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PubMed1995

Association of out-of-hospital criteria with need for hospital admission.

OBJECTIVE: To validate high-risk historical and physiologic out-of-hospital criteria as predictors of the need for hospitalization following ED evaluation. METHODS: Consecutive patients entered into the Suffolk County advanced life support system were enrolled. Previously proposed historical and physiologic "high-risk" criteria for hospitalization were prospectively collected. Criteria were associated with the need for hospital admission following ED evaluation. RESULTS: 1,238 patients were enrolled; 391 were released from an ED after transport. Most patients (843/1,238; 68%) were admitted to a hospital; and four died in the ED. Factors associated with an increased likelihood of admission or death among the transported patients were: bradycardia (90% admitted, p < 0.02); hypotension (80%, p < 0.03); hypertension (89%, p < 0.03); and age > 55 years (81%, p < 0.0001). Unresponsiveness and other abnormal vital signs were not associated with admission on univariate analysis. Logistic regression analysis identified two other factors associated with admission or death: tachycardia (72% admitted, p < 0.01) and head injury (78% admitted, p < 0.001). CONCLUSIONS: Abnormal pulse or blood pressure, head injury, and age > 55 years are associated with patients' requiring hospital admission after accessing the emergency medical services system. These criteria may aid the design of out-of-hospital refusal-of-care policies.

Adolescent↗

PubMed1996

Hospital or general practice? Results of two experiments limiting the number of self referrals of patients with injuries to hospitals in The Netherlands.

OBJECTIVE: To describe the results of two Dutch experiments aimed at limiting the number of self referrals to accident and emergency (A&E) departments of a newly opened hospital. METHODS: Basic design for both field experiments was a one group test-retest study, with the opening of a new hospital being the experimental factor. Data refer (1) to the number of patient contacts for acute somatic and non-somatic professional help with traumata and intoxications filled in on contact registration forms, and (2) to patient reports based on written questionnaires and interviews by telephone. RESULTS: Both studies show that it is possible to limit the number of self referrals, although it is important to be aware of possible side effects. The solution chosen in one of the cities, with patients visiting the A&E department being sent back to a general practitioner, was highly effective but resulted in a series of complaints from the public. This forced the authorities to abandon their original policy. The model chosen in the other city, with two specialized health centres serving as an alternative for the free A&E department of the new hospital, was somewhat less successful in preventing patients from going directly to a hospital, but was much more acceptable for the public. CONCLUSIONS: Both studies showed that controlling the number of self referrals to the A&E departments of hospitals is possible. However, the more rigid the model, the more difficult it will be to have this model accepted by patients. Based on arguments like cost-effectiveness, a better solution might be not to discourage people from going to the hospital with minor injuries, but to integrate primary health care (PHC) and hospital facilities.

Emergency Service, Hospital↗

PubMed1993

A randomised controlled trial of domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital.

This study compared the functional ability and perceived health status of stroke patients treated by a domiciliary rehabilitation team or by routine hospital-based services after discharge from hospital. Patients discharged from two acute and three rehabilitation hospitals in Nottingham were randomly allocated in three strata (Health Care of the Elderly, General Medical and Stroke Unit) to receive domiciliary or hospital-based care after discharge. Functional recovery was assessed by the Extended Activities of Daily Living (ADL) scale three and six months after discharge and perceived health at six months was measured by the Nottingham Health Profile. A total of 327 eligible patients of 1119 on a register of acute stroke admissions were recruited over 16 months. Overall there were no differences between the groups in their Extended ADL scores at three or six months, or their Nottingham Health Profile scores at six months. In the Stroke Unit stratum, patients treated by the domiciliary team had higher household (p = 0.02) and leisure activity (p = 0.04) scores at six months than those receiving routine care. In the Health Care of the Elderly stratum, death or a move into long-term institutional care at six months occurred less frequently in patients allocated to the routine service, about half of whom attended a geriatric day hospital. Overall there was no difference in the effectiveness of the domiciliary and hospital-based services, although younger stroke unit patients appeared to do better with home therapy while some frail elderly patients might have benefited from day hospital attendance.

Activities of Daily Living↗

PubMed1992

Patient and hospital characteristics related to in-hospital mortality after lung cancer resection.

Several recent reports from academic centers have documented very low postoperative mortality after lung cancer surgery. However, generalizing these studies to community hospitals is potentially limited by reporting bias. From California hospital discharge abstracts, we identified 12,439 adults who underwent pulmonary resection for lung or bronchial tumors between January 1983 and December 1986. In-hospital mortality was 3.8 percent after wedge resection, 3.7 percent after segmental resection, 4.2 percent after lobectomy, and 11.6 percent after pneumonectomy. In multivariate regression models, the significant predictors of in-hospital death included age 60 years or more, male gender, extended resection, chronic lung or heart disease, diabetes and hospital volume. High-volume hospitals experienced better outcomes than low-volume hospitals, although unmeasured severity of illness may be a confounder. The overall mortality in this community-based sample exceeds that reported by selected centers and provides a better foundation for advising patients.

Aged↗

PubMed2000

Bacterial pneumonia in hospitalized patients with HIV infection: the Pulmonary Complications, ICU Support, and Prognostic Factors of Hospitalized Patients with HIV (PIP) Study.

STUDY OBJECTIVES: To describe the causative organisms and factors associated with bacterial pneumonia and to assess its impact on the outcome of hospitalized patients with HIV. DESIGN: Prospective, observational. SETTING: A university-affiliated medical center. METHODS: We included 1,225 consecutive hospital admissions, from April 1995 through March 1998, of 599 adults with HIV. We collected data on APACHE II (acute physiology and chronic health evaluation II) score, leukocyte and CD4+ lymphocyte counts, length of hospital stay, ICU admission rate, and case-fatality rate. Chest radiographs and laboratory results were reviewed. The presence of bacterial pneumonia was noted. RESULTS: Bacterial pneumonia was diagnosed in 111 hospitalizations (9%): 80 (72%) were community-acquired infections. The CD4+ lymphocyte count was lower (median, 38 vs 66/microL, p = 0.0027), APACHE II score higher (17 vs 13, p < 0. 0001), length of hospital stay longer (median, 6 vs 4), and ICU admission (28% vs 9%) and case-fatality rates (21% vs 4%) higher in patients with bacterial pneumonia compared with those without bacterial pneumonia. The most common pathogen was Pseudomonas aeruginosa (32 admissions), followed by Streptococcus pneumoniae (22 admissions), Staphylococcus aureus (16 admissions), and Haemophilus influenzae (11 admissions). Thirty-three (30%) of the pneumonias were bacteremic. Bacteremia was more common in pneumococcal than in pseudomonal pneumonia (95% vs 9%, p < 0.0001). Compared with patients with pneumococcal pneumonia, patients with pseudomonal pneumonia had lower leukocyte and CD4+ lymphocyte counts, longer hospital stay, and similar case-fatality rate. CONCLUSIONS: P aeruginosa is becoming a common cause of both community-acquired and nosocomial bacterial pneumonia in hospitalized patients with HIV, especially in those with low leukocyte and CD4+ lymphocyte counts.

AIDS-Related Opportunistic Infections↗

PubMed2000

New onset of venous thromboembolism among hospitalized patients at Brigham and Women's Hospital is caused more often by prophylaxis failure than by withholding treatment.

CONTEXT: Guidelines to prevent venous thromboembolism (VTE) have been widely distributed and generally have been assumed to be effective. Therefore, among hospitalized patients, the development of VTE is thought to occur in the context of omitted prophylaxis. OBJECTIVES: To describe hospitalized patients who develop VTE and to determine whether they received antecedent prophylaxis. DESIGN: Case series. SETTING: Brigham and Women's Hospital. PATIENTS: Three hundred eighty-four patients who developed in-hospital deep venous thrombosis or pulmonary embolism or who developed VTE within 30 days of prior hospital discharge. MAIN OUTCOME MEASURES: The relationship of developing new-onset VTE to the use or omission of antecedent in-hospital prophylaxis. RESULTS: Of the 384 identified patients, 272 had deep venous thrombosis alone, 62 had pulmonary embolism alone, and 50 had deep venous thrombosis and pulmonary embolism. Most were medical service patients; fewer than one fourth were general or orthopedic surgery patients. Overall, 52% had received antecedent VTE prophylaxis. Thirteen deaths (3.4%) were ascribed to pulmonary embolism, and prophylaxis was omitted in only 1 of those 13 patients. CONCLUSIONS: Most deaths from pulmonary embolism among patients hospitalized for other conditions occurred in the setting of failed prophylaxis rather than omitted prophylaxis. High-risk patients, especially medical service patients, warrant intensive VTE prophylaxis and close follow-up to ensure successful outcomes.

Adult↗

PubMed2002

[The Brazilian Hospital Information System and the acute myocardial infarction hospital care].

OBJECTIVE: To analyze the applicability of the Brazilian Unified Health System's national hospital database to evaluate the quality of acute myocardial infarction hospital care. METHODS: It was evaluated 1,936 hospital admission forms having acute myocardial infarction (AMI) as primary diagnosis in the municipal district of Rio de Janeiro, Brazil, in 1997. Data was collected from the national hospital database. A stratified random sampling of 391 medical records was also evaluated. AMI diagnosis agreement followed the literature criteria. Variable accuracy analysis was performed using kappa index agreement. RESULTS: The quality of AMI diagnosis registered in hospital admission forms was satisfactory according to the gold standard of the literature. In general, the accuracy of the variables demographics (sex, age group), process (medical procedures and interventions), and outcome (hospital death) was satisfactory. The accuracy of demographics and outcome variables was higher than the one of process variables. Under registration of secondary diagnosis was high in the forms and it was the main limiting factor. CONCLUSIONS: Given the study findings and the widespread availability of the national hospital database, it is pertinent its use as an instrument in the evaluation of the quality of AMI medical care.

Brazil↗

PubMed2004

Assessment of in-hospital cardiopulmonary resuscitation using Utstein template in a university hospital.

The aim of this study was to evaluate the effectiveness of in-hospital cardiopulmonary resuscitation (CPR) strategies and identify key predictors of post-CPR survival in a university hospital setting. Using a form recommended by the European Resuscitation Council, data regarding in-hospital CPR attempts from January 2001 to December 2002 were recorded and analyzed. The main outcomes of interest were immediate survival after CPR and survival to hospital discharge. Of 307 patients who suffered cardiac arrest in the study period, 103 (33.5%) were resuscitated. Of these 103 patients, 28 (27.2%) survived immediately and 12 (11.7%) survived to hospital discharge. The key predictors of immediate survival were CPR duration and initial cardiac rhythm as monitored by ventricular fibrillation/pulseless ventricular tachycardia (VF/VT). The key predictors of survival to hospital discharge were CPR duration, immediate defibrillation, Glasgow Coma Scale score, and Early Prediction Score. Together, our results suggest that in-hospital CPR strategies require improvement. They also underscore the importance of data collection and analysis in evaluating the effectiveness of inhospital CPR strategies.

Cardiopulmonary Resuscitation↗

PubMed2004

Excess hospitalizations, hospital days, and inpatient costs among people with diabetes in Andalusia, Spain.

OBJECTIVE: The goal of this study was to estimate the excess hospitalizations, hospital days, and inpatient costs attributable to diabetes in Andalusia, Spain (37 hospitals, 7,236,459 inhabitants), during 1999 compared with those without diabetes. RESEARCH DESIGN AND METHODS: This study was an analysis of all hospital discharges. Those with an ICD-9-CM code of 250 as either the main or secondary diagnosis were considered to have been admissions of individuals with diabetes. An estimate of costs was applied to each inpatient admission by assigning a cost weight based on the diagnostic-related group (DRG) related to each admission. RESULTS: A total of 538,580 admissions generated 4,310,654 hospital bed-days and total costs of 940,026,949 euro. People with diabetes accounted for 9.7% of all hospital discharges, 13.8% of total stays, and 14.1% of the total cost. Of the total cost for individuals with diabetes (132,509,217 euro), 58.3% were excess costs, of which 47% was attributable to cardiovascular complications and 43% to admissions for comorbid diseases. Individuals 45-75 years of age accounted for 75% of the excess costs. The rate of admissions during the study year was 145 per 1,000 inhabitants for individuals with diabetes compared with 70 admissions per 1,000 inhabitants for individuals without diabetes. CONCLUSIONS: The costs arising from hospitalization of individuals with diabetes are disproportionate in relation to their prevalence. For those aged >or=45 years, cardiovascular complications were clearly the most important factor determining increased costs from diabetes.

Adolescent↗

PubMed1991

Can short hospital admissions be avoided? A review of admissions of less than 24 hours' duration in a paediatric teaching hospital.

OBJECTIVE: To review the records of children admitted to hospital for less than 24 hours to assess the appropriateness of the admission and subsequent discharge, and the suitability of these patients for admission to a short stay area rather than the hospital wards. DESIGN: Retrospective study consisting of a one in three sample of all children admitted to the hospital's general medical units over one year. All admissions were listed sequentially, and every third patient was included in the study. SETTING: Royal Children's Hospital, Melbourne; a tertiary paediatric hospital with a major primary care role. PARTICIPANTS: There were a total of 660 patients eligible for inclusion in the study; 220 were selected, and all records were reviewed. RESULTS: It was found that although 87.7% of admissions could be justified on medical grounds alone, the children quickly recovered with at least 65% being fit for discharge within 12 hours of admission. In spite of this the mean duration of admission was 17.0 hours. The majority of patients were suffering from easily diagnosed and treated disorders, with 78.9% falling into four diagnostic groups (asthma, ingestions, infections, and convulsions). Criteria for admission to a short stay observation area were satisfied in 65% of patients (at the time of the study no such area existed in the hospital). No patients were discharged inappropriately early. CONCLUSIONS: A significant number of children require brief hospitalisation for relatively minor illness, but unnecessary delays caused by administrative aspects of hospital admission and relatively infrequent inpatient review by medical staff often lengthen the period of admission. Significant cost savings are possible with the use of a short stay facility, and a large number of patients are suitable for this form of care.

Australia↗

PubMed1999

Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary-care hospital.

OBJECTIVE: To investigate the nature and duration of clinical instability (i.e., abnormalities in simple physical observations or laboratory test results) in hospital patients before a "critical event" (i.e., a cardiac arrest or an unplanned admission to intensive care). DESIGN: Retrospective survey of medical records of all patients having critical events (CEs) over 12 months. Data on hospital and Intensive Care Unit (ICU) patients were obtained for comparison with the study population. SETTING: A 300-bed metropolitan teaching hospital with a seven-bed ICU. PATIENTS: All patients having CEs over a 12-month period (January to December 1997). MAIN OUTCOME MEASURES: Number of patients with clinical instability before a CE; duration of clinical instability before a CE; number of medical reviews of each patient before a CE; mortality rate and length of hospital stay for all patients. RESULTS: There were 122 CEs in 112 patients (median, 1; range, 1-4). Of the CEs, 79 were unplanned ICU admissions (14 subsequent to cardiac arrest calls), and 43 were cardiac arrest calls not resulting in ICU admission. Each CE was preceded by a median of two (range, 0-9) criteria for clinical instability. The median duration of instability before a CE was 6.5 hours (range, 0-432 hours), and in that time a median of two (range, 0-13) medical reviews took place. The incidence of CEs in the total hospital population (122 CEs/19,853 admissions) and in ICU patients (79 unplanned admissions/515 admissions) was 0.6% and 15%, respectively. There were 70 deaths (62%) among the 112 patients, compared with a total of 392 deaths (2% of admissions) in the hospital, of which 107 were in ICU. CONCLUSIONS: Very few patients suffer a CE while in hospital. However, those who do frequently manifest abnormalities in simple physical observations and laboratory test results before the CE. More rapid intervention in response to warning signs might provide a better outcome for these patients.

Adult↗

PubMed2000

[The cottage hospital model, a key to better cooperation in health care--let the cottage hospital survive!].

The cottage hospital model may be defined as an intermediary service between primary care and the general hospital. On the basis of experience and studies from Finnmark county, the northern-most county in Norway, this article makes a case for a revival of the cottage hospitals. They may improve comprehensive patient care and cooperation between care levels, to the benefit of groups of patients who often are in a squeeze between care levels: the elderly, the chronically ill, and the severely ill and dying patients. The cottage hospitals may also contribute to strengthening the chain of service in acute medicine. The professional challenges of work in a cottage hospital may attract practitioners to primary health care. We suggest that 1% of the funds set aside for ongoing national programmes for the elderly, in cancer care and mental illnesses are used for cottage hospital beds, as this may contribute to increasing the viability of these programmes. The extra cost upgrading 1,000 of a total of 27,000 nursing home beds in Norway to cottage hospital standard is estimated to be modest.

Community Health Services↗

PubMedDate not supplied

Strengthening hospital nursing, Part III. Differences among professional groups in the hospital planning process.

Interdisciplinary hospital planning processes are examined. Nurses, physicians, hospital administrators, and support and ancillary personnel from 75 hospitals participating in the national Strengthening Hospital Nursing Program indicate their perceptions of the project in relation to the centrality of the program in their hospitals, planning team development, and political issues. Differences and similarities among the professional groups are discussed. Additional articles on the Strengthening Hospital Nursing Program have appeared in the May and June 1992 issues of JONA. Part 1 explored the planning process in single and consortium hospital sites, and Part 2 examined the characteristics of effective planning processes.

Attitude of Health Personnel↗

PubMed2006

Disparities in diabetes-related hospitalizations: relationship of age, sex, and race/ethnicity with hospital discharges, lengths of stay, and direct inpatient charges.

OBJECTIVE: To identify any differences in hospitalization rates of diabetes patients by age, sex, or race/ethnicity. DESIGN: A cross-sectional study of Georgia hospital discharge data between 1998 and 2001. PATIENTS/PARTICIPANTS: Patients with a principal discharge diagnosis of diabetes. MAIN OUTCOME MEASURES: Adjusted hospitalization data (discharge rates, length of stay, direct charges) reported as standardized rates per 10,000 person-years, standardized rate differences, and standardized rate ratios, compared by age, sex, and race/ethnicity. RESULTS: Diabetes was the principal diagnosis in 50,301 discharges (average age, 51 years; length of stay, 5.1 days; median total charge, $5893). Persons > or = 60 years old had higher discharge rates, longer stays, and higher charges than persons 18-29 years old. Women had fewer hospitalizations, shorter stays, and lower charges than men. Non-Hispanic Blacks had more than three times as many hospitalizations, markedly longer stays, and higher charges than non-Hispanic Whites. Hispanics with diabetes had lower hospitalization rates, shorter stays, and lower charges than Whites. CONCLUSIONS: Differences by age, sex, and race/ethnicity in hospital discharge rates, lengths of stay, and charges exist for diabetes inpatients. Further study should examine potential causes (severity of disease, comorbidity, and differential access to preventive care) of these disparities.

Adolescent↗

PubMed2006

[Hospital acquired pneumonia at the intensive care units. The active nosocomial infections surveillance programme of Polish Society of Hospital Infections].

Currently, the Polish Society of Hospital Infections is coordinating a national program of active surveillance of nosocomial infections. One of its elements is the control of hospital acquired pneumonia (PNEU) on Intensive Care Units. This paper analyzes the epidemiology and etiology of hospital acquired pneumonia (PNEU) at the Intensive Care Units (ICU). Surveillance was conducted by means of an active method of detection and registration of infections by the Infection Control Team (ICT) in cooperation with the unit personnel, in accordance with CDC definitions, during the years: 2002-2003 IN 8 Polish ICU -surgical, medical and mixed. A total of 11 587 hospitalized patients from ICU were covered by the program, with 191 confirmed cases of PNEU. The average cumulative incidence of PNEU was 5.6% (median 4.9%), incidence density of Ventilator Associated Pneumonia (VAP) on average reached 17.9 per thousand (median 18.8 per thousand); mortality of patients with PNEU totaled 12.6% and for patients on ventilator and with coexisting infections 15.0% and 20%, respectively--it wasn't high enough to be statistically significant. Dominant etiologic factors of hospital acquired pneumonia in patients with a risk factor were Pseudomonas aeruginosa and Escherichia coli Methicillin-resistant Staphylococcus aureus(MRSA) comprised 21.1% of isolated S. aureus strains. The analyzes in this paper show that it's possible to effectively implement uniform methods of detection, qualification and analysis in relatively new settings at Polish hospitals, where tools of modern hospital epidemiology are only used since the mid 90-ties.

Cross Infection↗

PubMed2006

Cerebrovascular insult hospital cases in the Clinical Hospital Mostar (Bosnia and Herzegovina) from 1999 to 2003--an example of an institutional register.

The analysis of a cerebro-vascular insult hospitalized cases in the Clinical Hospital Mostar as a retrospective epidemiological study was done in the Clinical Hospital Mostar for the period from 1999 to 2003. The major source of data was medical documentation of this hospital (an institutional register), the only hospital for the treatments of 457,491 inhabitants who gravitate by a health insurance for the treatment in this hospital. The study included a total of 1,555 cerebro-vascular insult cases treated in the Clinical Hospital Mostar Among them 727 (46.8%) were male patients, while 828 (53.2%) cases were female. The majority of the cases were above 50 years of life. Majority of treated female patients were older than 61 (45.6% of all cases), as well as among male patients (31.3%). The least number of cases was under 41 years in both groups (1.2%). Prevalence of risk factors was 2,035 cases (74%). During the same period risk factors research for entire Federation of Bosnia and Herzegovina (FBiH) was performed on the sample of 2,750 national insurance holders, out of which 852 gravitate for treatment in CB Mostar. Out of them 1.7% was found to suffer of cerebro vascular insult.

Adult↗

PubMed1991

Hospital use by HIV patients in Italy: a retrospective longitudinal study. National Study Group on HIV-Related Hospital Use.

Hospital-based treatment for HIV patients consumes considerable health care resources, and for planning purposes it is important to know the hospital needs for each stage of infection. In this paper, we report the results of a national study in Italy on hospital stay for cohorts of patients hospitalized for the first time with HIV-related illnesses during the years 1984-86 and 1987-88. Using the Kaplan-Meier survival methods, we demonstrate a substantial decrease in the proportion of time spent in the hospital by patients newly diagnosed with AIDS (from 49% to 25%) in the latter study period. Treatment with zidovudine (ZDV), estimated only for 1988, emphasizes this trend even more. A reduction in hospital use also occurred for AIDS-related complex (ARC) and persistent general lymphadenopathy (PGL) patients. Possible reasons for this decrease in proportion of time spent in the hospital include longer life span of patients and expansion of outpatient care, as has already been reported in the United States.

AIDS-Related Complex↗

PubMed1989

[Hospital epidemiology of HIV infection in the Parisian public hospitals].

The evolution of hospitalization for patients with HIV infections in Parisian public hospitals (Assistance Publique de Paris) can be analyzed from the data base containing discharge diagnoses and from the results of a cross-sectional survey "on a given day". At present, the activity associated with HIV infection represents more than 2% of the total activity of this institution. From 1982 to 1987, HIV-associated activity increased extremely rapidly, treating patients in acute care hospitals and clinical departments and concomitantly developing home care and day hospitalizations. The latter were responsible for the substantial decrease in the average length of hospitalization. Home care and day care hospitalizations for HIV infection continued to increase during 1988, while longer-term hospitalizations decreased.

France↗