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PubMed2006

Hospital-acquired venous thromboembolism and prophylaxis in an integrated hospital delivery system.

BACKGROUND: Without prophylaxis, hospital-acquired deep vein thrombosis (DVT) is approximately 10-40% among medical or general surgical patients and thromboprophylaxis for high-risk patients is currently recommended. This study analyse the risk factors associated with patients who developed a hospital-acquired venous thromboembolism (VTE) and what prior prophylaxis, if any, were given to these patients. METHODS: We identified 1 year of secondary VTE from seven metropolitan hospitals. A random sample was selected and reviewed retrospectively. Data abstracted included age, gender, VTE risk factors, surgeries, VTE prophylaxis, and anticoagulant dosing. Data analysis consisted of descriptive statistics. RESULTS: A total of 118 patients with mean age 72.1 years (range 23-96) and 55.1% female. There were 60.2% DVT followed by 36.4% pulmonary embolism (PE); 7.6% had both DVT and PE diagnosed. About 73.7% of the study patients had two or more VTE risk factors. Five (4.2%) patients with hospital-acquired VTE had no risk factors. Overall, 88.5% of patients with risk factors received adequate VTE prophylaxis; 20.3% received heparin or enoxaparin, 56.6% received warfarin, and 11.5% received mechanical prophylaxis secondary to drug contraindications. Nine (8.0%) patients with risk factors and no contraindications, did not received any prophylaxis while four patients (3.5%) received inadequate prophylaxis. All-cause mortality was 13.6% (16/118). CONCLUSION: Less than 5% of hospital-acquired VTE occurred in patients with no risk factors while 74% occurred in patients with two or more risk factors. In this seven-hospital study, 11.5% of hospital-acquired VTE with prior risk factors did not receive adequate prophylaxis. Educational in-services on the new CHEST guidelines should be provided within the hospitals to increase adherence to prophylaxis guidelines.

Adult↗

PubMed2006

Clinical predictors of in-hospital mortality in patients with snake bite: a retrospective study from a rural hospital in central India.

OBJECTIVE: To determine the association between selected admission risk factors and in-hospital mortality in patients admitted with venomous snake bite to a rural tertiary care hospital in central India. METHODS: Retrospective cohort study of patients aged 12 years or older admitted to a rural hospital in central India between January 2000 and December 2003 with venomous snake bites. The primary endpoint was in-hospital mortality. We used Cox proportional-hazards regression analysis to evaluate the association between risk factors (home-to-hospital distance, bite-to-hospital time, vomiting, neurotoxicity, urine albumin, serum creatinine concentration and whole-blood clotting time) and in-hospital mortality. RESULTS: Two hundred and seventy-seven patients [mean age 32 (SD 12) years; 188 men (68%)] were admitted with venomous snake bite, 29 patients (11%) died. The probability of survival at day 7 was 83%. Vomiting [hazard ratio 6.51 (95% CI 1.94-21.77), P < or = 0.002], neurotoxicity [hazard ratio 3.15 (95% CI 1.45-6.83), P = 0.004] and admission serum creatinine concentration [hazard ratio 1.35 (95% CI 1.17-1.56), P < or = 0.001] were associated with higher risk of death in the adjusted analysis. CONCLUSIONS: In our rural hospital setting, the overall mortality rate was 11 per 100 cases of snake bite. Vomiting, neurotoxicity and serum creatinine are significant predictors of mortality among inpatients with snake bite. These predictors can help clinicians assess prognosis of their patients more accurately and parsimoniously and also serve as useful signposts for clinical decision-making.

Adolescent↗

PubMed1996

Hospital admission risk profile (HARP): identifying older patients at risk for functional decline following acute medical illness and hospitalization.

OBJECTIVES: To develop and validate an instrument for stratifying older patients at the time of hospital admission according to their risk of developing new disabilities in activities of daily living (ADL) following acute medical illness and hospitalization. DESIGN: Multi-center prospective cohort study. SETTING: Four university and two private non-federal acute care hospitals. PATIENTS: The development cohort consists of 448 patients and the validation cohort consists of 379 patients who were aged 70 and older and who were hospitalized for acute medical illness between 1989 and 1992. MEASUREMENTS: All patients were evaluated on hospital admission to identify baseline demographic and functional characteristics and were then assessed at discharge and 3 months after discharge to determine decline in ADL functioning. RESULTS: Logistic regression analysis identified three patient characteristics that were independent predictors of functional decline in the development cohort: increasing age, lower admission Mini-Mental Status Exam scores, and lower preadmission IADL function. A scoring system was developed for each predictor variable and patients were assigned to low, intermediate, and high risk categories. The rates of ADL decline at discharge for the low, intermediate, and high risk categories were 17%, 28%, and 56% in the development cohort and 19%, 31%, and 55% in the validation cohort, respectively. Patients in the low risk category were significantly more likely to recover ADL function and to avoid nursing home placement during the 3 months after discharge. CONCLUSION: Hospital Admission Risk Profile (HARP) is a simple instrument that can be used to identify patients at risk of functional decline following hospitalization. HARP can be used to identify patients who might benefit from comprehensive discharge planning, specialized geriatric care, and experimental interventions designed to prevent/reduce the development of disability in hospitalized older populations.

Activities of Daily Living↗

PubMed1988

Use of hospital beds: a cohort study of admissions to a provincial teaching hospital.

An instrument was developed to study the use of hospital beds and discharge arrangements of a cohort of 847 admissions to the John Radcliffe Hospital, Oxford, for a three week period during February-March 1986. For only 38% of bed days were patients considered to have medical, nursing, or life support reasons for requiring a provincial teaching hospital bed. The requirements for a bed in the hospital decreased with the patient's age and length of stay in hospital. For only a tenth of patients was the general practitioner concerned in discussions with hospital staff about the patient's discharge and less than one third of patients had been given more than 24 hours' notice of discharge. Several features might increase the proportion of bed days that are occupied by patients with positive reasons for being in hospital. Among these are an increased frequency of ward rounds by consultants, or delegating discharge decisions by consultants to other staff; providing diagnostic related protocols for planning the length of stay in hospital; planned discharges; and providing liaison nurses to help with communication with primary care staff.

Bed Occupancy↗

PubMed1995

Success of cardiopulmonary resuscitation after heart attack in hospital and outside hospital.

OBJECTIVES: To determine factors associated with cardiopulmonary resuscitation being attempted after cardiac arrest from myocardial infarction, in or outside hospital, and estimate short term and long term survival rates. DESIGN: Descriptive cross sectional and cohort study. SETTING: Community based register of all suspected heart attacks and sudden cardiac deaths in Lower Hunter region of New South Wales, Australia. SUBJECTS: 4924 men and women aged 25-69. MAIN OUTCOME MEASURES: Rates of attempted cardiopulmonary resuscitation and survival after successful resuscitation. RESULTS: Cardiopulmonary resuscitation was attempted in 41% of cases of cardiac arrest after myocardial infarction outside hospital and 63% of cases in hospital. Survival rates at 28 days were 12% and 39% respectively. Among the survivors, although 41% had another myocardial infarction (or coronary death), 81% of both groups were still alive two years later. Younger and better educated people were more likely to receive cardiopulmonary resuscitation in either setting, and being married predicted cardiopulmonary resuscitation being attempted outside hospital. Younger age predicted better survival rates after attempted resuscitation in hospital. CONCLUSIONS: The reasons for better education to predict cardiopulmonary resuscitation being attempted need explanation. The higher survival rate after cardiopulmonary resuscitation in hospital compared with outside hospital and the good long term prognosis for survivors in both settings suggest that attempts to improve success of cardiopulmonary resuscitation outside hospital may be worth while.

Adult↗

PubMed1999

Systematic review of day hospital care for elderly people. The Day Hospital Group.

OBJECTIVE: To examine the effectiveness of day hospital attendance in prolonging independent living for elderly people. DESIGN: Systematic review of 12 controlled clinical trials (available by January 1997) comparing day hospital care with comprehensive care (five trials), domiciliary care (four trials), or no comprehensive care (three trials). SUBJECTS: 2867 elderly people. MAIN OUTCOME MEASURES: Death, institutionalisation, disability, global "poor outcome," and use of resources. RESULTS: Overall, there was no significant difference between day hospitals and alternative services for death, disability, or use of resources. However, compared with subjects receiving no comprehensive care, patients attending day hospitals had a lower odds of death or "poor" outcome (0.72, 95% confidence interval 0.53 to 0.99; P<0.05) and functional deterioration (0.61, 0.38 to 0.97; P<0.05). The day hospital group showed trends towards reductions in hospital bed use and placement in institutional care. Eight trials reported treatment costs, six of which reported that day hospital attendance was more expensive than other care, although only two analyses took into account cost of long term care. CONCLUSIONS: Day hospital care seems to be an effective service for elderly people who need rehabilitation but may have no clear advantage over other comprehensive care. Methodological problems limit these conclusions, and further randomised trials are justifiable.

Aged↗

PubMed2004

Admission predictors of in-hospital mortality and subsequent long-term outcome in survivors of ventricular fibrillation out-of-hospital cardiac arrest: a population-based study.

BACKGROUND: Survival following out-of-hospital cardiac arrest (OHCA) from ventricular fibrillation (VF) is poor and dependent on a rapid emergency response system. Improvements in emergent early response have resulted in a higher percentage of patients surviving to admission. However, the admission variables that predict both short- and long-term survival in a region with high discharge survival following OHCA require further study in order to identify survivors at subsequent highest risk. METHODS: All patients with OHCA arrest in Olmsted County Minnesota between 1990 and 2000 who received defibrillation of VF by emergency services were included in the population-based study. Baseline patient admission characteristics in survivor and nonsurvivor groups were compared. Survivors to hospital discharge were prospectively followed to determine long-term survival. RESULTS: Two hundred patients suffered a VF arrest. Of these patients, 145 (73%) survived to hospital admission (7 died within the emergency department) and 79 (40%) were subsequently discharged. Sixty-six (83%) were male, with an average age of 61.9 +/- 15.9 years. Univariate predictors of in-hospital mortality included call-to-shock time (6.6 vs. 5.5 min, p = 0.002), a nonwitnessed arrest (75.4 vs. 92.4%, p = 0.008), in-field use of epinephrine (27.8 vs. 93.4%, p < 0.001), age (68.1 vs. 61.9 years, p = 0.017), hypertension (36.1 vs. 14.1%, p = 0.005), ejection fraction (32.4 vs. 42.4, p = 0.012), and use of digoxin (34.9 vs. 12.7%, p = 0.002). Of all these variables, hypertension [hazard ratio (HR) 4.0, 95% CI 1.1-14.1, p = 0.03], digoxin use (HR 4.5, 95% CI 1.3-15.6, p = 0.02), and epinephrine requirement (HR 62.0, 95% CI 15.1-254.8, p < 0.001) were multivariate predictors of in-hospital mortality. Nineteen patients (24%) had died prior to the survey follow-up. Five patients experienced a cardiac death, resulting in a 5-year expected cardiac survival of 92%. Multivariate variables predictive of long-term mortality include digoxin use (HR 3.02, 95% CI 1.80-5.06, p < 0.001), hypertension (HR 2.06, 95% CI 2.12-3.45, p = 0.006), and call-to-shock time (HR 1.18, 95% CI 1.01-1.38, p = 0.038). CONCLUSION: A combined police/fire/EMS defibrillation program has resulted in an increase of patients surviving to hospital admission after OHCA. This study confirms the need to decrease call-to-shock times, which influence both in-hospital and long-term mortality. This study also identifies the novel demographic variables of digoxin and hypertension, which were also independent risk factors of increased in-hospital and long-term mortality. Identification of these variables may provide utility in identifying those at high-risk of subsequent mortality after resuscitation.

Aged↗

PubMed1989

The effect of precertification on the rate of hospitalization of patients with low back pain. A case study comparing hospitalization rates of patients covered by workers' compensation and no-fault automobile insurance in New York State.

This report is a study of the rates of hospitalization of two similar groups of patients with a diagnosis of medical low back pain resulting from an injury. It is based on a 7-year experience with utilization review. None of the patients had met the minimal criteria for hospitalization described by the "Reference Criteria for Short-Stay Hospital Review" of the American Medical Association (1). One of these two groups was required to undergo a preservice review (precertification) before hospitalization. The other group did not undergo this precertification. This study tests the hypotheses that there is a significant incidence of unnecessary hospitalization of patients with medical low back pain and that precertification does reduce this rate of hospitalization. It also tests the hypothesis that race, age, and gender correlate with this unnecessary hospitalization. Further, it examines the relationship between the precertification process and the time of admission and the length of stay once admitted. The methods used are defined, and the controversy surrounding precertification and unnecessary hospitalization in general, and for low back pain in particular, is described.

Age Factors↗

PubMed2001

Supported discharge shortens hospital stay in patients hospitalized because of an exacerbation of COPD.

This prospective, controlled, but not formally randomized study investigates the feasibility and efficiency of an alternative to standard hospitalization for patients with exacerbated chronic obstructive pulmonary disease (COPD), based upon supported discharge with nurse supervision at home. Over a 12-month period, emergency physicians, not directly involved in the study, admitted 205 patients with exacerbated COPD to the authors' respiratory unit. Patients were included in the supported discharge group (n=105) if they voluntarily chose to participate in the programme and lived in the city of Palma de Mallorca (where adequate home support could be provided). Patients not fulfilling these criteria (mainly residents outside the city) served as controls (n=100). Inpatient treatment was standardized in all patients and included oxygen therapy, bronchodilators, antibiotics and steroids. Both groups were comparable in terms of age (mean +/- SD: 70 +/- 10 versus 65 +/- 11 yr for supported discharge and control group, respectively), severity of airflow obstruction (forced expiratory volume in one second 45 +/- 18% reference versus 46 +/- 19% ref.), comorbidity and socioeconomic status. Length of hospital stay (LOS) in the supported discharge group was shorter (5.9 +/- 2.8 versus 8.0 +/- 5.1 days, p < 0.001). After discharge, a respiratory nurse visited supported discharge patients at home during 7.3 +/- 3.8 days. Only one patient (1%) required hospital readmission during this period of time. The reduced LOS resulted in a lower utilization of hospital beds at any given point in time throughout the study period. Within the framework and potential limitations of this study, the results indicate that the supported discharge programme in Spain: 1) allows a significant reduction in the length of hospital stay of patients hospitalized because of an exacerbation of chronic obstructive pulmonary disease; 2) does not result in an inappropriately increased rate of hospital readmissions; and 3) reduces the utilization of hospital resources.

Aged↗

PubMed1980

Home health services for previously hospitalized and non-hospitalized patients with circulation ailments: a research note.

This research note is an investigation of the effectiveness of a home nursing program which compares a group of patients with circulation problems who were hospitalized prior to service with a similar group which was not hospitalized. Four outcome measures are utilized: mortality, stabilization, hospitalization, and nursing home confinement. It is hypthesized that because of the greater likelihood of complication and severity of illness experienced by the hospitalized patients, they should exhibit higher mortality, hospitalization and nursing home confinement, and lower stabilization at discharge. The hypotheses are analyzed by means of the t-test. Results indicate the hypotheses to be in the direction expected with the exception of nursing home confinement which is more likely to occur among those not previously hospitalized. Implications of this study suggest that home health programs would seem to have a greater chance of success among circulatory patients who are not hospitalized prior to service. In analyzing the effectiveness of home health programs in the future, investigators should recognize the intervening effects of hospital admission on the patients.

Aftercare↗

PubMed1991

Hospital choice criteria: an empirical evaluation of active hospital clients.

Because of increasing competition, hospital administrators need to understand the criteria consumers use when making the choice of hospital services. This empirical study found the physical plant of the hospital in addition to the hospital staff play prominent roles in consumer selection of a hospital. A hospitals' overall reputation in addition to any previous contact with the hospital also have a major impact on hospital choice.

Adolescent↗

PubMed2003

Comparing hospital infections in the elderly versus younger adults: an experience in a Brazilian University Hospital.

The elderly population will grow rapidly over the next 25 years, however there is little information about hospital infections in this group of patients in Brazil. We examined the prevalence of nosocomial and community infections in elderly ((3) 65 years) patients and their relationship with intrinsic and extrinsic risk factors in a Brazilian University Hospital. A total of 155 hospitalized elderly patients were evaluated, and clinical and demographic information about each patient was obtained from hospital records. The rates of nosocomial and community infections were 16.1% and 25.6%, respectively. When the elderly group with and without nosocomial infections was analyzed, practically all the risk factors considered (use of antibiotics, invasive devices, surgery and time of hospitalization) were significantly more associated with the patients with hospital infection. All patients with nosocomial infections were taking antibiotics and most of them (56.0%) were being treated with two or more antibiotics; the length of hospitalization was double (p=0.007) compared to patients who had not acquired hospital infection. The most frequent sites of nosocomial and community infections were surgical (56.0%) and the skin (37.1%), and most of the patients (47.5%) were in the surgical clinic wards. In conclusion, the elderly patients were more likely to develop a nosocomial infection (16.1% prevalence). Surgical infection accounted for the majority (56.0%) of the nosocomial infections, in contrast with North American studies that indicate urinary tract infections to be the commonest.

Adolescent↗

PubMed2001

"Evil reports" for "ignorant minds"? Patient experience and public confidence in the emerging modern hospital: Vancouver General Hospital, 1912.

The process whereby the 19th-century Canadian charity hospital for the sick poor was transformed into a centre for scientific health care for the whole community was well in hand by World War I. To fund this transition, and to cope with the subsequent unrelieved demand from all social classes for accessibility to hospitalization, hospitals instituted differentiated services, offering premium care and privacy to paying patients whose fees, in turn, sustained a more economical level of open ward maintenance for indigent patients. As the record of a 1912 public investigation into patient grievances and complaints against the Vancouver General Hospital reveals, the commodification of hospital-based health care reproduced in the hospital environment the social attitudes, controls, and structures of the wider community. This development appeared to contradict the hospitals promise of undifferentiated, scientifically-mediated, medical efficiency and efficacy for all, and its reputation as a humane and caring institution. Notwithstanding the inquiry's conclusion that these grievances were "evil reports" designed to appeal to "ignorant minds," they reveal a patient population of already informed consumers ready, willing and able to discriminate between the promise and the reality of hospital-centred health care for all.

Canada↗

PubMed2003

An outbreak of severe acute respiratory syndrome among hospital workers in a community hospital in Hong Kong.

BACKGROUND: During outbreaks, hospital workers are at high risk for nosocomial infection with severe acute respiratory syndrome (SARS)-associated coronavirus. OBJECTIVE: To examine how hospital workers became infected and whether they transmit the virus to their families. DESIGN: Retrospective descriptive study. SETTING: 529-bed community hospital in Hong Kong. PATIENTS: 40 hospital workers infected with SARS-associated coronavirus over a 6-week period (25 March through 5 May 2003). MEASUREMENTS: Percentage of infected hospital workers according to job category. RESULTS: The cumulative incidence was highest among health care assistants, followed by physicians and nurses (8%, 5%, and 4%, respectively). Most hospital workers were infected from direct contact with patients with SARS, who primarily were in general wards and had unsuspected infection. At the time of contact, all hospital workers had used masks but not necessarily other protective devices. Affected hospital workers did not infect their families. CONCLUSION: Before isolation of all patients with clinically confirmed or suspected SARS, routine use of several protective devices, and training of staff in infection control, many health care workers were infected with SARS from patients with unsuspected cases.

Adult↗

PubMedDate not supplied

Hospitals set 1992 public policy agenda. California Association of Hospitals and Health Systems.

On behalf of patients and hospitals who care for them, CAHHS developed this year's public policy agenda in cooperation with the Hospital Council of Northern and Central California, the Hospital Council of San Diego and Imperial Counties, and the Hospital Council of Southern California. CAHHS and the Hospital Councils work with the hospital constituency groups to maximize the effectiveness of hospitals and present a unified front on major issues. As advocates for patients and hospitals, CAHHS places the highest value on life, the treatment of patients with dignity, and equitable access to quality care.

California↗

PubMed2000

Integration between GPs and hospitals: lessons from a division-hospital program.

The aim of the study reported here was to evaluate current initiatives in GP-hospital integration and highlight areas where further research, development and evaluation are required. Seven pre-existing GP-hospital programs were selected and given supplementary funding to allow for more effective evaluation. These local evaluations were then incorporated into a national program on GP-hospital collaboration. We found that the seven projects made substantial progress towards their goals, and in the process highlighted important aspects of successful collaboration. The collective evaluation of DHIP identified expected benefits of collaboration for patients (improved access to services, reduced anxiety, and fewer post discharge complications), for GPs (increased involvement in acute care and in hospital decision making), and for service organisations (stronger working relationships, increased capacity, and greater efficiency). Barriers to service integration were also identified, including the different cultures of Divisions and hospitals, their lack of internal coherence and the Commonwealth-state divide. The evaluation showed that much has been achieved in building the relationships and the capacity needed for GP-hospital collaboration, and that effective models exist. The current challenge is to extend successful models across health areas and make effective collaboration part of the normal system of care. Substantial progress towards integrated care relies on a shift from a focus on systems within general practice or hospital environments to a patient centred approach. This will require general practice, hospitals, community services and consumer organisations to form long term partnerships and move beyond their currently disjointed view of acute and community care. The development of practical indicators for integrated care will support the process and facilitate shared learning across Commonwealth and state divides.

Australia↗

PubMed2001

[Impact of hospital admissions for pneumonia in a tertiary Spanish hospital].

BACKGROUND: Impact of hospital admissions for pneumonia during 1998 in the Hospital Clínic, Barcelona. PATIENTS AND METHOD: Retrospective information on the hospitalizations for pneumonia was collected. RESULTS: During 1998 a total of 626 adult were admitted with a hospital diagnosis of pneumonia (72% were >/= 65 years). The average length of stay was 10 days. Half of these patients were previously hospitalized during the preceding 5 years. CONCLUSIONS: Hospital admissions due to pneumonia (17 cases per 1.000 hospitalizations) accounted for an estimated cost of 2.3% of the cost of all the hospitalized patients.

Aged↗

PubMed2002

The impact of managed care penetration and hospital quality on efficiency in hospital staffing.

The state of California has recently mandated minimum nurse-staffing ratios, raising concerns about possible affects on hospital efficiency. In this study, we examine how market factors and quality were related to staffing levels in California hospitals in 1995 (prior to implementation of the new law). We are particularly interested in the affect of managed care penetration on this aspect of hospital efficiency because the call to legislative action was predicated on fears that hospitals were reducing staffing below optimal levels in response to managed care pressures. We derive a unique measure of excess staffing in hospitals based on a data envelopment analysis (DEA) production function model, which explicitly includes ancillary care among the inputs and outputs. This careful specification of production is important because ancillary care use has risen relative to daily hospital services, with the spread of managed care and advances in medical technology. We find that market share (adjusted for size) and market concentration are the major determinants of excess staffing while managed care penetration is insignificant. We also find that poor quality (outcomes worse than expected) is associated with less efficient staffing. These findings suggest that the larger, more efficient urban hospitals will be penalized more heavily under binding staffing ratios than smaller, less-urban hospitals.

Bed Occupancy↗