Admission to hospital is the treatment of choice for anorexia nervosa in adolescent patients who are medically unstable; however, stays are often prolonged and frequently disrupt normal adolescent development, family functioning, school and work productivity. We sought to determine the costs of inpatient treatment in this population from a hospital and caregiver perspective, and to identify determinants of such costs. Methods We used micro-costing methods for this cohort study involving all adolescent patients (age 12–18 yr) admitted for treatment of anorexia nervosa at a tertiary care child and adolescent eating disorder program in Toronto, between Sept. 1, 2011, and Mar. 31, 2013. We used hospital administrative data and Canadian census data to calculate hospital and caregiver costs. Results We included 73 adolescents in our cohort for cost-analysis. We determined a mean total hospital cost in 2013 Canadian dollars of $51 349 (standard deviation [SD] $26 598) and a mean total societal cost of $54 932 (SD $27 864) per admission, based on a mean length of stay of 37.9 days (SD 19.7 d). We found patient body mass index (BMI) to be the only significant negative predictor of hospital cost (p < 0.001). For every unit increase in BMI, we saw a 15.7% decrease in hospital cost. In addition, we found higher BMI (p < 0.001) and younger age (p < 0.05) to be significant negative predictors of caregiver costs. Interpretation The economic burden of inpatient treatment for adolescents with anorexia nervosa on hospitals and caregivers is substantial, especially among younger patients and those with lower BMI. Recognizing the symptoms of eating disorders early may preclude the need for admission to hospital altogether or result in admissions at higher BMIs, thereby potentially reducing these costs. PMID:26389097

Functional level during the first 2 years after moderate and severe traumatic brain injury.

PubMed

Sandhaug, Maria; Andelic, Nada; Langhammer, Birgitta; Mygland, Aase

2015-01-01

Long-term outcomes after TBI are examined to a large extent, but longitudinal studies with more than 1-year follow-up time after injury have been fewer in number. The course of recovery may vary due to a number of factors and it is still somewhat unclear which factors are contributing. The aim of this study was to describe the functional level at four time points up to 24 months after traumatic brain injury (TBI) and to evaluate the predictive impact of pre-injury and injury-related factors. A cohort study. Outpatient. Sixty-five patients with moderate (n = 21) or severe (n = 44) TBI. The patients with TBI were examined with Functional Independence Measure (FIM) and Glasgow Outcome Scale Extended (GOSE) at 3 months, 12 months and 24 months after injury. Possible predictors were analysed in a regression model using FIM total score at 24 months as the outcome measure. FIM scores improved significantly from rehabilitation unit discharge to 24 months after injury, with peak levels at 3 and 24 months after injury (p < 0.001), for the whole TBI group and the group with severe TBI. The moderate TBI group did not show significant FIM score improvement during this time period. GOSE scores for the whole group and the moderate group improved significantly over time, but the severe group did not. FIM at admission to the rehabilitation unit and GCS score at admission to the rehabilitation unit were closest to being significant predictors of FIM total scores 24 months after injury (B = 0.265 and 2.883, R(2 )= 0.39, p = 0.073, p = 0.081). FIM levels improved during the period from rehabilitation unit discharge to 3 months follow-up; thereafter, there was a 'plateauing' of recovery. In contrast, GOSE 'plateauing' of recovery was at 12 months. The study results may indicate that two of the most used outcome measures in TBI research are more relevant for assessment of the functional recovery in a sub-acute phase than in later stages of TBI recovery.

Integrating a Patient-Controlled Admission Program Into Mental Health Hospital Service: A Multicenter Grounded Theory Study.

PubMed

Ellegaard, Trine; Bliksted, Vibeke; Mehlsen, Mimi; Lomborg, Kirsten

2018-05-01

Patient-controlled admissions (PCAs) enable mental health patients by means of a contract to initiate an admission at a mental health hospital unit without using traditional admission procedures. This study was part of a 3-year Danish multicenter project, and we explored how mental health professionals experienced and managed the implementation of a PCA program. The methodology was grounded theory and the sample included 26 participants. We performed a constant comparative analysis to explore the concerns, attitudes, and strategies of mental health professionals. We developed a model of how the mental health professionals strived to integrate PCA into clinical practice. The process was motivated by the idea of establishing a partnership with patients and involved two interrelated strategies to manage (a) the patient-related duties and (b) the admission contracts. The professionals moved from a phase of professional discomfort to a phase of professional awareness, and ended up with professional comprehension.

Evaluating MEDEVAC Force Structure Requirements Using an Updated Army Scenario, Total Army Analysis Admission Data, Monte Carlo Simulation, and Theater Structure.

PubMed

Fulton, Lawrence; Kerr, Bernie; Inglis, James M; Brooks, Matthew; Bastian, Nathaniel D

2015-07-01

In this study, we re-evaluate air ambulance requirements (rules of allocation) and planning considerations based on an Army-approved, Theater Army Analysis scenario. A previous study using workload only estimated a requirement of 0.4 to 0.6 aircraft per admission, a significant bolus over existence-based rules. In this updated study, we estimate requirements for Phase III (major combat operations) using a simulation grounded in previously published work and Phase IV (stability operations) based on four rules of allocation: unit existence rules, workload factors, theater structure (geography), and manual input. This study improves upon previous work by including the new air ambulance mission requirements of Department of Defense 51001.1, Roles and Functions of the Services, by expanding the analysis over two phases, and by considering unit rotation requirements known as Army Force Generation based on Department of Defense policy. The recommendations of this study are intended to inform future planning factors and already provided decision support to the Army Aviation Branch in determining force structure requirements. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

Impact of whole-body rehabilitation in patients receiving chronic mechanical ventilation.

PubMed

Martin, Ubaldo J; Hincapie, Luis; Nimchuk, Mark; Gaughan, John; Criner, Gerard J

2005-10-01

To evaluate the prevalence and magnitude of weakness in patients receiving chronic mechanical ventilation and the impact of providing aggressive whole-body rehabilitation on conventional weaning variables, muscle strength, and overall functional status. Retrospective analysis of 49 consecutive patients. Multidisciplinary ventilatory rehabilitation unit in an academic medical center. Forty-nine consecutive chronic ventilator-dependent patients referred to a tertiary care hospital ventilator rehabilitation unit. None. Patients were 58 +/- 7 yrs old with multiple etiologies for respiratory failure. On admission, all patients were bedridden and had severe weakness of upper and lower extremities measured by a 5-point muscle strength score and a 7-point Functional Independence Measurement. Postrehabilitation, patients had increases in upper and lower extremity strength (p < .05) and were able to stand and ambulate. All weaned from mechanical ventilation, but three required subsequent intermittent support. Six patients died before hospital discharge. Upper extremity strength on admission inversely correlated with time to wean from mechanical ventilation (R = .72, p < .001). : Patients receiving chronic ventilation are weak and deconditioned but respond to aggressive whole-body and respiratory muscle training with an improvement in strength, weaning outcome, and functional status. Whole-body rehabilitation should be considered a significant component of their therapy.

Modelling physiological deterioration in post-operative patient vital-sign data.

PubMed

Pimentel, Marco A F; Clifton, David A; Clifton, Lei; Watkinson, Peter J; Tarassenko, Lionel

2013-08-01

Patients who undergo upper-gastrointestinal surgery have a high incidence of post-operative complications, often requiring admission to the intensive care unit several days after surgery. A dataset comprising observational vital-sign data from 171 post-operative patients taking part in a two-phase clinical trial at the Oxford Cancer Centre, was used to explore the trajectory of patients' vital-sign changes during their stay in the post-operative ward using both univariate and multivariate analyses. A model of normality based vital-sign data from patients who had a "normal" recovery was constructed using a kernel density estimate, and tested with "abnormal" data from patients who deteriorated sufficiently to be re-admitted to the intensive care unit. The vital-sign distributions from "normal" patients were found to vary over time from admission to the post-operative ward to their discharge home, but no significant changes in their distributions were observed from halfway through their stay on the ward to the time of discharge. The model of normality identified patient deterioration when tested with unseen "abnormal" data, suggesting that such techniques may be used to provide early warning of adverse physiological events.

Evaluating Maternity Units: a prospective cohort study of freestanding midwife-led primary maternity units in New Zealand-clinical outcomes.

PubMed

Grigg, Celia P; Tracy, Sally K; Tracy, Mark; Daellenbach, Rea; Kensington, Mary; Monk, Amy; Schmied, Virginia

2017-08-29

To compare maternal and neonatal birth outcomes and morbidities associated with the intention to give birth in a freestanding primary level midwife-led maternity unit (PMU) or tertiary level obstetric-led maternity hospital (TMH) in Canterbury, Aotearoa/New Zealand. Prospective cohort study. 407 women who intended to give birth in a PMU and 285 women who intended to give birth at the TMH in 2010-2011. All of the women planning a TMH birth were 'low risk', and 29 of the PMU cohort had identified risk factors. Mode of birth, Apgar score of less than 7 at 5 min and neonatal unit admission. labour onset, analgesia, blood loss, third stage of labour management, perineal trauma, non-pharmacological pain relief, neonatal resuscitation, breastfeeding, gestational age at birth, birth weight, severe morbidity and mortality. Women who planned a PMU birth were significantly more likely to have a spontaneous vaginal birth (77.9%vs62.3%, adjusted OR (AOR) 1.61, 95% CI 1.08 to 2.39), and significantly less likely to have an instrumental assisted vaginal birth (10.3%vs20.4%, AOR 0.59, 95% CI 0.37 to 0.93). The emergency and elective caesarean section rates were not significantly different (emergency: PMU 11.6% vs TMH 17.5%, AOR 0.88, 95% CI 0.55 to 1.40; elective: PMU 0.7% vs TMH 2.1%, AOR 0.34, 95% CI 0.08 to 1.41). There were no significant differences between the cohorts in rates of 5 min Apgar score of <7 (2.0%vs2.1%, AOR 0.82, 95% CI 0.27 to 2.52) and neonatal unit admission (5.9%vs4.9%, AOR 1.44, 95% CI 0.70 to 2.96). Planning to give birth in a primary unit was associated with similar or reduced odds of intrapartum interventions and similar odds of all measured neonatal well-being indicators. The results of this study support freestanding midwife-led primary-level maternity units as physically safe places for well women to plan to give birth, with these women having higher rates of spontaneous vaginal births and lower rates of interventions and their associated morbidities than those who planned a tertiary hospital birth, with no differences in neonatal outcomes. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Evaluating Maternity Units: a prospective cohort study of freestanding midwife-led primary maternity units in New Zealand—clinical outcomes

PubMed Central

Grigg, Celia P; Tracy, Sally K; Tracy, Mark; Daellenbach, Rea; Kensington, Mary; Monk, Amy; Schmied, Virginia

2017-01-01

Objective To compare maternal and neonatal birth outcomes and morbidities associated with the intention to give birth in a freestanding primary level midwife-led maternity unit (PMU) or tertiary level obstetric-led maternity hospital (TMH) in Canterbury, Aotearoa/New Zealand. Design Prospective cohort study. Participants 407 women who intended to give birth in a PMU and 285 women who intended to give birth at the TMH in 2010–2011. All of the women planning a TMH birth were ‘low risk’, and 29 of the PMU cohort had identified risk factors. Primary outcomes Mode of birth, Apgar score of less than 7 at 5 min and neonatal unit admission. Secondary outcomes: labour onset, analgesia, blood loss, third stage of labour management, perineal trauma, non-pharmacological pain relief, neonatal resuscitation, breastfeeding, gestational age at birth, birth weight, severe morbidity and mortality. Results Women who planned a PMU birth were significantly more likely to have a spontaneous vaginal birth (77.9%vs62.3%, adjusted OR (AOR) 1.61, 95% CI 1.08 to 2.39), and significantly less likely to have an instrumental assisted vaginal birth (10.3%vs20.4%, AOR 0.59, 95% CI 0.37 to 0.93). The emergency and elective caesarean section rates were not significantly different (emergency: PMU 11.6% vs TMH 17.5%, AOR 0.88, 95% CI 0.55 to 1.40; elective: PMU 0.7% vs TMH 2.1%, AOR 0.34, 95% CI 0.08 to 1.41). There were no significant differences between the cohorts in rates of 5 min Apgar score of <7 (2.0%vs2.1%, AOR 0.82, 95% CI 0.27 to 2.52) and neonatal unit admission (5.9%vs4.9%, AOR 1.44, 95% CI 0.70 to 2.96). Planning to give birth in a primary unit was associated with similar or reduced odds of intrapartum interventions and similar odds of all measured neonatal well-being indicators. Conclusions The results of this study support freestanding midwife-led primary-level maternity units as physically safe places for well women to plan to give birth, with these women having higher rates of spontaneous vaginal births and lower rates of interventions and their associated morbidities than those who planned a tertiary hospital birth, with no differences in neonatal outcomes. PMID:28851782

Patterns of antiepileptic drug overdose differ between men and women: admissions to the Edinburgh Poisons Unit, 2000-2007.

PubMed

Nixon, A C; Doak, M W; Crozier, H; Crooks, D P; Waring, W S

2009-01-01

Antiepileptic drugs are increasingly used in patients with psychiatric disorders who are at increased risk of self-harm. This might increase the likelihood that these agents are used as a means of overdose. This study was designed to examine the rate of occurrence of antiepileptic drug overdose between 2000 and 2007. A retrospective observational study examined patterns of antiepileptic drug overdose in patients admitted to the Edinburgh Poisons Unit, and compared prescription data for the corresponding region. Data were compared using chi-square trend tests. There were 18 010 admissions to the Toxicology Unit, and 613 patients ingested at least one antiepileptic drug (3.4%). The most frequently implicated were carbamazepine, sodium valproate, phenytoin and lamotrigine, which corresponded with those most commonly prescribed. Women were more likely to ingest lamotrigine than men (P < 0.0001), and less likely to ingest sodium valproate (P = 0.0234). Patients that ingested antiepileptic drugs were more likely to be admitted to hospital for >1 day (22% vs. 8%, P < 0.0001) and need transfer to a psychiatric facility (14% vs. 7%, P < 0.0001). Patients that ingested antiepileptic drugs required more intensive medical and psychiatric intervention compared to ingestion of other agents. Significant gender differences were noted in the specific antiepileptic drug ingested. Further work is required to establish whether this discrepancy may be explained by gender-based prescribing practices.

[Retrospective study of children referred from paediatric intensive care to palliative care: Why and for what].

PubMed

García-Salido, Alberto; Santos-Herranz, Paula; Puertas-Martín, Verónica; García-Teresa, María Ángeles; Martino-Alba, Ricardo; Serrano-González, Ana

2018-01-01

The creation of paediatric palliative care units (PPCU) could optimise the management of children with palliative focus after admission to a paediatric intensive care unit (PICU). This study describes the clinical and epidemiological characteristics of children referred from PICU to the PPCU of the Autonomous Community of Madrid (CAM). The overall treatment, relapses, re-admissions, and deaths, if occurred, are described. A retrospective review was performed using the medical records from children transferred from the CAM paediatric intensive care units to the paediatric palliative care unit (1 March 2008-31 January 2015). A total of 41 patients were included (26 male/15 female) with a median age of 33 months (range 1-228). In the follow by the PPCU follow-up, the main approaches were respiratory (invasive ventilation with tracheostomy tube 8/41), nutritional (gastrostomy in 20/41), and pharmacological (anti-epileptics in 29/41 and 34/41 on antibiotic treatment). Hospital re-admission was required by 11/41 patients, with no re-admissions to PICU. Of the 13/41 patients who died, 9/13 was at home, with all of them accompanied by the primary caregivers and family, and only 1/9 with the presence of the home team. The palliative approach at home is feasible in children, and the integration of PPCU could optimise the comprehensive care of previously critically ill children. It is necessary to achieve an optimal domiciliary care should be achieved, and not just because of patient death. More observational, multicentre and prospective studies are needed to confirm these findings. Copyright © 2016 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.

Reaffirming Diversity: A Legal Analysis of the University of Michigan Affirmative Action Cases. A Joint Statement of Constitutional Law Scholars.

ERIC Educational Resources Information Center

Harvard Civil Rights Project, Cambridge, MA.

On June 23, 2003, the United States Supreme Court upheld the constitutionality of race-conscious admissions policies designed to promote diversity in higher education. The Grutter versus Bollinger decision upheld the University of Michigan Law School race-conscious admissions policy as constitutional. However, in Gratz versus Bollinger, it held…

Stroke Laterality Bias in the Management of Acute Ischemic Stroke.

PubMed

McCluskey, Gavin; Wade, Carrie; McKee, Jacqueline; McCarron, Peter; McVerry, Ferghal; McCarron, Mark O

2016-11-01

Little is known of the impact of stroke laterality on the management process and outcome of patients with acute ischemic stroke (AIS). Consecutive patients admitted to a general hospital over 1 year with supratentorial AIS were eligible for inclusion in the study. Baseline characteristics and risk factors, delays in hospital admission, imaging, intrahospital transfer to an acute stoke unit, stroke severity and classification, length of hospital admission, as well as 10-year mortality were measured and compared among right and left hemisphere AIS patients. There were 141 patients (77 men, 64 women; median age 73 [interquartile range 63-79] years), There were 71 patients with left hemisphere AIS and 70 with right hemisphere AIS. Delays to hospital admission from stroke onset to neuroimaging were similar among right and left hemisphere AIS patients. Delay in transfer to an acute stroke unit (ASU) following hospital admission was on average 14 hours more for right hemisphere compared to left hemisphere AIS patients (P = .01). Laterality was not associated with any difference in 10-year survival. Patients with mild and nondominant AIS merit particular attention to minimize their intrahospital transfer time to an ASU. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

8 CFR 247.1 - Scope of part.

Code of Federal Regulations, 2010 CFR

2010-01-01

... admission to the United States, would entitle him to a nonimmigrant status under paragraph (15)(A) or (15)(G... United States, would entitle him to a nonimmigrant status under paragraph (15)(E) of section 101(a) of...

Healthcare utilization in adults with opioid dependence receiving extended release naltrexone compared to treatment as usual.

PubMed

Soares, William E; Wilson, Donna; Rathlev, Niels; Lee, Joshua D; Gordon, Michael; Nunes, Edward V; O'Brien, Charles P; Friedmann, Peter D

2018-02-01

Opioid use disorders have reached epidemic proportions, with overdose now the leading cause of accidental death in the United States. Extended release naltrexone (XR-NTX) has emerged as a medication treatment that reduces opioid use and craving. However, the effect of XR-NTX therapy on acute healthcare utilization, including emergency department visits and inpatient hospitalizations, remains uncertain. The objective of the current study is to evaluate hospital-based healthcare resource utilization in adults involved in the criminal justice system with a history of opioid use disorder randomized to XR-NTX therapy compared with treatment as usual (TAU) during a 6-month treatment phase and 12months post-treatment follow up. This retrospective exploratory analysis uses data collected in a published randomized trial. Comparisons of the number of emergency department visits and hospital admissions (for drug detox, psychiatric care and other medical reasons) were performed using chi square tests for any admission and negative binomial models for number of admissions. Of the 308 participants randomized, 96% had utilization data (76% complete 6months, 67% complete follow up). No significant differences were seen in overall healthcare utilization (IRR=0.88, 95%CI 0.63-1.23, p=0.45), or substance use-related drug detox hospitalizations (IRR=0.83, 95%CI 0.32-2.16, p=0.71). Despite having more participants report chronic medical problems at baseline (43% vs. 32%, p=0.05), those receiving XR-NTX generally experienced equivalent or lower rates of healthcare utilization compared to TAU. The XR-NTX group had significantly lower medical/surgical related hospital admissions (IRR=0.55, 95%CI 0.30-1.00, p=0.05) during the course of the entire study. XR-NTX did not significantly increase rates of healthcare utilization compared to TAU. Provider concerns regarding healthcare utilization should not preclude the consideration of XR-NTX as therapy for opioid use disorders. Copyright © 2018 Elsevier Inc. All rights reserved.

Development of a PICU in Nepal: the experience of the first year.

PubMed

Basnet, Sangita; Shrestha, Shrijana; Ghimire, Amrit; Timila, Dipsal; Gurung, Jeena; Karki, Utkarsha; Adhikari, Neelam; Andoh, Jennifer; Koirala, Janak

2014-09-01

Analysis of hospitalization data can help elucidate the pattern of morbidity and mortality in any given area. Little data exist on critically ill children admitted to hospitals in the resource-limited nation of Nepal. We sought to characterize the profile, management, and mortality of children admitted to one PICU. Retrospective analysis. A newly established PICU in Nepal. All patients between the ages of 0 to 16 years admitted to the PICU from July 2009 to July 2010. None. In 12 months, 126 children were admitted to the PICU including 43% female patients. Sixty-three percent were under 5 years. Twenty-nine percent came from tertiary care hospitals and 38% from rural areas outside Kathmandu. Only 18% were transported by ambulance. Median distance travelled to be admitted was 30 km (interquartile range, 10-193). Highest number of admissions were in spring (40%) followed by summer (25%). Almost half were admitted for shock (45%), particularly septic shock (30%). The second commonest reason for admission was neurologic etiologies (15%). Neonatal admissions were also significant (19%). Mortality was 26% and was significantly associated with septic shock (p < 0.01), mechanical ventilation (p < 0.01), and multiple organ dysfunction (< 0.05). Almost one third of patients required mechanical ventilation; median duration was 4 days (interquartile range, 2-8). Mean length of stay in the hospital was 6.2 days (± 5.3) and median 4 (interquartile range, 2.5-9.0). Median Pediatric Risk of Mortality II score for nonsurvivors was 12 (interquartile range, 7-21), and median Pediatric Index of Mortality II for nonsurvivors was 10 (interquartile range, 3-32). Within a short time of opening, the PICU has been seeing significant numbers of critically ill children. Despite adverse conditions and limited resources, survival of 75% is similar to many units in developing nations. Sepsis was the most common reason for PICU admission and mortality.

Autoimmune Encephalitis at the Neurological Intensive Care Unit: Etiologies, Reasons for Admission and Survival.

PubMed

Harutyunyan, Gayane; Hauer, Larissa; Dünser, Martin W; Karamyan, Anush; Moser, Tobias; Pikija, Slaven; Leitinger, Markus; Novak, Helmut F; Trinka, Eugen; Sellner, Johann

2017-08-01

Early recognition and treatment of autoimmune encephalitis (AE) has become an essential issue in clinical practice. However, little is known about patients with deteriorating conditions and the need for intensive care treatment. Here, we aimed to characterize underlying aetiologies, clinical symptoms, reasons for intensive care admission, and mortality of critically ill patients with AE. We conducted a retrospective chart review of all patients with "definite" or "probable" diagnoses of AE treated at our neurological intensive care unit between 2002 and 2015. We collected and analyzed clinical, paraclinical, laboratory findings and assessed the mortality at last follow-up based on patient records. Twenty-seven patients [median age 55 years (range 25-87), male = 16] were included. Thirteen (48%) had "definite" AE. The most common reasons for admission were status epilepticus (7/27, 26%) and delirium (4/27, 15%). One-year survival was 82%, all five deceased were male, and 3 (60%) of them had "probable" disease. The non-survivors (median follow-up 1 year) were more likely to have underlying cancer and higher need for respiratory support compared to the survivors (p < 0.041, and p = 0.004, respectively). Clinical presentations and outcomes in critically ill patients with AE are diverse, and the most common leading cause for intensive care unit admission was status epilepticus. The association of comorbid malignancy and the need for mechanical ventilation with mortality deserves further attention.

Patient Management and Psychopharmacological Treatment Associated to Smoking Ban in an Acute Psychiatric Unit.

PubMed

Bergé, Daniel; Mané, Anna; Fonseca, Francina; Toll, Alba; Merino, Ana; Pérez, Victor; Bulbena, Antoni

2015-08-01

This study investigates differences in terms of clinical and treatment management in psychiatric hospitalization associated to smoking ban. We collected data regarding medication, socio-demographic and admission characteristics from all patients admitted to an acute psychiatric hospital before and after a smoking ban was in force. We also assessed a limited sample of patients before and after the ban regarding nicotine dependence, motivation to quit smoking and attitudes towards the ban. More number of leaves of absence and movement restrictions during the ban period occurred in comparison to the pre-ban period. On the contrary a lack of significant differences in terms of hospital stay (duration, rate of voluntary admissions and voluntary discharges), use of sedatives and doses of antipsychotics was found. A period of adjustment regarding the deal with leave of access and facilitate nicotine replacement treatment may help future psychiatric facilities planning smoking free policies.

Local Medicaid Home- and Community-Based Services Spending and Nursing Home Admissions of Younger Adults

PubMed Central

Keohane, Laura; Mor, Vincent

2014-01-01

We used fixed-effect models to examine the relationship between local spending on home- and community-based services (HCBSs) for cash-assisted Medicaid-only disabled (CAMOD) adults and younger adult admissions to nursing homes in the United States during 2001 through 2008, with control for facility and market characteristics and secular trends. We found that increased CAMOD Medicaid HCBS spending at the local level is associated with decreased admissions of younger adults to nursing homes. Our findings suggest that states’ efforts to expand HCBS for this population should continue. PMID:25211711

Local Medicaid home- and community-based services spending and nursing home admissions of younger adults.

PubMed

Thomas, Kali S; Keohane, Laura; Mor, Vincent

2014-11-01

We used fixed-effect models to examine the relationship between local spending on home- and community-based services (HCBSs) for cash-assisted Medicaid-only disabled (CAMOD) adults and younger adult admissions to nursing homes in the United States during 2001 through 2008, with control for facility and market characteristics and secular trends. We found that increased CAMOD Medicaid HCBS spending at the local level is associated with decreased admissions of younger adults to nursing homes. Our findings suggest that states' efforts to expand HCBS for this population should continue.

Use of Modified Positive Behavioral Interventions and Supports in a Psychiatric Inpatient Unit for High-Risk Youths.

PubMed

Reynolds, Elizabeth K; Grados, Marco A; Praglowski, Nancy; Hankinson, Jessica C; Deboard-Lucas, Renee; Goldstein, Laura; Perry-Parrish, Carisa K; Specht, Matthew W; Ostrander, Rick

2016-05-01

Despite a call for the reduction and ultimate elimination of the use of seclusion and restraint, research on reduction of these practices in behavioral programs has been limited. This study sought to examine the effectiveness of a modified version of the Positive Behavioral Interventions and Supports (M-PBIS) implemented in a youth psychiatric inpatient unit to reduce use of seclusion and restraint. This naturalistic, prospective study covered a four-year period (1,485 admissions). The number of seclusion and restraint events, mean duration of events, and percentage of patients placed in seclusion or restraint were reduced, as was the overall seclusion rate for the unit. Furthermore, there was a significant reduction in the use of pro re nata (PRN) medications for agitation. These findings suggest that M-PBIS is a promising intervention to use in youth psychiatric inpatient units to reduce seclusion and restraint and PRNs.

Admission temperatures following radiant warmer or incubator transport for preterm infants <28 weeks: a randomised study.

PubMed

Meyer, Michael P; Bold, Geoff T

2007-07-01

Sixty two infants <28 weeks were occlusively wrapped and randomised to radiant warmer or incubator transport to the neonatal unit. Median axillary temperature on arrival was 36.8 degrees C in both groups. Target temperatures (36.5-37.5 degrees C) were achieved in 60% of the incubator group compared to 75% in the warmer group (not statistically significant). While powered to detect a 35% difference between warming devices, a more modest difference is not excluded.

Can an emergency department-based Clinical Decision Unit successfully utilize alternatives to emergency hospitalization?

PubMed

Roberts, Mark Vignesha; Baird, Wendy; Kerr, Paul; O'Reilly, Seamus

2010-04-01

To evaluate a Clinical Decision Unit (CDU) designed to utilize alternatives to emergency hospitalization. CDUs are one model of care designed to strengthen the gatekeeper role of Emergency Departments (EDs). This retrospective cohort study was carried out in a UK NHS acute hospital. All 854 patients in the CDU cohort were compared with three age-stratified, historical cohorts from the same clinical centre. The median age was 62 years (range 16-94).The main outcome measures were discharge to general practitioner, outpatient services or hospitalization, the 30-day unplanned reattendance rate for those not hospitalized, and monthly medical admission figures. Approximately 511 [59.8%, 95% confidence interval (CI): 56.5-63.1%] to 560 (65.6%, 95% CI: 62.3-68.7%) patients were admitted in the comparison cohorts, compared with only 186 (21.8%, 95% CI: 19.1-24.7%) in the CDU cohort (P≤0.05). Approximately 243 (28.5%, 95% CI: 25.5-31.6%) to 289 (33.8%, 95% CI: 30.7-37.1%) patients were discharged to general practitioner services in the comparison groups, compared with 562 (65.8%, 95% CI: 62.6-68.9%) in the CDU group (P≤0.05). Approximately eight (0.9, 95% CI: 0.5-1.8%) to 17 (2%, 95% CI: 1.2-3.2%) patients in the comparison groups were discharged to outpatient clinics, compared with 82 (9.6%, 95% CI: 7.8-11.8%) in the CDU group (P≤0.05). There was no consistent trend towards statistically significant rises in unplanned reattendance (P>0.05). Monthly medical admissions fell substantially during CDU operation. This CDU model was associated with statistically and clinically significant reductions in hospital admissions. The judicious application of this CDU model to other ED environments can be expected to yield similar benefits.

Variations in mortality rates among Canadian neonatal intensive care units

PubMed Central

Sankaran, Koravangattu; Chien, Li-Yin; Walker, Robin; Seshia, Mary; Ohlsson, Arne; Lee, Shoo K.

2002-01-01

Background Most previous reports of variations in mortality rates for infants admitted to neonatal intensive care units (NICUs) have involved small groups of subpopulations, such as infants with very low birth weight. Our aim was to examine the incidence and causes of death and the risk-adjusted variation in mortality rates for a large group of infants of all birth weights admitted to Canadian NICUs. Methods We examined the deaths that occurred among all 19 265 infants admitted to 17 tertiary-level Canadian NICUs from January 1996 to October 1997. We used multivariate analysis to examine the risk factors associated with death and the variations in mortality rates, adjusting for risks in the baseline population, severity of illness on admission and whether the infant was outborn (born at a different hospital from the one where the NICU was located). Results The overall mortality rate was 4% (795 infants died). Forty percent of the deaths (n = 318) occurred within 2 days of NICU admission, 50% (n = 397) within 3 days and 75% (n = 596) within 12 days. The major conditions associated with death were gestational age less than 24 weeks (59 deaths [7%]), gestational age 24–28 weeks (325 deaths [41%]), outborn status (340 deaths [42%]), congenital anomalies (270 deaths [34%]), surgery (141 deaths [18%]), infection (108 deaths [14%]), hypoxic–ischemic encephalopathy (128 deaths [16%]) and small for gestational age (i.e., less than the third percentile) (77 deaths [10%]). There was significant variation in the risk-adjusted mortality rates (range 1.6% to 5.5%) among the 17 NICUs. Interpretation Most NICU deaths occurred within the first few days after admission. Preterm birth, outborn status and congenital anomalies were the conditions most frequently associated with death in the NICU. The significant variation in risk-adjusted mortality rates emphasizes the importance of risk adjustment for valid comparison of NICU outcomes. PMID:11826939

Early hospital mortality prediction of intensive care unit patients using an ensemble learning approach.

PubMed

Awad, Aya; Bader-El-Den, Mohamed; McNicholas, James; Briggs, Jim

2017-12-01

Mortality prediction of hospitalized patients is an important problem. Over the past few decades, several severity scoring systems and machine learning mortality prediction models have been developed for predicting hospital mortality. By contrast, early mortality prediction for intensive care unit patients remains an open challenge. Most research has focused on severity of illness scoring systems or data mining (DM) models designed for risk estimation at least 24 or 48h after ICU admission. This study highlights the main data challenges in early mortality prediction in ICU patients and introduces a new machine learning based framework for Early Mortality Prediction for Intensive Care Unit patients (EMPICU). The proposed method is evaluated on the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC-II) database. Mortality prediction models are developed for patients at the age of 16 or above in Medical ICU (MICU), Surgical ICU (SICU) or Cardiac Surgery Recovery Unit (CSRU). We employ the ensemble learning Random Forest (RF), the predictive Decision Trees (DT), the probabilistic Naive Bayes (NB) and the rule-based Projective Adaptive Resonance Theory (PART) models. The primary outcome was hospital mortality. The explanatory variables included demographic, physiological, vital signs and laboratory test variables. Performance measures were calculated using cross-validated area under the receiver operating characteristic curve (AUROC) to minimize bias. 11,722 patients with single ICU stays are considered. Only patients at the age of 16 years old and above in Medical ICU (MICU), Surgical ICU (SICU) or Cardiac Surgery Recovery Unit (CSRU) are considered in this study. The proposed EMPICU framework outperformed standard scoring systems (SOFA, SAPS-I, APACHE-II, NEWS and qSOFA) in terms of AUROC and time (i.e. at 6h compared to 48h or more after admission). The results show that although there are many values missing in the first few hour of ICU admission, there is enough signal to effectively predict mortality during the first 6h of admission. The proposed framework, in particular the one that uses the ensemble learning approach - EMPICU Random Forest (EMPICU-RF) offers a base to construct an effective and novel mortality prediction model in the early hours of an ICU patient admission, with an improved performance profile. Copyright © 2017 Elsevier B.V. All rights reserved.

Hyponatraemia in cancer patients on an inpatient rehabilitation unit.

PubMed

Nelson, M; Palmer, J L; Fu, J; Williams, J L; Yadav, R; Guo, Y

2014-05-01

This study identifies the incidence of hyponatraemia in cancer patients on an inpatient rehabilitation unit and examines the association between admission hyponatraemia and rehabilitation length of stay (LOS), functional outcome, and survival. After institutional review committee's approval, we retrospectively reviewed medical records of 295 consecutive patients who were admitted to this inpatient cancer rehabilitation unit between 27 January 2009 through 31 July 2010 in a tertiary cancer centre. The incidence of hyponatraemia in cancer patients admitted to our inpatient rehabilitation unit was 41.4%. Median rehabilitation LOS for patients with mild (Na 130-134 mEq/L) and moderate-severe (Na < 130 mEq/L) hyponatraemia was 11 and 15 days, respectively, which was significantly longer than patients with eunatraemia (10 days; P = 0.03). Functional Independence Measure gain for ambulation and transfers during inpatient rehabilitation stay was not significantly different between three different patient groups. We concluded that large portion of patients who require acute inpatient rehabilitation presented with hyponatraemia, which is associated with prolonged rehabilitation LOS. Whether aggressive management of hyponatraemia will shorten rehabilitation stay needs further study. © 2013 John Wiley & Sons Ltd.

Commercial enteral formulas and nutrition support teams improve the outcome of home enteral tube feeding.

PubMed

Klek, Stanislaw; Szybinski, Piotr; Sierzega, Marek; Szczepanek, Kinga; Sumlet, Magdalena; Kupiec, Monika; Koczur-Szozda, Elzbieta; Steinhoff-Nowak, Malgorzata; Figula, Krzysztof; Kowalczyk, Tomasz; Kulig, Jan

2011-05-01

The benefits of home enteral tube feeding (HETF) provided by nutrition support teams (NSTs) have been questioned recently, given the growing costs to the healthcare system. This study examined the effect of a specialized home enteral nutrition program on clinical outcome variables in HETF patients. The observational study included 203 patients (103 women, 100 men; mean age 52.5 years) receiving HETF with homemade diets for at least 12 months before starting a specialized home nutrition program for another 12 months consisting of provision of commercial enteral formulas and the guidance of an NST. Both study periods were compared regarding the number of hospital admissions, length of hospital and intensive care unit (ICU) stay, and costs of hospitalization. A specialized HETF program significantly reduced the number of hospital admissions and the duration of hospital and ICU stays. The need for hospitalization and ICU admission was significantly reduced, with odds ratios of 0.083 (95% confidence interval, 0.051-0.133, P < .001) and 0.259 (95% confidence interval, 0.124-0.539, P < .001), respectively. Specialized HETF was associated with a significant decrease in the prevalence of pneumonia (24.1% vs 14.2%), respiratory failure (7.3% vs 1.9%), urinary tract infection (11.3% vs 4.9%), and anemia (3.9% vs 0%) requiring hospitalization. The average yearly cost of hospital treatment decreased from $764.65 per patient to $142.66 per year per patient. The specialized HETF care program reduces morbidity and costs related to long-term enteral feeding at home.

A quality improvement project to improve admission temperatures in very low birth weight infants.

PubMed

Lee, H C; Ho, Q T; Rhine, W D

2008-11-01

To review the results of a quality improvement (QI) project to improve admission temperatures of very low birth weight inborn infants. The neonatal intensive care unit at Lucile Packard Children's Hospital underwent a QI project to address hypothermic preterm newborns by staff education and implementing processes such as polyethylene wraps and chemical warming mattresses. We performed retrospective chart review of all inborn infants with birth weight <1500 g during the 18 months prior to (n=134) and 15 months after (n=170) the implementation period. Temperatures were compared between periods. Multivariable logistic regression was used to account for potential confounding variables. We compared mortality rates and grade 3 or 4 intraventricular hemorrhage rates between periods. The mean temperature rose from 35.4 to 36.2 degrees C (P<0.0001) after the QI project. The improvement was consistent and persisted over a 15-month period. After risk adjustment, the strongest predictor of hypothermia was being born in the period before implementation of the QI project (odds ratio 8.12, 95% confidence interval 4.63, 14.22). Although cesarean delivery was a strong risk factor for hypothermia prior to the project, it was no longer significant after the project. There was no significant difference in death or intraventricular hemorrhage detected between periods. There was a significant improvement in admission temperatures after a QI project, which persisted beyond the initial implementation period. Although there was no difference in mortality or intraventricular hemorrhage rates, we did not have sufficient power to detect small differences in these outcomes.

Effect of vitamin C supplementation on stroke recovery: a case-control study.

PubMed

Rabadi, Meheroz H; Kristal, Bruce S

2007-01-01

Epidemiological studies have associated increased dietary intake of antioxidants (vitamin C, E, and beta-carotene) in preventing and decreasing the extent of ischemic brain injury. The effect of vitamin C supplementation on functional recovery after stroke has not been studied. In this retrospective, case-control study of 23 patients with ischemic stroke taking vitamin C were identified and matched for age, sex, onset to admission, and admission total functional independence measure (TFIM) with 23 patients with ischemic stroke not taking Vitamin C supplementation. Vitamin C 1000 mg daily was prescribed on admission to our unit mainly to patients who were undernourished (defined as significant weight loss and/or 90% or less ideal body weight for age and sex) and those with pressure sores. The outcome measures were: change in the TFIM, FIM-Cognition (FIM-Cog), and FIM-Motor sub-scores, discharge disposition, and length of stay (LOS). The change in TFIM (20 +/- 13 standard deviation [SD] vs. 26 +/- 6, p = 0.20), FIM-Cog (3 +/- 3 SD vs. 4 +/- 5, p = 0.41), FIM-Motor (15 +/- 11 SD vs. 20 +/- 13, p = 0.21) sub-scores were less in the vitamin C treated group, but these differences did not reach statistical significance. Similarly, no significant differences were found in LOS (21 +/- 9 SD vs. 23 +/- 9, p = 0.59), and discharge disposition (home/institution) (9/10 vs. 13/9, p = 0.60) between the vitamin C and the control groups. This study suggests vitamin C supplementation did not enhance functional recovery in undernourished ischemic stroke patients.

Heart rate and leukocytes after air and ground transportation in artificially ventilated neonates: a prospective observational study.

PubMed

Grosek, Stefan; Mlakar, Gorazd; Vidmar, Ivan; Ihan, Alojz; Primozic, Janez

2009-01-01

To evaluate the effect of interhospital air and ground transportation of artificially ventilated neonates on heart rate and peripheral blood leukocyte counts. Prospective, observational study. Level III multidisciplinary Neonatal and Pediatric Intensive Care Unit. Fifty-eight near-term artificially ventilated transported neonates between May 2006 and April 2007. Day-helicopter, day- and night-ground transportation. Heart rate at retrieval, on admission to the ICU and 1 h later, and peripheral blood leukocyte counts on admission and 1 d later were compared. Fifteen neonates were transported by helicopter during the daytime (D-HEL), 20 by daytime ground and 23 by nighttime ground transportation (D-GROUND, N-GROUND). No differences in delivery mode, birth weight, gestational age, gender, primary diagnoses for transportation, response time and duration of transportation were found between the groups. Similarly, no differences in pH, pCO(2), blood pressure and skin temperature at retrieval and on admission to the ICU were found between the three groups. The mean heart rate at retrieval did not differ significantly, while on arrival in the ICU and 1 h later the D-GROUND group of patients showed a significantly higher mean heart rate compared to the D-HEL and N-GROUND groups. Moreover, leukocyte counts on arrival in the ICU showed significantly higher leukocyte counts in the D-GROUND group of patients compared to the D-HEL group of patients. These results demonstrate that there is an association between daytime ground transportation and higher heart rate and peripheral blood leukocytes.

[Children's medically complex diseases unit. A model required in all our hospitals].

PubMed

Climent Alcalá, Francisco José; García Fernández de Villalta, Marta; Escosa García, Luis; Rodríguez Alonso, Aroa; Albajara Velasco, Luis Adolfo

2018-01-01

The increase in survival of children with severe diseases has led to the rise of children with chronic diseases, sometimes with lifelong disabilities. In 2008, a unit for the specific care of medically complex children (MCC) was created in Hospital La Paz. To describe the work and care activities of this Unit. Patients and methods An analysis was performed on all discharge reports of the Unit between January 2014 and July 2016. The MCC Unit has 6 beds and daily outpatient clinic. A total of 1,027 patients have been treated since the creation of the unit, with 243 from 2014. The median age was 24.2 months (IQ: 10.21-84.25). The large majority (92.59%) have multiple diseases, the most frequent chronic conditions observed were neurological (76.95%), gastrointestinal (63.78%), and respiratory diseases (61.72%). More than two-thirds (69.54%) of MCC are dependent on technology, 53.49% on respiratory support, and 35.80% on nutritional support. Hospital admission rates have increased annually. There have been 403 admissions since 2014, of which 8.93% were re-admissions within 30 days of hospital discharge. The median stay during 2014-2016 was 6 days (IQ: 3-14). The occupancy rate has been above 100% for this period. Currently, 210 patients remain on follow-up (86.42%), and 11 children (4.53%) were discharged to their referral hospitals. The mortality rate is 9.05% (22 deaths). The main condition of these 22 patients was neurological (9 patients). Infectious diseases were the leading cause of death. MCC should be treated in specialized units in tertiary or high-level hospitals. Copyright © 2016 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.

Changes in NHS organization of care and management of hospital admissions with COPD exacerbations between the national COPD audits of 2003 and 2008.

PubMed

George, P M; Stone, R A; Buckingham, R J; Pursey, N A; Lowe, D; Roberts, C M

2011-10-01

The 2003 UK Chronic Obstructive Pulmonary Disease (COPD) audit revealed wide variability between hospital units in care delivered. To assess whether processes of care, patient outcomes and organization of care have improved since 2003. A UK national audit was performed in 2008 to survey the organization and delivery of clinical care provided to patients admitted to hospital with COPD. All UK acute hospital Trusts (units) were invited to participate. Each unit completed cross-sectional resource and organization questionnaires and a prospective clinical audit comprising up to 60 consecutively admitted cases of COPD exacerbation. Comparison between 2003 and 2008 includes aggregated statistics for units participating in both audit rounds. A total of 192 units participated in both audit rounds (6197 admissions in 2003 and 8170 in 2008). In 2008, patients were older and of a poorer functional class. Overall mortality was unchanged but adjusting for age and performance status, inpatient mortality (P = 0.05) and 90-day mortality (P = 0.001) were both reduced in 2008. More patients were discharged under a respiratory specialist (P < 0.01), treated with non-invasive ventilation if acidotic (P < 0.001) and accepted onto early discharge schemes (P < 0.01) while median length of stay fell from 6 to 5 days (P < 0.001). Within these mean data, however, there remains considerable inter-unit variation in organization, resources and outcomes. Overall improvements in resources and organization are accompanied by reduced mortality, shorter admissions and greater access to specialist services. There remains, however, considerable variation in the quality of secondary care provided between units.

Air pollution and hospital admissions for asthma in a tropical city: Kaohsiung, Taiwan

DOE Office of Scientific and Technical Information (OSTI.GOV)

Shang-Shyue Tsai; Meng-Hsuan Cheng; Hui-Fen Chiu

2006-07-15

This study was undertaken to determine whether there is an association between air pollutants levels and hospital admissions for asthma in Kaohsiung, Taiwan. Hospital admissions for asthma and ambient air pollution data for Kaohsiung were obtained for the period from 1996 through 2003. The relative risk of hospital admission was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. In the single-pollutant models, on warm days ({>=}25{sup o}C) statistically significant positive associations were found in all pollutants except sulfur dioxide. On cool days ({<=} 25{sup o}C) all pollutants were significantly associatedmore » with asthma admissions. For the two pollutant models, CO and O{sub 3} were significant in combination with each of the other four pollutants on warm days. On cool days NO{sub 2} remained statistically significant in all the two-pollutant models. This study provides evidence that higher levels of ambient pollutants increase the risk of hospital admissions for asthma.« less

Characteristics of women in a prison mental health assessment unit in England and Wales (2008-2010).

PubMed

Hales, Heidi; Somers, Nadia; Reeves, Chrissy; Bartlett, Annie

2016-04-01

The high prevalence of mental disorders among women in prison is recognised worldwide. In England and Wales, successive governments and independent reports have argued that the equivalent of community care in prisons is acceptable but that some mental health assessment units (MHAUs), staffed by professional clinicians, should remain. These have not been researched. This paper aimed to explore patterns of use of a MHAU in a women's prison in England and to test the hypothesis that it was being used only, as intended--to hold women pending transfer to a health service hospital or in a bona fide crisis. Anonymised data on all women transferred to one MHAU between 1 January 2008 and 31 August 2010 were obtained from the prison files and subjected to descriptive analysis. Less than a third of these women were transferred to an outside hospital; this group stayed longest in the unit. An overlapping group of 52% of the women was under a special assessment, care in custody and teamwork protocol because of suicide or serious self-harm risk. Thus, 188 (68%) admissions fulfilled national protocol criteria for MHAU admissions. Two in five women admitted were released or returned to ordinary prison locations. Nevertheless, over 80% of the women were known to external mental health services, and 64 (30%) were so unwell on arrival in prison that they were transferred directly to the MHAU. Over a third of admissions were of women admitted more than once during the 32 months of study, and this was significantly more likely after release from prison directly to the community. Our hypothesis was not sustained, and it seems unlikely that this prison MHAU is unique in being used outside its strict remit. A shift from studying the epidemiology of mental disorder in prisons to the epidemiology of mental health needs could benefit this vulnerable group and the wider community alike. Copyright © 2015 John Wiley & Sons, Ltd.

Nutrient intake, peripheral edema, and weight change in elderly recuperative care patients.

PubMed

Sullivan, Dennis H; Johnson, Larry E; Dennis, Richard A; Roberson, Paula K; Garner, Kimberly K; Padala, Prasad R; Padala, Kalpana P; Bopp, Melinda M

2013-06-01

It is unclear whether serial measures of body weight are valid indicators of nutritional status in older patients recovering from illness. Objectives. Investigate the relative influence of nutrient intake and changes in peripheral edema on weight change. A prospective cohort study of 404 older men (mean age = 78.7±7.5 years) admitted to a transitional care unit of a Department of Veterans Affairs nursing home. Body weight and several indicators of lower extremity edema were measured at both unit admission and discharge. Complete nutrient intake assessments were performed daily. Over a median length of stay of 23 days (interquartile range: 15-41 days), 216 (53%) participants gained or lost more than or equal to 2.5% of their body weight. Two hundred eighty-two (70%) participants had recognizable lower extremity pitting edema at admission and/or discharge. The amount of weight change was strongly and positively correlated with multiple indicators of both nutrient intake and the change in the amount of peripheral edema. By multivariable analysis, the strongest predictor of weight change was maximal calf circumference change (partial R (2) = .35, p < .0001), followed by average daily energy intake (partial R (2) = .14, p < .0001), and the interaction of energy intake by time (partial R (2) = .02, p < .0001). Many older patients either gain or lose a significant amount of weight after admission to a transitional care unit. Because of the apparent high prevalence of co-occurring changes in total body water, the weight changes do not necessarily represent changes in nutritional status. Although repeat calf circumference measurements may provide some indication as to how much of the weight change is due to changes in body water, there is currently no viable alternative to monitoring the nutrient intake of older recuperative care patients in order to ensure that their nutrient needs are being met.

Severe maternal morbidity and breastfeeding outcomes in the early post-natal period: a prospective cohort study from one English maternity unit.

PubMed

Furuta, Marie; Sandall, Jane; Cooper, Derek; Bick, Debra

2016-10-01

Previous research has identified potential issues of establishing and maintaining breastfeeding among women who experience severe maternal morbidity associated with pregnancy and birth, but evidence in the UK maternity population was scarce. We explored the association between severe maternal morbidity and breastfeeding outcomes (uptake and prevalence of partial and exclusive breastfeeding) at 6 to 8 weeks post-partum in a UK sample. Data on breastfeeding outcomes were obtained from a large cohort study of women who gave birth in one maternity unit in England to assess the impact of women's experiences of severe maternal morbidity (defined as major obstetric haemorrhage, severe hypertensive disorder or high dependency unit/intensive care unit admission) on their post-natal health and other important outcomes including infant feeding. Results indicated that among women who responded (n = 1824, response rate = 53%), there were no statistically significant differences in breastfeeding outcomes between women who did or did not experience severe morbidity, except for women with severe hypertensive disorder who were less likely to breastfeed either partially or exclusively at 6 to 8 weeks post-partum. Rather, breastfeeding outcomes were related to multi-dimensional factors including sociodemographic (age, ethnicity, living arrangement), other pregnancy outcomes (neonatal intensive care unit admission, mode of birth, women's perceived control during birth) and post-natal psychological factors (depressive symptoms). Women who experience severe maternal morbidity can be reassured that establishing successful breastfeeding can be achieved. More studies are required to understand what support is best for women who have complex health/social needs to establish breastfeeding. © 2015 John Wiley & Sons Ltd.

Cardiac surgery fast-track treatment in a postanesthetic care unit: six-month results of the Leipzig fast-track concept.

PubMed

Ender, Joerg; Borger, Michael Andrew; Scholz, Markus; Funkat, Anne-Kathrin; Anwar, Nadeem; Sommer, Marcus; Mohr, Friedrich Wilhelm; Fassl, Jens

2008-07-01

The authors compared the safety and efficacy of a newly developed fast-track concept at their center, including implementation of a direct admission postanesthetic care unit, to standard perioperative management. All fast-track patients treated within the first 6 months of implementation of our direct admission postanesthetic care unit were matched via propensity scores and compared with a historical control group of patients who underwent cardiac surgery prior to fast-track implementation. A total of 421 fast-track patients were matched successfully to 421 control patients. The two groups of patients had a similar age (64 +/- 13 vs. 64 +/- 12 yr for fast-track vs. control, P = 0.45) and European System for Cardiac Operative Risk Evaluation-predicted risk of mortality (4.8 +/- 6.1% vs. 4.6 +/- 5.1%, P = 0.97). Fast-track patients had significantly shorter times to extubation (75 min [45-110] vs. 900 min [600-1140]), as well as shorter lengths of stay in the postanesthetic or intensive care unit (4 h [3.0-5] vs. 20 h [16-25]), intermediate care unit (21 h [17-39] vs. 26 h [19-49]), and hospital (10 days [8-12] vs. 11 days [9-14]) (expressed as median and interquartile range, all P < 0.01). Fast-track patients also had a lower risk of postoperative low cardiac output syndrome (0.5% vs. 2.9%, P < 0.05) and mortality (0.5% vs. 3.3%, P < 0.01). The Leipzig fast-track protocol is a safe and effective method to manage cardiac surgery patients after a variety of operations.

Telemedicine to Improve Access to Specialist Care in Fetal Heart Rate Monitoring: Analysis of 17 Years of TOCOMAT Network Clinical Activity.

PubMed

Tagliaferri, Salvatore; Esposito, Francesca Giovanna; Ippolito, Adelaide; Mereghini, Flavia; Magenes, Giovanni; Martinelli, Pasquale; Campanile, Marta; Signorini, Maria Gabriella

2017-03-01

The objective of this article is to provide an overview of the clinical experience of our telemedicine network (TOCOMAT) for fetal well-being assessment through computerized Cardiotocography (cCTG), analyzing cultural, socioeconomic, and environmental conditions of pregnant women and its economic sustainability over time. We used the central data store, including all cCTG records collected in Campania region (Italy) during 17 years of activity. The Operations Center acquires the traces recorded in the Remote Units and simultaneously performs a complex fetal heart rate analysis. An Internet or phone conference calling is available to discuss the information transmitted. Finally, the report is send back to the Remote Units. The number of cCTG traces performed was constantly increasing, despite the progressive reduction in the number of peripheral units involved. Pregnant women in Remote Unit group were younger and overweight and showed a higher incidence of diabetes and fetal defects than Operations Center ones. Moreover, a high rate of African migrant women and low socioeconomic and cultural standards were found in Remote Unit group. The cost analysis showed an economic advantage both in the reduction of inappropriate admissions and in the improvement of admission indicators (hospital stay days) for pregnant women. The global economic recession has had a significant impact on the Italian regional healthcare system and socioeconomic deprivation. Telemedicine could avoid unnecessary referral to Level III centers (Hospital) in Campania region, where the average population density is very high, allowing equal access to ultra-specialist assessment irrespective of the geographical location of the pregnant woman with medium to high risk, as well as rationalizing the costs for maternal and fetal care.

Distributions and Behavior of Vital Signs in Critically Ill Children by Admission Diagnosis.

PubMed

Eytan, Danny; Goodwin, Andrew J; Greer, Robert; Guerguerian, Anne-Marie; Mazwi, Mjaye; Laussen, Peter C

2018-02-01

Define the distributions of heart rate and intraarterial blood pressure in children at admission to an ICU based on admission diagnosis and examine trends in these physiologic signs over 72 hours from admission (or to discharge if earlier). A retrospective analysis of continuously acquired signals. A quaternary and primary referral children's hospital with a general PICU and cardiac critical care unit. One thousand two hundred eighty-nine patients less than 18 years old were analyzed. Data from individual patient admissions were divided into 19 groups by primary admission diagnosis or surgical procedure. None. Distributions at admission are dependent on patient age and admission diagnosis (p < 10). Heart rate decreases over time, whereas arterial blood pressure is relatively stable, with differences seen in the directions and magnitude of these trends when analyzed by diagnosis group (p < 10). Multiple linear regression analysis shows that patient age, diagnosis group, and physiologic vital sign value at admission explain 50-63% of the variation observed for that physiologic signal at 72 hours (or at discharge if earlier) with admission value having the greatest influence. Furthermore, the variance of either heart rate or arterial blood pressure for the individual patient is smaller than the variance measured at the level of the group of patients with the same diagnosis. This is the first study reporting distributions of continuously measured physiologic variables and trends in their behavior according to admission diagnosis in critically ill children. Differences detected between and within diagnostic groups may aid in earlier recognition of outliers as well as allowing refinement of patient monitoring strategies.

Tempering pediatric hospitalist supervision of residents improves admission process efficiency without decreasing quality of care.

PubMed

Biondi, Eric A; Leonard, Michael S; Nocera, Elizabeth; Chen, Rui; Arora, Jyoti; Alverson, Brian

2014-02-01

Many academic pediatric hospital medicine (PHM) divisions have recently increased in-house supervision of residents, often providing 24/7 in-house attending coverage. Contrary to this trend, we removed mandated PHM attending input during the admission process. We present an evaluation of this process change. This cohort study compared outcomes between patients admitted to the PHM service before (July 1, 2011-September 30, 2011) and after (July 1, 2012-September 30, 2012) the process change. We evaluated time from admission request to inpatient orders, length of stay (LOS), frequency of change in antibiotic choice, and rapid response team (RRT) calls within 24 hours of admission. Data were obtained via chart abstraction and from administrative databases. Wilcoxon rank sum and Fisher exact tests were used for analysis. We identified 182 and 210 admissions in the before and after cohorts, respectively. Median time between emergency department admission request and inpatient orders was significantly shorter after the change (123 vs 62 minutes, P < 0.001). We found no significant difference in LOS, the number of changes to initial resident antibiotic choice, standard of care, or RRTs called within the first 24 hours of admission. Removing mandated attending input in decision making for PHM admissions significantly decreased time to inpatient resident admission orders without a change in measurable clinical outcomes. © 2013 Society of Hospital Medicine.

Changes in the epidemiology of gastroenteritis in a paediatric short stay unit following the introduction of rotavirus immunisation.

PubMed

Akikusa, Jonathan D; Hopper, Sandy M; Kelly, Julian J; Kirkwood, Carl D; Buttery, Jim P

2013-02-01

Acute gastroenteritis (AGE) has been a significant component of the clinical load in the short stay unit (SSU) at the Royal Children's Hospital (RCH) since its establishment in 2004. Since the introduction of routine rotavirus immunisation in Australia in 2007 there has been a clinical impression of a substantial reduction in AGE managed in the SSU. This study aimed to examine changes in the epidemiology of AGE in the SSU, and RCH overall, between 2005 and 2009 and explore whether this reflects a change specifically in AGE due to rotavirus. Discharge coding data for AGE from all inpatient wards, the SSU and emergency department (ED) at the RCH were examined. Stool virology results for the same period were analysed. Since 2007 there has been a 58% reduction in AGE admissions to the SSU. The median age of patients admitted to the RCH with rotaviral enteritis has increased from 1.3 years to 3.8 years. Presentations to the ED for AGE have fallen from 53 to 34 cases per 1000 attendances between 2004 and 2009, and admission rates from the ED have fallen from 23 to 13% of AGE presentations. Detection rates of rotavirus fell from 13.1 to 6.7% between 2005 and 2009. A marked decrease in AGE-related clinical activity and reduction in rotavirus detection at the RCH has occurred since the introduction of routine rotavirus immunisation in Australia. This has significant resource planning implications for units based on short stay models of care. © 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

[Even more critical medicine: a retrospective analysis of casualties admitted to the intensive care unit in the Spanish Military Hospital in Herat (Afghanistan)].

PubMed

Navarro Suay, R; Bartolomé Cela, E; Jara Zozaya, I; Hernández Abadía de Barbará, A; Gutiérrez Ortega, C; García Labajo, J D; Planas Roca, A; Gilsanz Rodríguez, F

2011-04-01

To analyze casualties from firearm and explosives injuries who were admitted to the Intensive Care Unit in the Spanish ROLE-2E from December 2005 to December 2008 and to evaluate which damaging agent had produced the highest morbidity-mortality in our series using score indices with anatomical base (ISS and NISS). Observational and retrospective study performed between 2005 and 2008. Polyvalent Intensive Care Unit in the Spanish Military Hospital of those deployed in Afghanistan. The inclusion criteria were all patients who had been wounded by firearm or by explosive devices and who had been admitted in ICU in Spanish Military Hospital in Herat (Afghanistan). The anatomic scores Injury Severity Score and the New Injury Severity Score (NISS) were applied to all the selected patients to estimate the grade of severity of their injuries. Independent: damaging agent, injured anatomical area, protection measures and dependent: mortality, surgical procedure applied, score severity and socio-demographics and control variables. Eighty-six casualties, 30 by firearm and 56 by explosive devices. Applying the NISS, 38% of the casualties had suffered severe injuries. Mean stay in the ICU was 2.8 days and mortality was 10%. Significant differences in admission to the ICU for the damaging agent were not observed (P=.142). No significant differences were observed in the need for admission and stay in the ICU according to the damaging agent. The importance of the strategy, care and logistics of the intensive care military physician in Intensive Medicine in the Operating Room in Afghanistan is stressed. © 2010 Elsevier España, S.L. and SEMICYUC. All rights reserved.

Prematurity, atopy, and childhood asthma in Puerto Ricans

PubMed Central

Rosas-Salazar, Christian; Ramratnam, Sima K.; Brehm, John M.; Han, Yueh-Ying; Boutaoui, Nadia; Forno, Erick; Acosta-Pérez, Edna; Alvarez, María; Colón-Semidey, Angel; Canino, Glorisa; Celedón, Juan C.

2013-01-01

Background Puerto Rican children share a disproportionate burden of prematurity and asthma in the United States. Little is known about prematurity and childhood asthma in Puerto Rican subjects. Objective We sought to examine whether prematurity is associated with asthma in Puerto Rican children. Methods We performed a case-control study of 678 children aged 6 to 14 years with (n = 351) and without (n = 327) asthma living in San Juan, Puerto Rico. Prematurity was defined by parental report for our primary analysis. In a secondary analysis, we only included children whose parents reported prematurity that required admission to the neonatal intensive care unit. Asthma was defined as physician-diagnosed asthma and wheeze in the prior year. We used logistic regression for analysis. All multivariate models were adjusted for age, sex, household income, atopy (≥1 positive IgE level to common allergens), maternal history of asthma, and early-life exposure to environmental tobacco smoke. Results In a multivariate analysis there was a significant interaction between prematurity and atopy on asthma (P = .006). In an analysis stratified by atopy, prematurity was associated with a nearly 5-fold increased odds of asthma in atopic children (adjusted odds ratio, 4.7; 95% CI, 1.5–14.3; P = .007). In contrast, there was no significant association between prematurity and asthma in nonatopic children. Similar results were obtained in our analysis of prematurity requiring admission to the neonatal intensive care unit and asthma. Conclusions Our results suggest that atopy modifies the estimated effect of prematurity on asthma in Puerto Rican children. Prematurity might explain, in part, the high prevalence of atopic asthma in this ethnic group. PMID:24139607

Prematurity, atopy, and childhood asthma in Puerto Ricans.

PubMed

Rosas-Salazar, Christian; Ramratnam, Sima K; Brehm, John M; Han, Yueh-Ying; Boutaoui, Nadia; Forno, Erick; Acosta-Pérez, Edna; Alvarez, María; Colón-Semidey, Angel; Canino, Glorisa; Celedón, Juan C

2014-02-01

Puerto Rican children share a disproportionate burden of prematurity and asthma in the United States. Little is known about prematurity and childhood asthma in Puerto Rican subjects. We sought to examine whether prematurity is associated with asthma in Puerto Rican children. We performed a case-control study of 678 children aged 6 to 14 years with (n = 351) and without (n = 327) asthma living in San Juan, Puerto Rico. Prematurity was defined by parental report for our primary analysis. In a secondary analysis, we only included children whose parents reported prematurity that required admission to the neonatal intensive care unit. Asthma was defined as physician-diagnosed asthma and wheeze in the prior year. We used logistic regression for analysis. All multivariate models were adjusted for age, sex, household income, atopy (≥1 positive IgE level to common allergens), maternal history of asthma, and early-life exposure to environmental tobacco smoke. In a multivariate analysis there was a significant interaction between prematurity and atopy on asthma (P = .006). In an analysis stratified by atopy, prematurity was associated with a nearly 5-fold increased odds of asthma in atopic children (adjusted odds ratio, 4.7; 95% CI, 1.5-14.3; P = .007). In contrast, there was no significant association between prematurity and asthma in nonatopic children. Similar results were obtained in our analysis of prematurity requiring admission to the neonatal intensive care unit and asthma. Our results suggest that atopy modifies the estimated effect of prematurity on asthma in Puerto Rican children. Prematurity might explain, in part, the high prevalence of atopic asthma in this ethnic group. Copyright © 2013 American Academy of Allergy, Asthma & Immunology. Published by Mosby, Inc. All rights reserved.

The association between glucose levels and hospital outcomes in patients with acute exacerbations of chronic obstructive pulmonary disease

PubMed Central

Islam, Ebtesam A.; Limsuwat, Chok; Nantsupawat, Teerapat; Berdine, Gilbert G.; Nugent, Kenneth M.

2015-01-01

BACKGROUND: Corticosteroids used for chronic obstructive pulmonary disease (COPD) exacerbations can cause hyperglycemia in hospitalized patients, and hyperglycemia may be associated with increased mortality, length of stay (LOS), and re-admissions in these patients. MATERIALS AND METHODS: We did three retrospective studies using charts from July 2008 through June 2009, January 2006 through December 2010, and October 2010 through March 2011. We collected demographic and clinical information, laboratory results, radiographic results, and information on LOS, mortality, and re-admission. RESULTS: Glucose levels did not predict outcomes in any of the studied cohorts, after adjustment for covariates in multivariable analysis. The first database included 30 patients admitted to non-intensive care unit (ICU) hospital beds. Six of 20 non-diabetic patients had peak glucoses above 200 mg/dl. Nine of the ten diabetic patients had peak glucoses above 200 mg/dl. The maximum daily corticosteroid dose had no apparent effect on the glucose levels. The second database included 217 patients admitted to ICUs. The initial blood glucose was higher in patients who died than those who survived using bivariate analysis (P = 0.015; odds ratio, OR, 1.01) but not in multivariable analysis. Multivariable logistic regression analysis also demonstrated that glucose levels did not affect LOS. The third database analyzing COPD re-admission rates included 81 patients; the peak glucose levels were not associated with re-admission. CONCLUSIONS: Our data demonstrate that COPD patients treated with corticosteroids developed significant hyperglycemia, but the increase in blood glucose levels did not correlate with the maximum dose of corticosteroids. Blood glucose levels were not associated with mortality, LOS, or re-admission rates. PMID:25829959

Financial impact of adopting implantable loop recorder diagnostic for unexplained syncope compared with conventional diagnostic pathway in Portugal.

PubMed

Providência, Rui; Candeias, Rui; Morais, Carlos; Reis, Hipólito; Elvas, Luís; Sanfins, Vitor; Farinha, Sara; Eggington, Simon; Tsintzos, Stelios

2014-05-06

To estimate the short- and long-term financial impact of early referral for implantable loop recorder diagnostic (ILR) versus conventional diagnostic pathway (CDP) in the management of unexplained syncope (US) in the Portuguese National Health Service (PNHS). A Markov model was developed to estimate the expected number of hospital admissions due to US and its respective financial impact in patients implanted with ILR versus CDP. The average cost of a syncope episode admission was estimated based on Portuguese cost data and landmark papers. The financial impact of ILR adoption was estimated for a total of 197 patients with US, based on the number of syncope admissions per year in the PNHS. Sensitivity analysis was performed to take into account the effect of uncertainty in the input parameters (hazard ratio of death; number of syncope events per year; probabilities and unit costs of each diagnostic test; probability of trauma and yield of diagnosis) over three-year and lifetime horizons. The average cost of a syncope event was estimated to be between 1,760€ and 2,800€. Over a lifetime horizon, the total discounted costs of hospital admissions and syncope diagnosis for the entire cohort were 23% lower amongst patients in the ILR group compared with the CDP group (1,204,621€ for ILR, versus 1,571,332€ for CDP). The utilization of ILR leads to an earlier diagnosis and lower number of syncope hospital admissions and investigations, thus allowing significant cost offsets in the Portuguese setting. The result is robust to changes in the input parameter values, and cost savings become more pronounced over time.

Association Between Hospital Admission Risk Profile Score and Skilled Nursing or Acute Rehabilitation Facility Discharges in Hospitalized Older Adults.

PubMed

Liu, Stephen K; Montgomery, Justin; Yan, Yu; Mecchella, John N; Bartels, Stephen J; Masutani, Rebecca; Batsis, John A

2016-10-01

To evaluate whether the Hospital Admission Risk Profile (HARP) score is associated with skilled nursing or acute rehabilitation facility discharge after an acute hospitalization. Retrospective cohort study. Inpatient unit of a rural academic medical center. Hospitalized individuals aged 70 and older from October 1, 2013 to June 1, 2014. Participant age at the time of admission, modified Folstein Mini-Mental State Examination score, and self-reported instrumental activities of daily living 2 weeks before admission were used to calculate HARP score. The primary predictor was HARP score, and the primary outcome was discharge disposition (home, facility, deceased). Multivariate analysis was used to evaluate the association between HARP score and discharge disposition, adjusting for age, sex, comorbidities, and length of stay. Four hundred twenty-eight individuals admitted from home were screened and their HARP scores were categorized as low (n = 162, 37.8%), intermediate (n = 157, 36.7%), or high (n = 109, 25.5%). Participants with high HARP scores were significantly more likely to be discharged to a facility (55%) than those with low HARP scores (20%) (P < .001). After adjustment, participants with high HARP scores were more than four times as likely as those with low scores to be discharged to a facility (odds ratio = 4.58, 95% confidence interval = 2.42-8.66). In a population of older hospitalized adults, HARP score (using readily available admission information) identifies individuals at greater risk of skilled nursing or acute rehabilitation facility discharge. Early identification for potential facility discharges may allow for targeted interventions to prevent functional decline, improve informed shared decision-making about post-acute care needs, and expedite discharge planning. © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.

Predisposing Factors for Hypoglycemia and Its Relation With Mortality in Critically Ill Patients Undergoing Insulin Therapy in an Intensive Care Unit

PubMed Central

Mahmoodpoor, Ata; Hamishehkar, Hadi; Beigmohammadi, Mahammadtaghi; Sanaie, Sarvin; Shadvar, Kamran; Soleimanpour, Hassan; Rahimi, Ahsan; Safari, Saeid

2016-01-01

Background: Hypoglycemia is a common and the most important complication of intensive insulin therapy in critically ill patients. Because of hypoglycemia’s impact on the cardinal organs as a fuel, if untreated it could results in permanent brain damage and increased mortality. Objectives: In this study, we aim to evaluate the incidence of hypoglycemia, its risk factors, and its relationship with mortality in critically ill patients. Patients and Methods: Five hundred adult patients who admitted to an intensive care unit (ICU) were enrolled in this study. A program of glycemic control with a target of 100 - 140 mg/dL was instituted. We used the threshold of 150 mg/dL for septic patients, which were monitored by point of care devices for capillary blood measurement. We detected hypoglycemia with a blood sugar of less than 50 mg/dL and with the detection of each episode of hypoglycemia, blood glucose measurement was performed every 30 minutes. Results: Five hundred patients experienced at least one episode of hypoglycemia, almost always on the third day. Of 15 expired patients who had one hypoglycemia episode, the most common causes were multiple trauma and sepsis. Increases in the sequential organ failure assessment (SOFA) number augmented the hypoglycemia risk to 52% (P < 0.001). Moreover, in patients with acute kidney injury (AKI), the risk of hypoglycemia is 10 times greater than in those without AKI (RR: 10.3, CI: 3.16 - 33.6, P < 0.001). ICU admission blood sugar has a significant relationship with mortality (RR: 1.01, CI: 1.004 - 1.02, P < 0.006). Hypoglycemia increased the mortality rate twofold, but it was not significant (RR: 1.2, CI: 0.927 - 1.58, P = 0.221). Conclusions: Our results showed that the SOFA score, AKI, and hemoglobin A1c are the independent risk factors for the development of hypoglycemia and demonstrated that ICU admission blood glucose, Hba1c, and hypoglycemia increased the risk of death, but only ICU admission blood glucose is significantly related to increased mortality. PMID:27110538

Predisposing Factors for Hypoglycemia and Its Relation With Mortality in Critically Ill Patients Undergoing Insulin Therapy in an Intensive Care Unit.

PubMed

Mahmoodpoor, Ata; Hamishehkar, Hadi; Beigmohammadi, Mohammadtagi; Sanaie, Sarvin; Shadvar, Kamran; Soleimanpour, Hassan; Rahimi, Ahsan; Safari, Saeed

2016-02-01

Hypoglycemia is a common and the most important complication of intensive insulin therapy in critically ill patients. Because of hypoglycemia's impact on the cardinal organs as a fuel, if untreated it could results in permanent brain damage and increased mortality. In this study, we aim to evaluate the incidence of hypoglycemia, its risk factors, and its relationship with mortality in critically ill patients. Five hundred adult patients who admitted to an intensive care unit (ICU) were enrolled in this study. A program of glycemic control with a target of 100 - 140 mg/dL was instituted. We used the threshold of 150 mg/dL for septic patients, which were monitored by point of care devices for capillary blood measurement. We detected hypoglycemia with a blood sugar of less than 50 mg/dL and with the detection of each episode of hypoglycemia, blood glucose measurement was performed every 30 minutes. Five hundred patients experienced at least one episode of hypoglycemia, almost always on the third day. Of 15 expired patients who had one hypoglycemia episode, the most common causes were multiple trauma and sepsis. Increases in the sequential organ failure assessment (SOFA) number augmented the hypoglycemia risk to 52% (P < 0.001). Moreover, in patients with acute kidney injury (AKI), the risk of hypoglycemia is 10 times greater than in those without AKI (RR: 10.3, CI: 3.16 - 33.6, P < 0.001). ICU admission blood sugar has a significant relationship with mortality (RR: 1.01, CI: 1.004 - 1.02, P < 0.006). Hypoglycemia increased the mortality rate twofold, but it was not significant (RR: 1.2, CI: 0.927 - 1.58, P = 0.221). Our results showed that the SOFA score, AKI, and hemoglobin A1c are the independent risk factors for the development of hypoglycemia and demonstrated that ICU admission blood glucose, Hba1c, and hypoglycemia increased the risk of death, but only ICU admission blood glucose is significantly related to increased mortality.

Serum Lycopene Concentrations and Associations with Clinical Outcomes in a Cohort of Maternal-Infant Dyads.

PubMed

Hanson, Corrine; Lyden, Elizabeth; Furtado, Jeremy; Van Ormer, Matthew; White, Kimberly; Overby, Nina; Anderson-Berry, Ann

2018-02-13

Oxidative stress has been associated with adverse neonatal outcomes, and many carotenoids, including lycopene, potentially have antioxidant properties. The objective of this analysis was to explore the associations between serum lycopene concentrations, including lycopene isomers, and maternal-newborn outcomes. Maternal and cord blood samples were collected in 180 mother-infant pairs. Serum of total lycopene as well as the cis - and trans -isomers concentrations were measured using HPLC (High Performance Liquid Chromatography). Descriptive statistics were calculated; Spearman coefficients were used to assess correlations between maternal and cord concentrations. The relationship between lycopene concentration and outcomes were evaluated with linear and logistic regression models, with adjustment for relevant confounders. A p ≤ 0.05 was considered statistically significant. Maternal and cord serum lycopene concentrations were positively correlated for total lycopene ( r = 0.30, p < 0.0001), cis -lycopene ( r = 0.29, p = 0.0002); and trans -lycopene ( r = 0.32, p < 0.0001). Maternal concentrations of cis -lycopene were significantly lower in mothers whose infants developed respiratory distress syndrome compared to those who did not (0.336 ± 0.171 vs. 0.445 ± 0.238 µmol/L, p = 0.04) and also in mothers whose babies were admitted to the newborn intensive care unit compared to those who were not (0.380 ± 0.202 vs. 0.458 ± 0.244 µmol/L, p = 0.04). Conversely, cord concentrations of trans -lycopene were significantly higher in infants who developed RDS (Respiratory Distress Syndrome) (0.023 ± 0.012 vs. 0.016 ± 0.012, p = 0.007 for RDS vs. no RDS), and a similar pattern was seen NICU admission (0.023 ± 0.016 vs. 0.015 ± 0.009 µmol/L for NICU (Newborn Intensive Care Unit) admission vs. no NICU admission, p = 0.007). Maternal concentrations of total and cis -lycopene were positively associated with infant birth weight, length and head circumference after adjustment for relevant confounders. As serum carotenoids, including lycopene, are modifiable by diet, future research determining the clinical impact of these compounds is warranted.

The impact of patient demographics and comorbidities upon burns admitted to Tygerberg Hospital Burns Unit, Western Cape, South Africa.

PubMed

Cloake, T; Haigh, T; Cheshire, J; Walker, D

2017-03-01

In South Africa, burns are a major public health problem responsible for significant morbidity and long-term physical disability. This is, in part, due to a significant proportion of the urban population living in poorly constructed, combustible accommodation. The presence of co-morbid diseases such as diabetes and malignancy in patients with burns has been associated with a poorer outcome. The impact of other diseases such as HIV has yet to be defined. A retrospective data collection study analysed the 221 patients admitted to Tygerberg Hospital Burns Unit in 2011 and the first six months of 2013. Using hospital records, patient demographic data was collected alongside burn agent, ICU admission, complications, and patient outcome in terms of length of stay and mortality. The most common burn agent was hot liquid (45.7%). A significant proportion of patients were subject to intentional attacks (34.3%). Shack fires and flame accounted cumulatively for 85% of total inhalational burns, the highest rates of admission to ICU (85.5%), the highest rate of complications, as well as 92.3% of all total fatalities. HIV+ patients had a higher mortality (13.3% vs 5%, p=0.22) and a higher complication rate (46.7% vs 30%, p=0.21). There was no difference in length of stay between the HIV+ and HIV- cohort (12days vs. 15.5 days, p=0.916). Burns are a significant yet preventable cause of mortality and morbidity. The rising number of shack fires, responsible for extensive burns and resultant mortality is concerning and indicates urgent attention and action. HIV complicates the recovery from burn and is responsible for an increased rate of in hospital mortality. Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.

Pathogen colonization of the gastrointestinal microbiome at intensive care unit admission and risk for subsequent death or infection.

PubMed

Freedberg, Daniel E; Zhou, Margaret J; Cohen, Margot E; Annavajhala, Medini K; Khan, Sabrina; Moscoso, Dagmara I; Brooks, Christian; Whittier, Susan; Chong, David H; Uhlemann, Anne-Catrin; Abrams, Julian A

2018-06-23

Loss of colonization resistance within the gastrointestinal microbiome facilitates the expansion of pathogens and has been associated with death and infection in select populations. We tested whether gut microbiome features at the time of intensive care unit (ICU) admission predict death or infection. This was a prospective cohort study of medical ICU adults. Rectal surveillance swabs were performed at admission, selectively cultured for vancomycin-resistant Enterococcus (VRE), and assessed using 16S rRNA gene sequencing. Patients were followed for 30 days for death or culture-proven bacterial infection. Of 301 patients, 123 (41%) developed culture-proven infections and 76 (25%) died. Fecal biodiversity (Shannon index) did not differ based on death or infection (p = 0.49). The presence of specific pathogens at ICU admission was associated with subsequent infection with the same organism for Escherichia coli, Pseudomonas spp., Klebsiella spp., and Clostridium difficile, and VRE at admission was associated with subsequent Enterococcus infection. In a multivariable model adjusting for severity of illness, VRE colonization and Enterococcus domination (≥ 30% 16S reads) were both associated with death or all-cause infection (aHR 1.46, 95% CI 1.06-2.00 and aHR 1.47, 95% CI 1.00-2.19, respectively); among patients without VRE colonization, Enterococcus domination was associated with excess risk of death or infection (aHR 2.13, 95% CI 1.06-4.29). Enterococcus status at ICU admission was associated with risk for death or all-cause infection, and rectal carriage of common ICU pathogens predicted specific infections. The gastrointestinal microbiome may have a role in risk stratification and early diagnosis of ICU infections.

[FUNCTIONAL TRAJECTORIES BEFORE, DURING AND AFTER ACUTE HOSPITALIZATION OF OLDER ADULTS IN INTERNAL MEDICINE WARDS].

PubMed

Zisberg, Anna; Tonkikh, Orly; Sinoff, Gary; Admi, Hanna; Shapira, Chen; Gur-Yaish, Nurit; Shadmi, Efrat

2018-01-01

Hospital-associated functional decline (HAFD) is recognized as a leading cause of adverse hospitalization outcomes, such as prolonged hospitalization, falls, readmission, and mortality. Since most patients hospitalized in internal medicine wards are older-adults, HAFD presents a major challenge to internal medicine. Describe functional trajectories of older-adults (aged ≥70 years) before, during and after acute hospitalization in internal-medicine units. A prospective cohort study was conducted of 741 older-adults, hospitalized in two tertiary hospitals in Israel during the period 2009-2011. Basic functional status two weeks before admission, on-admission, at-discharge and one-month post-discharge was assessed using the modified Barthel Index (BI). Eight trajectories were identified. Two-thirds of the participants were completely or almost independent at the pre-morbid period. About a half of the older-adults were hospitalized with pre-admission functional decline, a quarter deteriorated or died during hospitalization, and one-third improved during hospitalization. Most of the older-adults who were stable in functioning at the pre-admission period (57.1%) remained stable during and post-hospitalization; however, about a third of them did not return to their pre-morbid functioning levels. Approximately half of those with pre-morbid functional decline experienced additional deterioration of at least 5 points on the BI scale. Pre-morbid instrumental functional status, comorbidity and depressive symptoms have been found to distinguish older adults with similar pre-admission and in-hospital functional trends. Eight functional trajectories describe the hospitalization period of older-adults in internal-medicine units. On-admission personal characteristics may be used to identify older-adults who are at risk of unwarranted hospitalization outcomes and thus allow intervention in the hospital-community interface.

The association of admission hyperglycaemia and adverse clinical outcome in medical emergencies: the multinational, prospective, observational TRIAGE study.

PubMed

Kutz, A; Struja, T; Hausfater, P; Amin, D; Amin, A; Haubitz, S; Bernard, M; Huber, A; Mueller, B; Schuetz, P

2017-07-01

The clinical relevance of hyperglycaemia in an emergency department population remains incompletely understood. We investigated the association between admission blood glucose levels and adverse clinical outcomes in a large emergency department cohort. We prospectively enrolled 7132 adult medical patients seeking emergency department care in three tertiary care hospitals in Switzerland, France and the USA. We used adjusted multivariable logistic regression models to examine the association between admission blood glucose levels and 30-day mortality, as well as adverse clinical course stratified by pre-existing diabetes and principal medical diagnoses. In 6044 people without diabetes (84.7%), severe hyperglycaemia, defined as a glucose level of > 11.1 mmol/l (200 mg/dl), was associated with a doubling in the risk of 30-day mortality [adjusted odds ratio (OR) 1.9; 95% confidence interval (95% CI), 1.1 to 3.3; P = 0.018] and a three-fold increase in the risk of intensive care unit admission (adjusted OR 3.0; 95% CI, 1.9 to 4.9; P < 0.001). These associations were similar among different diagnoses. In the population with diabetes (n = 1088), no association with 30-day mortality was found (adjusted OR 1.0; 95% CI, 0.6 to 1.8; P for interaction = 0.001), whereas the association with intensive care unit admission was weaker (adjusted OR 2.4; 95% CI, 1.5 to 4.1; P for interaction = 0.011). Overall 30-day mortality was higher in those with diabetes than in those without (6.1 vs. 4.4%, P = 0.015). In this large medical emergency department patient cohort, admission hyperglycaemia was strongly associated with adverse clinical course in people without diabetes. (Clinical Trial Registry No: NCT01768494). © 2017 Diabetes UK.

Pressure ulcer development in trauma patients with suspected spinal injury; the influence of risk factors present in the Emergency Department.

PubMed

Ham, H W Wietske; Schoonhoven, L Lisette; Schuurmans, M Marieke J; Leenen, L Luke P H

2017-01-01

To explore the influence of risk factors present at Emergency Department admission on pressure ulcer development in trauma patients with suspected spinal injury, admitted to the hospital for evaluation and treatment of acute traumatic injuries. Prospective cohort study setting level one trauma center in the Netherlands participants adult trauma patients transported to the Emergency Department on a backboard, with extrication collar and headblocks and admitted to the hospital for treatment or evaluation of their injuries. Between January and December 2013, 254 trauma patients were included. The following dependent variables were collected: Age, Skin color and Body Mass Index, and Time in Emergency Department, Injury Severity Score, Mean Arterial Pressure, hemoglobin level, Glasgow Coma Score, and admission ward after Emergency Department. Pressure ulcer development during admission was associated with a higher age (p 0.00, OR 1.05) and a lower Glasgow Coma Scale score (p 0.00, OR 1.21) and higher Injury Severity Scores (p 0.03, OR 1.05). Extra nutrition decreases the probability of PU development during admission (p 0.04, OR 0.20). Pressure ulcer development within the first 48h of admission was positively associated with a higher age (p 0.01, OR 1.03) and a lower Glasgow Coma Scale score (p 0.01, OR 1.16). The proportion of patients admitted to the Intensive Care Unit and Medium Care Unit was higher in patients with pressure ulcers. The pressure ulcer risk during admission is high in patients with an increased age, lower Glasgow Coma Scale and higher Injury Severity Score in the Emergency Department. Pressure ulcer risk should be assessed in the Emergency Department to apply preventive interventions in time. Copyright © 2016 Elsevier Ltd. All rights reserved.

Trends in health care resource utilization and pharmacological management of COPD in Taiwan from 2004 to 2010.

PubMed

Tsai, Ying-Huang; Yang, Tsung-Ming; Lin, Chieh-Mo; Huang, Shu-Yi; Wen, Yu-Wen

2017-01-01

COPD has attracted widespread attention worldwide. The prevalence of COPD in Taiwan has been reported, but little is known about trends in health care resource utilization and pharmacologic management in COPD treatment. The objective of this article was to study trends in health care resource utilization, pharmacologic management, and medical costs of COPD treatment in Taiwan. Reimbursement claims in the Taiwan National Health Insurance System from 2004 to 2010 were collected. The disease burden of COPD, including health care resource utilization and medical costs, was evaluated. The pharmacy cost of COPD increased from 2004 to 2010 due to the increased utilization of long-acting muscarinic antagonist (LAMA) and fixed-dose combination of long-acting β2-agonist and inhaled corticosteroid (LABA/ICS), whereas the cost of all other COPD-related medications decreased. The average outpatient department (OPD) cost per patient increased 29.3% from 1,070 USD in 2004 to 1,383 USD in 2010. The highest average total medical cost per patient was 3,434 USD in 2005, and it decreased 12.4% to 3,008 USD in 2010. There was no significant difference in the average number of OPD visits and emergency department visits per patient. The highest average number of hospital admissions was 0.81 in 2005, and it decreased to 0.65 in 2010. The average number of intensive care unit (ICU) admissions decreased from 0.52 in 2005 to 0.31 in 2010. From 2004 to 2010, the average total medical cost per patient of COPD was slightly decreased because of the decreased average number of hospital admissions and ICU admissions. The costs of both LAMA and LABA/ICS increased, while the cost for all other COPD-related medications decreased. These findings suggest that the increased utilization of LAMA and LABA/ICS may have contributed to the decreased average number of hospital admissions and ICU admissions in COPD patients from 2004 to 2010.

Reduced admissions for acute myocardial infarction associated with a public smoking ban: matched controlled study.

PubMed

Seo, Dong-Chul; Torabi, Mohammad R

2007-01-01

There has been no research linking implementation of a public smoking ban and reduced incidence of acute myocardial infarction (AMI) among nonsmoking patients. An ex post facto matched control group study was conducted to determine whether there was a change in hospital admissions for AMI among nonsmoking patients after a public smoking ban was implemented in Monroe County compared with Delaware County, Indiana without such a ban. Poisson analysis was conducted for 44 months of hospital admissions. A significant drop occurred in the number of admissions among nonsmoking patients in Monroe County after the ban whereas a nonsignificant decrease in the number of admissions occurred in Delaware County. The changes in the number of smoking-patient admissions before and after the ban were not significant.

Clinical characteristics and outcomes of obstetric patients admitted to the Intensive Care Unit: a 10-year retrospective review.

PubMed

Leung, N Y W; Lau, A C W; Chan, K K C; Yan, W W

2010-02-01

To review the characteristics and health-related quality-of-life outcomes of obstetric patients admitted to the Intensive Care Unit. Retrospective cohort study. A regional hospital in Hong Kong. Consecutive obstetric patients admitted to the Intensive Care Unit of Pamela Youde Nethersole Eastern Hospital from January 1998 to December 2007. Fifty obstetric patients (mean [standard deviation] age, 31 [6] years; mean gestational age, 34 [9] weeks) were analysed. The most common obstetric cause of admission was postpartum haemorrhage (n=19, 38%), followed by pregnancy-associated hypertension (n=7, 14%). The commonest non-obstetric cause of admission was sepsis (n=7, 14%). The commonest intervention was arterial line insertion (n=33, 66%) and mechanical ventilation (n=29, 58%). Maternal mortality was 6% (n=3), while the perinatal mortality rate was 8% (n=4). The average Short Form-36 Health Survey scores of our patients were lower than the norm for the Hong Kong population of the same age and gender. Postpartum haemorrhage and pregnancy-associated hypertension were the most common causes of admission to our Intensive Care Unit. Overall mortality was low. Long-term health-related quality of life in discharged patients was lower than the norm of the Hong Kong population. Appropriate antenatal care is important in preventing obstetric complications. Continued psychosocial follow-up of discharged patients has to be implemented.

Disparities in epilepsy surgery in the United States of America.

PubMed

Sánchez Fernández, Iván; Stephen, Christopher; Loddenkemper, Tobias

2017-08-01

The aim is to describe the epidemiology of epilepsy surgery in children and adults in the United States. We performed a descriptive study of the National Inpatient Sample (NIS) for the year 2012 and the Kids' Inpatient Database (KID) for the period 2010-2012, the largest all-payer databases on inpatient data in the USA. These databases estimate 97% of all inpatient hospital discharges in the USA. In the KID, 12,899 (0.2%) of admission records had brain surgery and 600 of the 4900 (12.2%) admissions with focal refractory epilepsy underwent epilepsy surgery. Epilepsy surgery occurred in 60% of Whites, 7% of Blacks, 15% of Hispanics, and 10% of other races. In the NIS, 99,650 (0.3%) of admission records had brain surgery and 1170 of the 9775 (12%) admissions with focal refractory epilepsy underwent epilepsy surgery. Epilepsy surgery occurred in 69% of Whites, 7% of Blacks, 9% of Hispanics, and 8% of other races. In both the KID and the NIS, lower socioeconomic status was mildly underrepresented in epilepsy surgery. In both pediatric and adult admissions, there was an overrepresentation of Whites and underrepresentation of Blacks, which persisted after stratifying by socioeconomic status. Females were underrepresented in epilepsy surgery, but gender disparities were partially explained by differences in socioeconomic status. Epilepsy surgery is not equally distributed across races in the USA and these differences are not fully attributable to differences in socioeconomic status. Racial disparities in epilepsy surgery similarly affect children and adults.

Predictors of fever-related admissions to a paediatric assessment unit, ward and reattendances in a South London emergency department: the CABIN 2 study.

PubMed

Bustinduy, Amaya L; Chis Ster, Irina; Shaw, Rebecca; Irwin, Adam; Thiagarajan, Jaiganesh; Beynon, Rhys; Ladhani, Shamez; Sharland, Mike

2017-01-01

To explore the risk factors for ward and paediatric assessment unit (PAU) admissions from the emergency department (ED). Prospective observational study. Febrile children attending a large tertiary care ED during the winter of 2014-2015. Ward and PAU admissions, National Institute for Health and Care Excellence (NICE) guidelines classification, reattendance to the ED within 28 days and antibiotic use. A total of 1097 children attending the children's ED with fever were analysed. Risk factors for PAU admission were tachycardia (RR=1.1, 95% CI (1 to 1.1)), ill-appearance (RR=2.2, 95% CI (1.2 to 4.2)), abnormal chest findings (RR=2.1, 95% CI (1.2 to 4.3)), categorised as NICE amber (RR 1.7 95% CI (1.2 to 2.5)). There was a 30% discordance between NICE categorisation at triage and statistical internal validation. Predictors of ward admission were a systemic (RR=6.9, 95% CI (2.4 to 19.8)) or gastrointestinal illness (RR=3.8, 95% (1.4 to 10.4)) and categorised as NICE Red (RR=5.9, 95% CI (2.2 to 15.3)). Only 51 children had probable bacterial pneumonia (4.6%), 52 children had a proven urinary tract infection (4.2%), with just 2 (0.2%) positive blood cultures out of 485 (44%) children who received an antibiotic. 15% of all children reattended by 28 days and were more likely to have been categorised as Amber and had investigations on initial visit. Risk factors for PAU and ward admissions are different in this setting with high reattendance rates and very low proportion of confirmed/probable serious bacterial infections. Future studies need to focus on reducing avoidable admissions and antibiotic treatment. 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/.

Higher Education in the United States.

ERIC Educational Resources Information Center

Doucette, Donald S.

Issues concerning higher education in the United States are considered, with attention to historical developments; functions and objectives; types of institutions and degrees; internal and external organization; finance; admissions, access, and financial assistance; student and faculty characteristics; distance and recurrent education;…

Energy demand in patients with stroke who are sedated and receiving mechanical ventilation.

PubMed

Bardutzky, Juergen; Georgiadis, Dimitrios; Kollmar, Rainer; Schwarz, Stefan; Schwab, Stefan

2004-02-01

The purpose of this study was 1) to determine the total energy expenditure (TEE) in patients with acute stroke who are sedated and receiving mechanical ventilation; and 2) to compare the TEE between patients with ischemic and hemorrhagic stroke. Thirty-four consecutive nonseptic patients with stroke requiring sedation and mechanical ventilation were prospectively examined; 13 of the patients had experienced spontaneous intracerebral hemorrhage and 21 cerebral ischemia of the middle cerebral artery territory. The TEE was evaluated using continuous indirect calorimetry during the first 5 days after admission to the intensive care unit. The serum albumin concentration was determined on admission and on Day 5. The TEE varied from 1560 +/- 240 to 1623 +/- 251 kcal/day. A highly significant correlation between the TEE and the basal energy expenditure (BEE), as predicted using the Harris-Benedict equation, was observed in both groups. No significant differences in the TEE were detected between the two groups or among the different study days. A highly significant correlation was found between the TEE and the predicted BEE in patients with acute stroke who have been sedated and have received mechanical ventilation. No significant differences were observed between patients with hemorrhagic and ischemic stroke. Further studies are needed to evaluate the effect of tailored feeding on clinical outcome in these patients.

Predictors of violent behavior among acute psychiatric patients: clinical study.

PubMed

Amore, Mario; Menchetti, Marco; Tonti, Cristina; Scarlatti, Fabiano; Lundgren, Eva; Esposito, William; Berardi, Domenico

2008-06-01

Violence risk prediction is a priority issue for clinicians working with mentally disordered offenders. The aim of the present study was to determine violence risk factors in acute psychiatric inpatients. The study was conducted in a locked, short-term psychiatric inpatient unit and involved 374 patients consecutively admitted in a 1-year period. Sociodemographic and clinical data were obtained through a review of the medical records and patient interviews. Psychiatric symptoms at admission were assessed using the Brief Psychiatric Rating Scale (BPRS). Psychiatric diagnosis was formulated using the Structured Clinical Interview for DSM-IV. Past aggressive behavior was evaluated by interviewing patients, caregivers or other collateral informants. Aggressive behaviors in the ward were assessed using the Overt Aggression Scale. Patients who perpetrated verbal and against-object aggression or physical aggression in the month before admission were compared to non-aggressive patients, moreover, aggressive behavior during hospitalization and persistence of physical violence after admission were evaluated. Violent behavior in the month before admission was associated with male sex, substance abuse and positive symptoms. The most significant risk factor for physical violence was a past history of physically aggressive behavior. The persistent physical assaultiveness before and during hospitalization was related to higher BPRS total scores and to more severe thought disturbances. Higher levels of hostility-suspiciousness BPRS scores predicted a change for the worse in violent behavior, from verbal to physical. A comprehensive evaluation of the history of past aggressive behavior and psychopathological variables has important implications for the prediction of violence in psychiatric settings.

Breastfeeding initiation in women with gestational diabetes mellitus.

PubMed

Cordero, L; Gabbe, S G; Landon, M B; Nankervis, C A

2013-01-01

In the United States, breastfeeding initiation (BFI) is reported for 75% of all live births; however, little information is available regarding mothers affected by gestational diabetes mellitus (GDM). To examine feeding practices and factors associated with BFI in women with GDM and their infants. A total of 303 GDM (58 late preterm and 245 term) pregnancies were studied. Infant feeding preference was ascertained on admission to labor and delivery. Variables known to influence BFI including maternal age, smoking, obesity, racial and educational characteristics were assessed. On admission 188 women intended to BF, 60 intended to feed formula and 55 were undecided. None of the women who wished to feed formula and 27% of the originally undecided later initiated BF. Regardless of feeding preference 163 (54%) of all mothers initiated BF. Similar BFI rates were found for 176 Class A1 and 127 class A2 women. Logistic regression analysis showed that intention to BF was the most significant predictor of BFI. Factors associated with BFI failure included African American race, lower education, smoking, obesity and admission to NICU. Following delivery 264 (87%) infants received well baby care while 39 (13%) were admitted to the NICU. Among 188 women who intended to BF, BFI involved 81% of 160 infants receiving well baby care and 61% of the 28 admitted to the NICU. More than half of women with GDM, who intended to BF, initiated BF. BFI failure remains associated with race, lower education level, smoking, obesity, preference for formula feeding and admission to NICU.

Epidemiological features of influenza in Canadian adult intensive care unit patients.

PubMed

Taylor, G; Abdesselam, K; Pelude, L; Fernandes, R; Mitchell, R; McGeer, A; Frenette, C; Suh, K N; Wong, A; Katz, K; Wilkinson, K; Mersereau, T; Gravel, D

2016-03-01

To identify predictive factors and mortality of patients with influenza admitted to intensive care units (ICU) we carried out a prospective cohort study of patients hospitalized with laboratory-confirmed influenza in adult ICUs in a network of Canadian hospitals between 2006 and 2012. There were 626 influenza-positive patients admitted to ICUs over the six influenza seasons, representing 17·9% of hospitalized influenza patients, 3·1/10,000 hospital admissions. Variability occurred in admission rate and proportion of hospital influenza patients who were admitted to ICUs (proportion range by year: 11·7-29·4%; 21·3% in the 2009-2010 pandemic). In logistic regression models ICU patients were younger during the pandemic and post-pandemic period, and more likely to be obese than hospital non-ICU patients. Influenza B accounted for 14·2% of all ICU cases and had a similar ICU admission rate as influenza A. Influenza-related mortality was 17·8% in ICU patients compared to 2·0% in non-ICU patients.

Do survivors of acute neurologic injury remember their stay in the neuroscience intensive care unit?

PubMed

Hocker, Sara; Anderson, Heidi L; McMahon, Katherine E; Wijdicks, Eelco F M

2013-06-01

Patients in medical, surgical, and trauma intensive care units (ICUs) are at risk for later development of symptoms of post-traumatic stress disorder (PTSD). Because acute brain injury can impair recall; we sought to show that neuroscience patients undergoing prolonged neuroscience ICU admission have limited memory of their ICU stay and thus are less likely to develop symptoms of PTSD. We surveyed patients >18 years admitted for 10 days or more to our neuroscience ICU over a 10-year period. The survey response rate was 50.5% (47/93). Forty percent (19/47) of respondents presented with coma. Recall of details of the ICU admission was limited. Fewer than 10% of patients who required mechanical ventilation recalled being on a ventilator. Only five patients (11%) had responses suggestive of possible post-traumatic stress syndrome. The most commonly experienced symptoms following discharge were difficulty sleeping, difficulty with concentration, and memory loss. Patients requiring prolonged neuroscience ICU admission do not appear to be traumatized by their ICU stay.

Measurement of Dead Space Fraction Upon ICU Admission Predicts Length of Stay and Clinical Outcomes Following Bidirectional Cavopulmonary Anastomosis.

PubMed

Cigarroa, Claire L; van den Bosch, Sarah J; Tang, Xiaoqi; Gauvreau, Kimberlee; Baird, Christopher W; DiNardo, James A; Kheir, John Nagi

2018-01-01

Increased alveolar dead space fraction has been associated with prolonged mechanical ventilation and increased mortality in pediatric patients with respiratory failure. The association of alveolar dead space fraction with clinical outcomes in patients undergoing bidirectional cavopulmonary anastomosis for single ventricle congenital heart disease has not been reported. We describe an association of alveolar dead space fraction with postoperative outcomes in patients undergoing bidirectional cavopulmonary anastomosis. In a retrospective case-control study, we examined for associations between alveolar dead space fraction ([PaCO2 - end-tidal CO2]/PaCO2), arterial oxyhemoglobin saturation, and transpulmonary gradient upon postoperative ICU admission with a composite primary outcome (requirement for surgical or catheter-based intervention, death, or transplant prior to hospital discharge, defining cases) and several secondary endpoints in infants following bidirectional cavopulmonary anastomosis. Cardiac ICU in a tertiary care pediatric hospital. Patients undergoing bidirectional cavopulmonary anastomosis at our institution between 2011 and 2016. None. Of 191 patients undergoing bidirectional cavopulmonary anastomosis, 28 patients were cases and 163 were controls. Alveolar dead space fraction was significantly higher in the case (0.26 ± 0.09) versus control group (0.17 ± 0.09; p < 0.001); alveolar dead space fraction at admission was less than 0.12 in 0% of cases and was greater than 0.28 in 35% of cases. Admission arterial oxyhemoglobin saturation was significantly lower in the case (77% ± 12%) versus control group (83% ± 9%; p < 0.05). Sensitivity and specificity for future case versus control assignment was best when prebidirectional cavopulmonary anastomosis risk factors, admission alveolar dead space fraction (AUC, 0.74), and arterial oxyhemoglobin saturation (AUC, 0.65) were combined in a summarial model (AUC, 0.83). For a given arterial oxyhemoglobin saturation, the odds of becoming a case increased on average by 181% for every 0.1 unit increase in alveolar dead space fraction. Admission alveolar dead space fraction and arterial oxyhemoglobin saturation were linearly associated with prolonged ICU length of stay, hospital length of stay, duration of mechanical ventilation, and duration of thoracic drainage (p < 0.001 for all). Following bidirectional cavopulmonary anastomosis, alveolar dead space fraction in excess of 0.28 or arterial oxyhemoglobin saturation less than 78% upon ICU admission indicates an increased likelihood of requiring intervention prior to hospital discharge. Increasing alveolar dead space fraction and decreasing arterial oxyhemoglobin saturation are associated with increased lengths of stay.

Prescribing errors in adult congenital heart disease patients admitted to a pediatric cardiovascular intensive care unit.

PubMed

Echeta, Genevieve; Moffett, Brady S; Checchia, Paul; Benton, Mary Kay; Klouda, Leda; Rodriguez, Fred H; Franklin, Wayne

2014-01-01

Adults with congenital heart disease (CHD) are often cared for at pediatric hospitals. There are no data describing the incidence or type of medication prescribing errors in adult patients admitted to a pediatric cardiovascular intensive care unit (CVICU). A review of patients >18 years of age admitted to the pediatric CVICU at our institution from 2009 to 2011 occurred. A comparator group <18 years of age but >70 kg (a typical adult weight) was identified. Medication prescribing errors were determined according to a commonly used adult drug reference. An independent panel consisting of a physician specializing in the care of adult CHD patients, a nurse, and a pharmacist evaluated all errors. Medication prescribing orders were classified as appropriate, underdose, overdose, or nonstandard (dosing per weight instead of standard adult dosing), and severity of error was classified. Eighty-five adult (74 patients) and 33 pediatric admissions (32 patients) met study criteria (mean age 27.5 ± 9.4 years, 53% male vs. 14.9 ± 1.8 years, 63% male). A cardiothoracic surgical procedure occurred in 81.4% of admissions. Adult admissions weighed less than pediatric admissions (72.8 ± 22.4 kg vs. 85.6 ± 14.9 kg, P < .01) but hospital length of stay was similar. (Adult 6 days [range 1-216 days]; pediatric 5 days [Range 2-123 days], P = .52.) A total of 112 prescribing errors were identified and they occurred less often in adults (42.4% of admissions vs. 66.7% of admissions, P = .02). Adults had a lower mean number of errors (0.7 errors per adult admission vs. 1.7 errors per pediatric admission, P < .01). Prescribing errors occurred most commonly with antimicrobials (n = 27). Underdosing was the most common category of prescribing error. Most prescribing errors were determined to have not caused harm to the patient. Prescribing errors occur frequently in adult patients admitted to a pediatric CVICU but occur more often in pediatric patients of adult weight. © 2013 Wiley Periodicals, Inc.

Dynamic and Personalized Risk Forecast in Step-Down Units. Implications for Monitoring Paradigms.

PubMed

Chen, Lujie; Ogundele, Olufunmilayo; Clermont, Gilles; Hravnak, Marilyn; Pinsky, Michael R; Dubrawski, Artur W

2017-03-01

Cardiorespiratory insufficiency (CRI) is a term applied to the manifestations of loss of normal cardiorespiratory reserve and portends a bad outcome. CRI occurs commonly in hospitalized patients, but its risk escalation patterns are unexplored. To describe the dynamic and personal character of CRI risk evolution observed through continuous vital sign monitoring of individual step-down unit patients. Using a machine learning model, we estimated risk trends for CRI (defined as exceedance of vital sign stability thresholds) for each of 1,971 admissions (1,880 unique patients) to a 24-bed adult surgical trauma step-down unit at an urban teaching hospital in Pittsburgh, Pennsylvania using continuously recorded vital signs from standard bedside monitors. We compared and contrasted risk trends during initial 4-hour periods after step-down unit admission, and again during the 4 hours immediately before the CRI event, between cases (ever had a CRI) and control subjects (never had a CRI). We further explored heterogeneity of risk escalation patterns during the 4 hours before CRI among cases, comparing personalized to nonpersonalized risk. Estimated risk was significantly higher for cases (918) than control subjects (1,053; P ≤ 0.001) during the initial 4-hour stable periods. Among cases, the aggregated nonpersonalized risk trend increased 2 hours before the CRI, whereas the personalized risk trend became significantly different from control subjects 90 minutes ahead. We further discovered several unique phenotypes of risk escalation patterns among cases for nonpersonalized (14.6% persistently high risk, 18.6% early onset, 66.8% late onset) and personalized risk (7.7% persistently high risk, 8.9% early onset, 83.4% late onset). Insights from this proof-of-concept analysis may guide design of dynamic and personalized monitoring systems that predict CRI, taking into account the triage and real-time monitoring utility of vital signs. These monitoring systems may prove useful in the dynamic allocation of technological and clinical personnel resources in acute care hospitals.

Hypophosphatemia and its clinical implications in critically ill children: a retrospective study.

PubMed

Kilic, Omer; Demirkol, Demet; Ucsel, Raif; Citak, Agop; Karabocuoglu, Metin

2012-10-01

The aims of this study were to determine the prevalence of hypophosphatemia and to discuss the clinical implications of hypophosphatemia in critically ill children. A retrospective review of the medical records of children admitted to the pediatric intensive care unit from December 2006 to December 2007 was conducted. In 60.2% (n = 71) of the patients, any serum phosphorous level at admission and at the third day or seventh day after admission to pediatric intensive care unit was in hypophosphatemic range. Sepsis was present in 22.9% (n = 27) of the children studied and was associated with hypophosphatemia (P = .02). Hypophosphatemia was also associated with use of furosemide (P = .04), use of steroid (P = .04), use of β(2) agonist (P = .026), and use of an H(2) blocker (P = .004). There was a significant association between hypophosphatemia and the rate to attain target caloric requirements by enteral route (P = .007). The median time to attain target caloric requirements by enteral route was 2.9 ± 1.9 (0.2-10) days in the normophosphatemic group and 4.4 ± 2.8 (0.3-12) days in the hypophosphatemic group. In the multiple regression model, solely the rate to attain the target caloric requirements by enteral route demonstrated independent association with hypophosphatemia (P = .006; β = .27; 95% confidence interval, 0.02-0.09). Significant association was found between hypophosphatemia and the duration of mechanical ventilation and between hypophosphatemia and pediatric intensive care unit length of stay (P = .02 and P = .001, respectively). Critically ill pediatric patients are prone to hypophosphatemia, especially if they cannot be fed early by enteral route. Hypophosphatemia is associated with an increased duration of mechanical ventilation and increased length of stay in the pediatric intensive care unit, suggesting that active repletion might improve these parameters. Copyright © 2012 Elsevier Inc. All rights reserved.

Cost containment and mechanical ventilation in the United States.

PubMed

Cohen, I L; Booth, F V

1994-08-01

In many ICUs, admission and discharge hinge on the need for intubation and ventilatory support. As few as 5% to 10% of ICU patients require prolonged mechanical ventilation, and this patient group consumes > or = 50% of ICU patient days and ICU resources. Prolonged ventilatory support and chronic ventilator dependency, both in the ICU and non-ICU settings, have a significant and growing impact on healthcare economics. In the United States, the need for prolonged mechanical ventilation is increasingly recognized as separate and distinct from the initial diagnosis and/or procedure that leads to hospitalization. This distinction has led to improved reimbursement under the prospective diagnosis-related group (DRG) system, and demands more precise accounting from healthcare providers responsible for these patients. Using both published and theoretical examples, mechanical ventilation in the United States is discussed, with a focus on cost containment. Included in the discussion are ventilator teams, standards of care, management protocols, stepdown units, rehabilitation units, and home care. The expanding role of total quality management (TQM) is also presented.

The business of palliative medicine--part 4: Potential impact of an acute-care palliative medicine inpatient unit in a tertiary care cancer center.

PubMed

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.

Risk stratification and prognostic performance of the predisposition, infection, response, and organ dysfunction (PIRO) scoring system in septic patients in the emergency department: a cohort study.

PubMed

Chen, Yun-Xia; Li, Chun-Sheng

2014-04-16

The predisposition, infection, response and organ dysfunction (PIRO) staging system was designed as a stratification tool to deal with the inherent heterogeneity of septic patients. The present study was conducted to assess the performance of PIRO in predicting multiple organ dysfunction (MOD), intensive care unit (ICU) admission, and 28-day mortality in septic patients in the emergency department (ED), and to compare this scoring system with the Mortality in Emergency Department Sepsis (MEDS) and Acute Physiology and Chronic Health Evaluation (APACHE II) scores. Consecutive septic patients (n = 680) admitted to the ED of Beijing Chao-Yang Hospital were enrolled. PIRO, MEDS, and APACHE II scores were calculated for each patient on ED arrival. Organ function was reassessed within 3 days of enrollment. All patients were followed up for 28 days. Outcome criteria were the development of MOD within 3 days, ICU admission or death within 28 days after enrollment. The predictive ability of the four components of PIRO was analyzed separately. Receiver operating characteristic (ROC) curve and logistic regression analysis were used to assess the prognostic and risk stratification value of the scoring systems. Organ dysfunction independently predicted ICU admission, MOD, and 28-day mortality, with areas under the ROC curve (AUC) of 0.888, 0.851, and 0.816, respectively. The predictive value of predisposition, infection, and response was weaker than that of organ dysfunction. A negative correlation was found between the response component and MOD, as well as mortality. PIRO, MEDS, and APACHE II scores significantly differed between patients who did and did not meet the outcome criteria (P < 0.001). PIRO and APACHE II independently predicted ICU admission and MOD, but MEDS did not. All three systems were independent predictors of 28-day mortality with similar AUC values. The AUC of PIRO was 0.889 for ICU admission, 0.817 for MOD, and 0.744 for 28-day mortality. The AUCs of PIRO were significantly greater than those of APACHE II and MEDS (P < 0.05) in predicting ICU admission and MOD. The study indicates that PIRO is helpful for risk stratification and prognostic determinations in septic patients in the ED.

Positive pressure--analysing the effect of the addition of non-invasive ventilation (NIV) to home airway clearance techniques (ACT) in adult cystic fibrosis (CF) patients.

PubMed

Stanford, Gemma; Parrott, Helen; Bilton, Diana; Agent, Penny

2015-05-01

There is no published literature on the frequency of use of non-invasive ventilation (NIV) with airway clearance techniques (ACT) throughout the cystic fibrosis (CF) population; 3.9% (191 people of 5062 registered) of the United Kingdom CF population older than 16 years are reported to use NIV in registry data; however, it is not specified if this is for ACT or respiratory failure. Using NIV with ACT decreases work of breathing and fatigue during in-patient admissions for CF patients. We hypothesised these effects could be replicated at home, potentially reducing hospital admissions. Fourteen adult patients with CF scored ease of clearance and breathlessness with ACT before and after addition of NIV to normal ACT routine using a visual analog scale. Patient views on NIV with ACT were collected via a structured interview. Number of home intravenous (IV) antibiotic courses and days in hospital was collected for one year pre- and post-NIV provision. Patients reported statistically significant improvements in ease of clearance (p = 0.011) and reduced breathlessness during ACT using NIV (p = 0.011). Structured interview results indicated patient reports of sputum clearance improved. In-patient days were lower, while home IV days were higher after NIV was set up, although not statistically significant. This study is limited by small numbers; however, trends towards less hospital admissions and greater patient ease while using NIV with ACT warrant further investigation.

Provision of out-of-hours services for acute upper gastrointestinal bleeding in England: results of the 2014-2015 BSG/NHS England national survey.

PubMed

Nedjat-Shokouhi, Bahman; Glynn, Michael; Denton, Erika R E; Greenfield, Simon M

2017-01-01

There has been a drive to raise the standard of management of acute upper gastrointestinal bleeding (AUGIB) in the UK, including three previous audits, sponsored by the British Society of Gastroenterology (BSG). To review the results of the latest BSG/National Health Service (NHS) England national survey of endoscopy services in England between 2014 and 2015. All NHS hospitals accepting acute admissions in England (168) were invited to respond to the survey. Overall, 142 hospitals (84%) returned data. 85% of hospitals used a validated risk assessment score at the time of patient's admission. While 80% of hospitals provided a 24/7 endoscopy service for unstable patients, and another 10% were in network to provide an acute service, only 60% performed an endoscopy within 24 hours for stable acute admissions or inpatients with AUGIB. 11% of hospitals operated an out-of-hours ad hoc rota. 43% felt that pressure from routine work affected their ability to offer a next-day oesophagogastroduodenoscopy service, while 20% of hospitals struggled to recruit endoscopists. 28% of units reported that the previous national audit performed in 2013 had a positive influence on service development. This survey has revealed significant deficiencies in provision of services for patients with AUGIB in England, without a significant increase in number of hospitals providing an emergency AUGIB service since the last national audit in 2013.

Point-of-Admission Serum Electrolyte Profile of Children less than Five Years Old with Dehydration due to Acute Diarrhoea.

PubMed

Okposio, Matthias Mariere; Onyiriuka, Alphonsus Ndidi; Abhulimhen-Iyoha, Blessing Imuetiyan

2015-12-01

Fluid, electrolytes and acid base disturbances are responsible for most deaths due to acute diarrhoea. The aim of this study is to describe the point-of-admission serum electrolyte profile of children with dehydration due to acute diarrhoea. In this cross-sectional study, the serum electrolyte levels of 185 children with dehydration due to acute diarrhoea were assessed at the point of admission at the Diarrhoea Treatment and Training Unit of the University of Benin Teaching Hospital. The age of the study population ranged from 29 days to 59 months. Out of a total of 185 subjects, 30 (16.2%), 114 (61.6%), and 41 (22.2%) had severe, moderate and mild dehydration, respectively. In addition, hyponatraemic dehydration was the most common type of dehydration, accounting for 60.5% of cases. Metabolic acidosis and hypokalaemia occurred in 59.5% and 44.3% of cases, respectively. Only the serum bicarbonate level was significantly affected by degree of dehydration (p = 0.001). Age of more than 12 months and presence of vomiting were significantly associated with hyponatraemia (p = 0.005 & p = 0.02), while age of less than or equal 12 months and absence of vomiting were associated with metabolic acidosis (p = 0.04 & p = 0.03). The degree of dehydration appears to be a good predictor of the occurrence of metabolic acidosis while age is a risk factor for hyponatraemia and metabolic acidosis.

The effect of completing a surrogacy information and decision-making tool upon admission to an intensive care unit on length of stay and charges.

PubMed

Hatler, Carol W; Grove, Charlene; Strickland, Stephanie; Barron, Starr; White, Bruce D

2012-01-01

Many critically ill patients in intensive care units (ICUs) are unable to communicate their wishes about goals of care, particularly about the use of life-sustaining treatments. Surrogates and clinicians struggle with medical decisions because of a lack of clarity regarding patients' preferences, leading to prolonged hospitalizations and increased costs. This project focused on the development and implementation of a tool to facilitate a better communication process by (1) assuring the early identification of a surrogate if indicated on admission and (2) clarifying the decision-making standards that the surrogate was to use when participating in decision making. Before introducing the tool into the admissions routine, the staff were educated about its use and value to the decision-making process. PROJECT AND METHODS: The study was to determine if early use of a simple method of identifying a patient's surrogate and treatment preferences might impact length of stay (LOS) and total hospital charges. A pre- and post-intervention study design was used. Nurses completed the surrogacy information tool for all patients upon admission to the neuroscience ICU. Subjects (total N = 203) were critically ill patients who had been on a mechanical ventilator for 96 hours or longer, or in the ICU for seven days or longer.The project included staff education on biomedical ethics, critical communication skills, early identification of families and staff in crisis, and use of a simple tool to document patients' surrogates and previously expressed care wishes. Data on hospital LOS and hospital charges were collected through a retrospective review of medical records for similar four-month time frames pre- and post-implementation of the assessment tool. Significant differences were found between pre- and post-groups in terms of hospital LOS (F = 6.39, p = .01) and total hospital charges (F = 7.03, p = .009). Project findings indicate that the use of a simple admission assessment tool, supported by staff education about its completion, use, and available resources, can decrease LOS and lower total hospital charges. The reasons for the difference between the pre- and post-intervention groups remain unclear. Further research is needed to evaluate if the quality of communications between patients, their legally authorized representatives, and clinicians--as suggested in the literature--may have played a role in decreasing LOS and total hospital charges.

Geriatric Hip Fracture Care: Fixing a Fragmented System.

PubMed

Anderson, Mary E; Mcdevitt, Kelly; Cumbler, Ethan; Bennett, Heather; Robison, Zachary; Gomez, Bryan; Stoneback, Jason W

2017-01-01

Fragmentation in geriatric hip fracture care is a growing concern because of the aging population. Patients with hip fractures at our institution historically were admitted to multiple different services and units, leading to unnecessary variation in inpatient care. Such inconsistency contributed to delays in surgery, discharge, and functional recovery; hospital-acquired complications; failure to adhere to best practices in osteoporosis management; and poor coordination with outpatient practitioners. To describe a stepwise approach to systems redesign for this patient population. We designed and implemented a comprehensive geriatric hip fracture program for patients aged 65 years and older at our academic Medical Center in October 2014. Key interventions included admission of all ward-status patients to the Orthopedics Service with hospitalist comanagement; geographic placement on the Orthopedics Unit; and standardized, evidence-based electronic order sets bundling geriatric best practices and a streamlined workflow for discharge planning. Hospital length of stay. We identified 271 admissions among 267 patients between January 1, 2012, and March 31, 2016; of those, 154 were before and 117 were after program implementation. Mean hospital length of stay significantly improved from 6.4 to 5.5 days (p = 0.004). The 30-day all-cause readmission rate and discharge disposition remained stable. The percentage of patients receiving osteoporosis evaluation and treatment increased significantly. The rate of completed 30-day outpatient follow-up also improved. Our comprehensive geriatric hip fracture program achieved and sustained gains in the quality and efficiency of care by improving fragmentation in the health care system.

Estimate of survival of patients admitted to a palliative care unit: a prospective study.

PubMed

Bruera, E; Miller, M J; Kuehn, N; MacEachern, T; Hanson, J

1992-02-01

In a prospective open study, 61 consecutive patients with advanced cancer admitted to a Palliative Care Unit underwent survival estimation by two independent physicians after a complete medical exam performed during the first day of admission. An independent research nurse also assessed each patient during the first day of admission. The assessment included activity, pain, nausea, depression, anxiety, anorexia, dry mouth, dyspnea, dysphagia, weight loss, and cognitive status. After the assessment was completed, patients were followed until discharge or death. In 47 evaluable patients, logistic regression showed a significant correlation between survival and dysphagia, cognitive failure, and weight loss. Accordingly, an "indicator of poor prognosis" was considered to exist in any patient who demonstrated weight loss of 10 kg or more plus cognitive failure (Mini-Mental State Questionnaire less than 24) plus dysphagia to solids or liquids. This indicator had a similar level of sensitivity, specificity, and overall accuracy, and a higher level of significance as compared with the assessment by physician #1 and physician #2, respectively. Our data suggest that three simple determinations, which may be performed by a nurse, can predict survival more or less than 4 wk as well as the assessments of two skilled physicians. These results need to be confirmed in other trials with large numbers of patients. Perhaps confirmation of these results and identification of other prognostic factors will result in staging systems for survival estimation of terminally ill cancer patients.

Evaluation of proposed casemix criteria as a basis for costing patients in the adult general intensive care unit.

PubMed

Stevens, V G; Hibbert, C L; Edbrooke, D L

1998-10-01

This study analyses the relationship between the actual patient-related costs of care calculated for 145 patients admitted sequentially to an adult general intensive care unit and a number of factors obtained from a previously described consensus of opinion study. The factors identified in the study were suggested as potential descriptors for the casemix in an intensive care unit that could be used to predict the costs of care. Significant correlations between the costs of care and severity of illness, workload and length of stay were found but these failed to predict the costs of care with sufficient accuracy to be used in isolation to define isoresource groups in the intensive care unit. No associations between intensive care unit mortality, reason for admission and intensive and unit treatments and costs of care were found. Based on these results, it seems that casemix descriptors and isoresource groups for the intensive care unit that would allow costs to be predicted cannot be defined in terms of single factors.