Journal articles: 'Acute medical admissions ; Patient journey ; Patient discharge'

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Pinkney, Jonathan, Susanna Rance, Jonathan Benger, Heather Brant, Sian Joel-Edgar, Dawn Swancutt, Debra Westlake, et al. "How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals." Health Services and Delivery Research 4, no. 3 (January 2016): 1–202. http://dx.doi.org/10.3310/hsdr04030.

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BackgroundHospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown.AimsTo investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners.MethodsThe project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources.FindingsPatients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity.ConclusionsThis research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions.FundingThe National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

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Rycroft, W., and B. Madi. "41 A New Ambulatory Frailty Pathway at Barnsley Hospital." Age and Ageing 50, Supplement_1 (March 2021): i12—i42. http://dx.doi.org/10.1093/ageing/afab030.02.

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Abstract Topic At Barnsley Hospital we targeted an improvement in the care of frail patients. The first objective was to improve the patient journey by reducing the amount of time that frail patients spend in busy acute environments. The second objective was to deliver more effective Comprehensive Geriatric Assessment which is recognised as gold standard management (Ellis, G. BMJ 2011;343:d6553). Intervention A new frailty chaired area was opened in July 2018 with capacity to receive up to 6 patients per day from acute admission areas and aim for same day discharge. We developed our own bespoke criteria to ensure that suitable ambulatory patients were identified to access this new pathway. This was called “FACT” Criteria- Frail, Ambulatory, Clinically stable, Time to call. Patients received an MDT model of care which was documented using a newly developed electronic tool called electronic Comprehensive Geriatric Assessment (eCGA). Improvement To evaluate the patient journey we measured the average time between the Acute Medical Unit (AMU) Post Take Ward Round (PTWR) and onward move. Comparison was made between the 2 month periods July—August and November—December 2018. This demonstrated that the average time reduced from 10.3 to 5.1 hours. Between July 2018 and April 2019 a total of 689 patients were assessed in the frailty chaired area of which 60.8% were discharged from the hospital the same day. Discussion The patient journey for frail ambulatory patients now involves significantly less time on AMU awaiting onward move. Comprehensive Geriatric Assessment is delivered more effectively and documented electronically using eCGA. This tool promotes better information sharing and has a specific section for advance care planning. This new pathway has a high same day discharge rate of 60.8% which reduces length of stay for our frail patients.

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Saxton, N., and D. Mayne. "43 Renewing the Frailty Experience: Bringing CGA Into the Emergency Department." Age and Ageing 50, Supplement_1 (March 2021): i12—i42. http://dx.doi.org/10.1093/ageing/afab030.04.

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Abstract Topic Early recognition and multidisciplinary management of frail patients in acute care is a national priority. This is reflected in the NHS 10 year plan, NHS Improvement (NHSI) and Getting It Right First Time (GIRFT) ambitions for acute care. The Sunderland Royal Hospital acute frailty service currently reviews frail patients on the Medical Admissions Unit (MAU) each morning. Analysis of our emergency department (ED) data demonstrates that most frail patients arrive to the ED between 12 pm and 18 pm leading to a cohort of frail patients who are not receiving comprehensive geriatric assessment early in their patient journey. Here, we present our piloted expansion of the frailty service into the ED. Intervention Currently the frailty service is provided on MAU between 9 am and 1 pm. The pilot service expansion ran for five weeks between September and October 2018 and involved the acute frailty team being available to ED and MAU from Monday to Friday 0830 am to 1700 pm. Frail patients were proactively identified using the ED patient tracker as well being referred to the team by ED staff. Improvement During the pilot, the team reviewed 131 additional patients. 85% were seen in ED. 61 patients were discharged directly from ED and 33 patients were admitted directly to a back of house medical ward resulting in reduced MAU occupancy rates in the evenings. Concerns that bringing full MDT assessment into ED might result in increased time spent in ED were proven to be unfounded. Median length of stay for admitted patients was low with 49% discharged within 7 days and 9.9% 30 day readmission rate. Feedback from ED and community teams was positive. Discussion It is recognised that early CGA is beneficial for patients with frailty syndromes who are admitted to hospital. Most commonly, this takes place on medical admissions wards. Through this pilot, we have demonstrated significant added benefits of bringing the acute frailty team and crucially CGA into the emergency department setting. As well as increased discharges directly from ED, we demonstrated a reduction in length of stay and readmissions as well as improved patient flow. Our aim is to permanently implement a seven day frailty service with input on MAU as well as ED.

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Wu, Jane, Olivia Misa, Christine T. Shiner, and Steven G. Faux. "Targeted rehabilitation may improve patient flow and outcomes: development and implementation of a novel Proactive Rehabilitation Screening (PReS) service." BMJ Open Quality 10, no. 1 (March 2021): e001267. http://dx.doi.org/10.1136/bmjoq-2020-001267.

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Rehabilitation programmes can be delivered to patients receiving acute care (‘in-reach rehabilitation’) and/or those who have completed acute care but experience ongoing functional impairments (‘subacute rehabilitation’). Access to these programmes depends on a rehabilitation assessment, but there are concerns that referrals for this assessment are often triggered too late in the acute care journey. We describe a Proactive Rehabilitation Screening (PReS) process designed to systematically screen patients during an acute hospital admission, and identify early those who are likely to require specialist rehabilitation assessment and intervention. The process is based on review of patient medical records on day 5 after acute hospital admission, or day 3 after transfer from intensive care to an acute hospital ward. Screening involves brief review of documented care needs, pre-existing and new functional disabilities, the need for allied health interventions and non-medical factors delaying discharge. From May 2017 to February 2019, the novel screening process was implemented as part of a service redesign of the rehabilitation consultation service. Four thousand consecutive screens were performed at the study site. Of those ‘ruled in’ by screening as needing a rehabilitation assessment, 86.0% went on to receive inpatient rehabilitation interventions. Of those ‘ruled out’ by screening, 92.1% did not go on to receive a rehabilitation intervention, while 7.9% did receive some form of rehabilitation intervention. Of all patients accepted into a rehabilitation programme (n=516), PReS was able to identify 53.6% (n=282) of them before the acute care teams made a referral (based on traditional criteria). In conclusion, we have designed and implemented a systematic, PReS service in one metropolitan Australian hospital. The process described was found to be time efficient and feasible to implement in an acute hospital setting. Further, it appeared to identify the majority of patients who went on to receive formal inpatient rehabilitation interventions.

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Oates, A. "524 QUALITY IMPROVEMENT PROJECT: INCORPORATING COMPREHENSIVE GERIATRIC ASSESSMENT INTO COMMUNITY HOSPITAL CLERKING." Age and Ageing 50, Supplement_2 (June 2021): ii8—ii13. http://dx.doi.org/10.1093/ageing/afab116.14.

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Abstract Elderly patients transferred to community hospitals often have complex medical, social, psychological, functional and pharmacological backgrounds that require careful assessment in order to create and deliver a high quality, patient-centred care plan. Unfortunately, time pressures experienced by staff in acute hospitals can make Comprehensive Geriatric Assessment (CGA) unfeasible for every patient. Moreover, junior members of the medical team may be unsure as to which aspects of a patient’s background and presentation constitute important elements of a CGA. Failure to recognise and document pertinent issues can lead to prolonged admissions, disjointed care and failed discharges. Admission to a community hospital presents a convenient ‘checkpoint’ in the patient’s hospital journey at which to undertake a CGA. Recording the relevant information in an effective clerking proforma when the patient is admitted ensures that this information is displayed clearly and in a way that is accessible to all members of the multidisciplinary team. The pre-existing clerking proforma at Amersham Community Hospital omitted several important elements of CGA (such as examination of feet and gait, assessment of mood, FRAX-UK score, creation of a problem list etc.) The aim of this quality improvement project was to create a thorough, yet user-friendly and time-efficient clerking proforma which incorporated the important components of CGA. Using BGS guidance and NICE quality standards, alongside suggestions from the medical team, the existing clerking proforma was adapted and reformed. After one month, feedback from the team was used to further improve the clerking proforma, ensuring that it was user-friendly, whilst meeting the standards set out by NICE and BGS. This was repeated as part of a second PDSA cycle. The improved clerking proforma enables junior doctors to undertake a thorough and holistic assessment, promoting efficient detection of issues and the delivery of a higher quality of care.

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Lovell, Ben, and Timothy Cooksley. "Editorial Volume 17 Issue 4 – Assessing, treating and prognosticating from the front door." Acute Medicine Journal 17, no. 4 (October 1, 2018): 174–76. http://dx.doi.org/10.52964/amja.0727.

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In our daily working lives, acute physicians strive to provide the best holistic care to our patients from the moment they arrive in hospital. Experienced healthcare professionals develop a gut feeling (generally recognised as the nagging internal voice of professional experience) about patients who may be more unwell than appearances suggest, or who may deteriorate despite showing signs of physiologically compensating quite well. The papers in this issue challenge us to examine how we prioritise, prognosticate and risk-stratify the patients we treat in acute medicine, how we remain cognisant and skilled in treating patients with more unusual acute medical conditions, and how we allocate resources in the NHS. There are many reasons for a patient to re-attend the Emergency Department (ED) in the days following a discharge. In the UK, these unplanned re-attendances are measured as a quality indicator, implying that patient’s return to the ED is due to a deficiency in the quality of their care. In this issue, Ludwig et al challenge this simplistic view by exploring the reasons why patients to come back to the ED and describe how these re-attendances can be ascribed to factors related either to the patient, the physician or the illness itself. Is there a reliable way to predict mortality and likelihood to require critical care at the point of admission? Two papers in this issue cover the subject of prognostication in acute medicine. Most acute medics are wary of transplanting illness-severity metrics from other disciplines and installing indiscriminately them in the ED and AMU. However, Holm and Brabrand have established that the Sequential Organ Failure Assessment (SOFA) score, a longtime staple of the Intensive Care Unit (ICU), can predict deterioration and death with acceptable accuracy in acute medical patients. This suggests that the SOFA score may inform treatment escalation plans and patient prioritisation at the ‘front door’. Bindraban et al have used the haematological indices of the full blood count develop an understanding of how front line tests may predict the patient journey. Whilst common sense suggests that those with the most abnormal blood test results at admission have worse outcomes, this paper quantifies and elaborates the relationship between the results on the computer screen and the patient in the hospital bed. When Grenfell Tower blazed in June 2017, the nearby AMUs cleared their beds as best they could and stood by to receive patients suffering with smoke-related injuries. Occurrences such as this remind us that the acute physician must be up to date with rare but important medical emergencies. In their review, Björkbom and Brabrand highlight the phenomenon smoke inhalation injury, and advise us that the period of in-patient observation should be slightly longer than we realise. “The most intense spending on acute health care in a lifetime occurs in the last few months of life”; from this statement Jones and Kellett lay out their argument that local mortality rates should inform and influence local healthcare spending. In an article that should provoke debate, they suggests significant adjustments in how financial resources are allocated, and how a national death registry could impact upon how the NHS spends its money.

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Prato, Laura, Lyndsay Lindley, Miriam Boyles, Louise Robinson, and Clare Abley. "Empowerment, environment and person-centred care: A qualitative study exploring the hospital experience for adults with cognitive impairment." Dementia 18, no. 7-8 (February 7, 2018): 2710–30. http://dx.doi.org/10.1177/1471301218755878.

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It is acknowledged that there are many challenges to ensuring a positive hospital experience for patients with cognitive impairment. The study (‘Improving hospital care for adults with cognitive impairment’) aimed to explore the positive and negative experiences of older adults with cognitive impairment (dementia and delirium) and their relatives and/or carers, during an acute hospital stay, from admission to discharge, using a qualitative, case study methodology. Six participants with cognitive impairment, eight relatives and 59 members of the health care team were recruited. Data was collected via ethnographic, observational periods at each stage of the hospital journey and through the use of semi-structured interviews with relatives, carers and health care staff including: medical staff; nursing staff; physiotherapists and ward managers. Interpretive phenomenological analysis was used to facilitate data analysis. 52 hours 55 minutes of ethnographic observations and 18 interviews with ward staff and relatives were undertaken. Three superordinate themes emerged from the data as crucial in determining the quality of the hospital experience: valuing the person; activities of empowerment and disempowerment and the interaction of environment with patient well-being. Whether the patient’s hospital experience was positive or negative was powerfully influenced by family involvement and ward staff actions and communication. Participants identified a requirement for a ward based activity service for patients with cognitive impairment. Further research must be undertaken focusing on the development of ward based activities for patients with cognitive impairment, alongside a move towards care which explores measures to improve and expand relative involvement in hospital care.

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Zingela, Zukiswa, Louise Stroud, Johan Cronje, Max Fink, and Stephanus van Wyk. "Protocol for a prospective descriptive prevalence study of catatonia in an acute mental health unit in urban South Africa." BMJ Open 10, no. 11 (November 2020): e040176. http://dx.doi.org/10.1136/bmjopen-2020-040176.

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IntroductionCatatonia arises from serious mental, medical, neurological or toxic conditions. The prevalence range depends on the setting and the range is anything from 7% to 63% in other countries. South African prevalence rates are currently unknown. The proposed study is a quantitative descriptive study using the Bush Francis Catatonia Screening Instrument as a screening tool with a data capturing information sheet to extract clinical information from patient folders. The study will investigate: (1) prevalence of catatonia, (2) clinical and demographic correlates associated with catatonia, (3) predictors of catatonia, (4) response to treatment and (5) subjective experience of catatonia.Methods and analysisThe setting is an acute mental health unit (MHU) within a regional, general medical hospital in Nelson Mandela Bay, South Africa, which accepts referrals from within the hospital and from outlying clinics. Participants will be recruited from inpatients in the MHU from beginning of September 2020 to end of August 2021. Most admissions are involuntarily, under the Mental Health Care Act of 2002 with an age range of 13 to over 65 years. Participants who screen positive for catatonia will be followed up after discharge for 3 months to measure outcomes. Primary outcomes will include the 12-month prevalence rate of catatonia, descriptive and other data on presentation and assessment of catatonia in the MHU. Secondary outcomes will include data on treatment response, participants’ report of their subjective experience of catatonia and predictors of catatonia. Descriptive statistics, multivariate binomial logistic regression and univariate analyses will be conducted to evaluate associations between catatonia and clinical or demographic data which could be predictors of catatonia. Survival analysis will be used to examine the time to recovery after diagnosis and initiation of treatment. The 95% CI will be used to demonstrate the precision of estimates. The level of significance will be p≤0.05.Ethics and disseminationThe study has received ethical approval from the Research and Ethics Committees of the Eastern Cape Department of Health, Walter Sisulu University and Nelson Mandela University. The results will be disseminated as follows: at various presentations and feedback sessions; as part of a PhD thesis in Psychology at Nelson Mandela University; and in a manuscript that will be submitted to a peer-reviewed journal.

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Ribbink, Marthe E., Janet L. Macneil-Vroomen, Rosanne van Seben, Irène Oudejans, and Bianca M. Buurman. "Investigating the effectiveness of care delivery at an acute geriatric community hospital for older adults in the Netherlands: a protocol for a prospective controlled observational study." BMJ Open 10, no. 3 (March 2020): e033802. http://dx.doi.org/10.1136/bmjopen-2019-033802.

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IntroductionHospital admission in older adults with multiple chronic conditions is associated with unwanted outcomes like readmission, institutionalisation, functional decline and mortality. Providing acute care in the community and integrating effective components of care models might lead to a reduction in negative outcomes. Recently, the first geriatrician-led Acute Geriatric Community Hospital (AGCH) was introduced in the Netherlands. Care at the AGCH is focused on the treatment of acute diseases, comprehensive geriatric assessment, setting patient-led goals, early rehabilitation and streamlined transitions of care.Methods and analysisThis prospective cohort study will investigate the effectiveness of care delivery at the AGCH on patient outcomes by comparing AGCH patients to two historic cohorts of hospitalised patients. Propensity score matching will correct for potential population differences. The primary outcome is the 3-month unplanned readmission rate. Secondary outcomes include functional decline, institutionalisation, healthcare utilisation, occurrence of delirium or falls, health-related quality of life, mortality and patient satisfaction. Measurements will be conducted at admission, discharge and 1, 3 and 6 months after discharge. Furthermore, an economic evaluation and qualitative process evaluation to assess facilitators and barriers to implementation are planned.Ethics and disseminationThe study will be conducted according to the Declaration of Helsinki. The Medical Ethics Research Committee confirmed that the Medical Research Involving Human Subjects Act did not apply to this research project and official approval was not required. The findings of this study will be disseminated through public lectures, scientific conferences and journal publications. Furthermore, the findings of this study will aid in the implementation and financing of this concept (inter)nationally.Trial registration numberNL7896; Pre-results.

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O’Dell, Thomas, Anjali Zalin, and Louella Vaughan. "The Challenges of Conducting Research on the Acute Medical Unit." Acute Medicine Journal 15, no. 4 (October 1, 2016): 212–14. http://dx.doi.org/10.52964/amja.0639.

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Conducting research on the Acute Medical Unit (AMU) poses unique challenges; the environment is one that sees a diverse range of patient groups and pathologies and holds the potential for easy patient recruitment to research studies, however is geared towards a specific set of triage and discharge goals. We conducted a study into Stress Hyperglycaemia (SH) on a busy AMU, which involved profiling glycaemic changes using specialist equipment and interventions in patients with unscheduled medical admissions, and experienced a number of challenges. This article discusses these challenges and proposes potential solutions. Conducting research on a busy AMU was complicated by factors including rapid patient and staff turnover, the differing goals of the AMU system and suboptimal staff engagement in labour intensive research. We endeavored to follow patients up in further visits after discharge but found they lacked engagement after the resolution of the acute illness requiring initial admission. In this article, we discuss these issues in more detail and suggest approaches for future AMU researchers.

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Roberts, Debra E., Robert G. Holloway, and Benjamin P. George. "Post-acute care discharge delays for neurology inpatients." Neurology: Clinical Practice 8, no. 4 (July 16, 2018): 302–10. http://dx.doi.org/10.1212/cpj.0000000000000492.

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BackgroundHospital stays for patients discharged to post-acute care are longer and more costly than routine discharges. Issues disrupting patient flow from hospital to post-acute care facilities are an underrecognized strain on hospital resources. We sought to quantify the burden of medically unnecessary hospital days for inpatients with neurologic illness and planned discharge to post-acute care facilities.MethodsWe conducted a retrospective evaluation of hospital discharge delays for patients with neurologic disease and plans for discharge to post-acute care. We identified 100 sequential hospital admissions to an academic neurology inpatient service that were medically ready for discharge from December 4, 2017, to January 25, 2018. For each patient, we quantified the number of medically unnecessary hospital days, or all days in the hospital following the determination of medical discharge readiness.ResultsAmong 100 patients medically ready for discharge with plans for post-acute care disposition (47 female, mean age 72.5 years, mean length of stay 12.3 days), 50 patients were planned for discharge to skilled nursing, 37 to acute rehabilitation, 10 to hospice/palliative care, and 3 to other facilities. There was a total of 1,226 patient-days, and 480 patient-days (39%) occurred following medical readiness for discharge. Medically unnecessary days ranged from 0 to 80 days per patient (mean 4.8, median 2.5, interquartile range 1–5 days).ConclusionUnnecessary hospital days represent a large burden for patients with neurologic illness requiring post-acute care on discharge. These discharge delays present an opportunity to improve hospital-wide patient flow.

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Lamsal, Daya Ram. "Acute Pesticide Poisoning: Review of Patients Attending at Emergency Department in Chitwan Medical College." Journal of Chitwan Medical College 3, no. 1 (August 22, 2013): 62–64. http://dx.doi.org/10.3126/jcmc.v3i1.8469.

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To find out the hospital based incidence, pattern and fatality of acute pesticide poisoning which may be helpful to develop better management strategy and preventive campaign. A total of 88 patients were reported in emergency with acute pesticide poisoning out of 178 total acute poisoning cases resulting in APP rate 49.43% of total poisoning cases. Male: Female ratio was 1:1.5. The age group specific incidence of acute poisoning showed 7.95% in 0-14 years, 45.55% in 15-29 years 30.68% in 30-44 years and 12.50% in 45-59 years and3.40% in 60 years and above. Out of 88 patients 79.55% admitted,20.45% of patient status was unknown as these patients were referred or refused admission. lost follow up .Among admitted patients 8.57% died and 91.43% dischared from hospital. Maximum case fatality ratio (28.57%) was due to endosulfan poisoning. Pesticide is responsible in 49.43% of all poisoning patients visiting to emergency department with the mortality of 6.80% among pesticide poisoning, Women have high morbidity but man predominantly exceeds on mortality rate.. Highest case fatality observed among the endosufan exposed group. How patients are getting such toxic poisons and why these victims are being exposed needs further study. Emphasis on case management and preventive campaigns would have some impact in reducing morbidity and mortality from acute pesticide poisoning. Journal of Chitwan Medical College 2013; 3(1): 62-64 DOI: http://dx.doi.org/10.3126/jcmc.v3i1.8469

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Andraweera, Nalinda, and Richard Seemann. "Acute rehospitalisation during the first 3 months of in-patient rehabilitation for traumatic brain injury." Australian Health Review 40, no. 1 (2016): 114. http://dx.doi.org/10.1071/ah15062.

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Objective Unplanned re-admission to acute care hospitals during in-patient rehabilitation causes disruption to the rehabilitation program and increases the cost of health care. The aims of the present study were to identify the frequency, reasons and duration of disruption to rehabilitation because of acute re-admissions during the first 3 months of in-patient rehabilitation for traumatic brain injury (TBI) and to investigate the correlation between the duration of acute rehospitalisation and the discharge functional independence measure (FIM) score. Methods A retrospective study was conducted on patients admitted for in-patient rehabilitation following TBI to a rehabilitation hospital in Auckland, New Zealand, between January 2009 and August 2013. Data on duration and reasons for acute rehospitalisation, as well as admission and discharge FIM scores, were obtained from electronic patient records. Pearson correlation was used to evaluate the relationship between the duration of acute rehospitalisation and the discharge FIM score. Results Of the 628 patients admitted for brain injury rehabilitation, 71 (11.3%) required acute rehospitalisation within the first 3 months. The main reasons for acute rehospitalisation were preventable medical causes (43.8%), including urinary tract infections, respiratory tract infections and coronary artery disease. Of the acute re-admissions, 76.6% were within the first month of admission to the rehabilitation centre and 46.6% needed in-patient treatment in the acute care hospital for >5 days. There was a moderately strong negative correlation between the duration of stay in the acute care hospital and the discharge FIM score (r = – 0.412; P = 0.0005). Conclusion A significant number of patients admitted for in-patient rehabilitation following TBI require acute rehospitalisation due to preventable medical causes. Because the duration of acute rehospitalisation has a negative impact on rehabilitation functional gain, preventive measures and surveillance need to be further investigated and optimised. What is known about the topic? The incidence of acute rehospitalisation of patients in the community following brain injury rehabilitation is 20%–25%, with approximately half the re-admissions being for elective reasons, including orthopaedic and reconstructive surgery. What does this paper add? Unplanned acute rehospitalisation during first 3 months of in-patient rehabilitation following TBI is due to preventable causes and results in lower FIM scores on discharge. What are the implications for practitioners? An uninterrupted rehabilitation programme is vital for achieving functional outcomes.

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O'Brien, Lauri, Jane Bassham, and Melissa Lewis. "Whiteboards and discharge traffic lights: visual management in acute care." Australian Health Review 39, no. 2 (2015): 160. http://dx.doi.org/10.1071/ah14131.

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Flinders Medical Centre was experiencing issues with timely discharge and knowing the potential discharges and in-patient bed capacity for the next day. This case study describes the application of ‘visual management’ theory to discharge processes. The solutions developed were ‘patient journey boards’ and ‘discharge traffic lights’. The implementation of these visual management systems has enabled the hospital to improve its discharge processes. What is known about the topic? Communication is critical to the delivery of safe patient care. There is little in the literature on the use of visual management principles and techniques in healthcare. What does the paper add? This paper provides a brief overview of visual management principles and gives two case study examples showing the development and implementation of visual management systems in an acute hospital setting to promote safe and efficient patient care. What are the implications for practitioners? Practitioners can learn visual management principles and how these have been applied to an acute healthcare context.

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Dixon, Mandy, Emma Robertson, Mohan George, and Femi Oyebode. "Risk factors for acute psychiatric readmission." Psychiatric Bulletin 21, no. 10 (October 1997): 600–603. http://dx.doi.org/10.1192/pb.21.10.600.

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A retrospective case note study explored readmissions to an acute psychiatric in-patient unit within six months of discharge. The study aimed to calculate a hospital readmission rate, to investigate the timing of readmissions, and to identify risk factors associated with readmission. The readmission rate was 27% with the majority of readmissions occurring within three months after discharge, suggesting the need for investigation of such early readmissions. The three factors found to predict readmission were: discharge against medical advice, number of previous admissions, and living alone or with family rather than in care. Implications for hospital service planning are considered.

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Muir, A., and S. Paul. "An audit of medical and nursing records of 100 emergency short-term (< 7 dys) psychiatric admissions to acute adult wards in Dumfries." European Psychiatry 26, S2 (March 2011): 748. http://dx.doi.org/10.1016/s0924-9338(11)72453-1.

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IntroductionThe study population is served by CMHTs and in addition (in one sector) by a Crisis and Home Treatment Team.ObjectivesTo evaluate the recorded admission and discharge processes in the medical and nursing notes.To record relevant clinical characteristics of the admission and the patient.AimsTo assess recorded admission and discharge processes against standards defined in the protocol.MethodsA random sample of 100 records, which met inclusion criteria, was selected. A protocol evaluating the recorded processes, and relevant information re the admission was completed by psychiatric trainees and senior nurses.Results51% of admissions occurred on week-ends and 58% occurred “out of hours”. In 35% of admissions a further admission had occurred within 4 weeks. 34% of admissions derived from 2 areas, highly correlated with deprivation. Alcohol or drug misuse contributed to 69% of admissions. In 77% of admissions, the patient was known to the service. 10% of patients had a diagnosis of major mental illness.Recorded medical and nursing assessments of admission were incomplete i.e. 66% of medical records and 80% of nursing records. Assessment of discharge records indicated similar failings in record -keeping.ConclusionsThe recurrent pattern of admissions(33%), the association with deprivation(34%) and drug or alcohol misuse(69%), indicate the need for more effective management of these patients. The failings in recording admission and discharge information are significant. Improvements in these processes could identify those patients who require additional support and /or are at risk of futher admissions.

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Peterson, Lance R., Marc O. Wright, Jennifer L. Beaumont, Vanida Komutanon, Parul A. Patel, Donna M. Schora, Bryan H. Schmitt, and Ari Robicsek. "Nonimpact of Decolonization as an Adjunctive Measure to Contact Precautions for the Control of Methicillin-Resistant Staphylococcus aureus Transmission in Acute Care." Antimicrobial Agents and Chemotherapy 60, no. 1 (October 12, 2015): 99–104. http://dx.doi.org/10.1128/aac.02046-15.

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ABSTRACTThis was an observational study comparing methicillin-resistantStaphylococcus aureus(MRSA) transmission with no decolonization of medical patients to required decolonization of all MRSA carriers during two consecutive periods: baseline with no decolonization of medical patients (16 months) and universal MRSA carrier decolonization (13 months). The setting was a one-hospital, 156-bed facility with 9,200 annual admissions. Regression models were used to compare rates of MRSA acquisition. The chi-square test was used to compare event frequencies. We used rates of MRSA clinical disease as an outcome monitor of the program. Analysis was done on 15,666 patients who had admission and discharge tests; 27.9% of inpatient days were occupied by a MRSA-positive patient (colonized patient-days) who received decolonization while hospitalized during the baseline period (this 27.9% represented those who had planned surgery) compared to 76.0% during the intervention period (P< 0.0001). The rate of MRSA transmission was 97 events (1.0%) for 9,415 admissions (2.0 transmission events/1,000 patient-days) during baseline and was 87 (1.4%) for 6,251 admissions (2.7 transmission events/1,000 patient-days) during intervention (P= 0.06; rate ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00). The MRSA nosocomial clinical disease rate was 5.9 infections/10,000 patient-days in the baseline period and was 7.2 infections/10,000 patient-days for the intervention period (rate ratio, 0.82; 95% CI, 0.46 to 1.45;P= 0.49). Decolonization of MRSA patients does not add benefit when contact precautions are used for patients colonized with MRSA in acute (hospital) care.

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Hammond, Drayton A., Melanie N. Smith, Kristen C. Lee, Danielle Honein, and April Miller Quidley. "Acute Decompensated Heart Failure." Journal of Intensive Care Medicine 33, no. 8 (September 16, 2016): 456–66. http://dx.doi.org/10.1177/0885066616669494.

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Heart failure (HF) is a societal burden due to its high prevalence, frequent admissions for acute decompensated heart failure (ADHF), and the economic impact of direct and indirect costs associated with HF and ADHF. Common etiologies of ADHF include medication and diet noncompliance, arrhythmias, deterioration in renal function, poorly controlled hypertension, myocardial infarction, and infections. Appropriate medical management of ADHF in patients is guided by the identification of signs and symptoms of fluid overload or low cardiac output and utilization of evidence-based practices. In patients with fluid overload, various strategies for diuresis or ultrafiltration may be considered. Depending on hemodynamics and patient characteristics, vasodilator, inotropic, or vasopressor therapies may be of benefit. Upon ADHF resolution, patients should be medically optimized, have lifestyle modifications discussed and implemented, and medication concierge service considered. After discharge, a multidisciplinary HF team should follow up with the patient to ensure a safe transition of care. This review article evaluates the management options and considerations when treating a patient with ADHF.

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Brand, Caroline A., Catherine T. Jones, Adrian J. Lowe, David A. Nielsen, Carol Roberts, Bellinda A. L. King, and Donald A. Campbell. "A transitional care service for elderly chronic disease patients at risk of readmission." Australian Health Review 28, no. 3 (2004): 275. http://dx.doi.org/10.1071/ah040275.

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Background: Multiple hospital admissions, especially those related to chronic disease, represent a particular challenge to the acute health care sector in Australia. Objective: To determine whether a nurse-led chronic disease management model of transitional care reduced re admissions to acute care. Design: A quasi-experimental controlled trial. Setting: A large tertiary metropolitan teaching hospital. Participants: 166 general medical patients aged >65 years with either a history of re admissions to acute care or multiple medical comorbidities. Intervention: Implementation of a chronic disease management model of transitional care aimed at improving patient management and reducing readmissions to acute care. Main outcome measures: Readmission rates and emergency department presentation rates at 3-and 6-month follow up. Secondary outcome measures include quality of life, discharge destination, and primary health care service utilisation. Results: There was no difference in readmission rates, emergency department presentation rates, quality of life, discharge destination or primary health care service utilisation. The difficulties inherent in evaluating this type of multifactorial intervention are discussed and consideration is given to patient factors, the difficulty of influencing readmission rates, and local system issues. Conclusion: The outcomes of this study reflect the tension that exists between implementing multifaceted integrated health service programs and attempting to evaluate them within complex and changing environments using robust research methodologies.

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Roseveare, Chris. "Editorial Volume 15 Issue 3." Acute Medicine Journal 15, no. 3 (July 1, 2016): 110. http://dx.doi.org/10.52964/amja.0619.

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Acute Medicine is full of ‘C-words’ – the Nursing and Midwifery Council’s ‘Six Cs’ (Care, Compassion, Competence, Commitment, Courage and Competence) are as relevant on the AMU as anywhere else in the Health Service; acute physicians would probably also include co-ordination, collaboration and crisis management, as winter looms before us. Dan Beckett’s paper from Forth Valley in Scotland, suggests another word that should be added to the list. As we strive to design sustainable rotas which span 7 days and comply with European work-time directives it is understandable that continuity often falls by the wayside, particularly in smaller Units. The transition from the acute medicine team to an in-patient specialist ward will usually, and appropriately, require hand-over of care. However, as described in this paper, patients who remain within the AMU may find that they see a different consultant each day. Moving to a model whereby patients in the AMU remained under the care of the admitting consultant was shown to shorten their AMU length of stay, facilitating transfer to the appropriate in-patient team, although not increasing the proportion of patients discharged directly from the unit. The authors proposed that this latter finding related to changes in the skill mix of the consultant team covering the AMU, demonstrating the complexity of the challenges we face. It would have been interesting to study the impact on patient satisfaction – as well as consultant job satisfaction – from this new model; my own, purely anecdotal data, suggests both may be considerably improved. This month’s case report selection illustrates some interesting clinical conundrums. Lower limb cellulitis is a common reason for presentation to the acute medical, or ambulatory care unit; however, when the rash or erythema is bilateral, there is often an alternative diagnosis. In the case described by Cranga and colleagues, antibiotics turned out be the cause (rather than the solution) to the problem. Early liaison with the dermatology team enabled the diagnosis of acute generalized erythematous pustulosis to be made, and resolution of the condition followed discontinuation of antibiotics. The authors include a useful table to support clinicians in making this (albeit rare) diagnosis. Emily McNicholas reminds us of the importance of a collateral history – it is not hard to see how a patient with fever, confusion and incontinence might be labelled as having a urinary tract infection; the retrospective story of a cocktail stick in the throat prior to onset of the symptoms might have pointed to the correct diagnosis is this had been obtained at the time of admission. This case also shows the dangers of separation of Emergency Department notes from those of hospital in-patients, even within the same organization – a problem which will be familiar to many UK readers of this journal. Patients with frailty represent a significant proportion of admissions to the acute medical take and often provide considerable management challenges. Natalie Offord and colleagues from the British Geriatric Society have described the development of the Frailsafe collaborative which clearly provides a major step forward. At the other end of the age spectrum, adolescents and young adults (AYAs) may represent a different kind of challenge for the acute medicine team. Some of the key messages from the recent Royal College of Physicians’ Acute Care Toolkit for AYAs are summarized in the article on p157. Anyone who is involved in managing this group of patients is recommended to read this article, and please look out for the link to a survey about this at the end of the article.

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Kafle, Dilli Ram, and Surendra Shah. "Outcome of Patients with Gullain Barre syndrome at Tertiary Care Hospital in Eastern Nepal." Journal of Nobel Medical College 6, no. 2 (April 5, 2018): 20–24. http://dx.doi.org/10.3126/jonmc.v6i2.19565.

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Background: Gullain Barre syndrome is the most common cause of acute flaccid paralysis. Early diagnosis and treatment improves survival in patients with Gullain Barre Syndrome.Material and Methods: The purpose of the study was to note the common clinical features and identify predictors of outcome in Patients with Gullain Barre Syndrome. It is a prospective study which was conducted at Nobel Medical College Teaching Hospital from April 2015 to March 2016.Results: Time between onset of symptoms, presentation to hospital and admission was 5 ± 4 days. Four Patients (20%) gave history of upper respiratory tract infections and 12 (60%) had diarrhoea. Limb weakness was the most common symptom, which was documented in 20 (100%) patients. Other common symptoms were limb paresthesia, limb pain, and bladder dysfunction. Cerebrospinal Fluid protein was raised in 16(80%) patients to more than 45 mg/dl. All of our patients had CSF cell count less than 10. One (5%) patient had normal nerve conduction study initially. Eight (40%) patients had axonal (AMAN) variant of GBS, 3(15%) had AMSAN variant of GBS, while 8(40%) had demyelinating neuropathy (AIDP). The mean duration of hospital stay was7.4 ±2.7 days. Three months after hospital discharge 12(60%) patients achieved complete recovery. Eight (40%) patients still needed some support with ambulation. Predictors of worse outcome were old age, rapid progression of disease and AMSAN variant of GBS.Conclusion: Gullain Barre syndrome is an important cause of acute flaccid paralysis in children and adults. Early diagnosis is based on history of symmetrical limb weakness, CSF Findings and nerve conduction study. Majority of patients improve with supportive care while some develop respiratory failure and needs mechanical intubation. Journal of Nobel Medical College Volume 6, Number 2, Issue 11 (July-December, 2017) Page:20-24

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Randles, Mary, Sylvia Hickey, Susanne Cotter, Carmel Walsh, Kieran O'Connor, Catherine O'Sullivan, Keith McGrath, et al. "144 The Use of a Multidisciplinary Team Discharge “Huddle” to Improve Patient Flow and Planning." Age and Ageing 48, Supplement_3 (September 2019): iii1—iii16. http://dx.doi.org/10.1093/ageing/afz102.30.

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Abstract Background Patient flow, the movement of patients is an integral part of the patient care pathway. With the goal of improving overall patient care and discharge planning, a hospital wide, multidisciplinary team based, patient discharge meeting or ‘HUDDLE’ was devised with the goal of facilitating onward care planning for all inpatients especially those with complex discharge needs in a city centre teaching hospital. Methods The patient flow huddle has evolved to include a Patient Flow Clinical Nurse Manager, Bed Manager, Medicine for Older Persons Clinical Nurse Specialist, Physiotherapist/Occupational Therapist, Consultant Geriatrician and Geriatric Medicine Registrar. Each team in the hospital are requested to attend at least twice a week. Predicted discharge dates are established. Teams discuss patients who have a requirement for rehabilitation, either short-term or complex rehabilitation and patients over 65 years who may need review from Older Persons Services .We sought to optimise issues including housing, home care packages, interim home supports, community intervention team referrals, integrated care and Nursing Home Support Scheme applications. Results There were 3918 Emergency Department presentations by adults over 75 in 2018 and 2113 admissions (3704, 2081 respectively in 2017). Accuracy for discharge within one day of PDD ranged from 52.5% (Jan) to 72.6 % (Nov). The average length of stay was 6.2days (SD 0.47). 172 patients (84 female, 88 male) were admitted for slow stream rehabilitation (median length of stay 30 days). Conclusion Rather than using a negative view of older adults as potential ‘bed blockers’, the discharge huddle allowed a pro-active approach to assist medical and surgical teams in the management and re-enablement of patients with complex care needs. Early identification of such patients with complex care and discharge needs allowed greater focus on appropriate planning earlier in the patient’s hospital journey.

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Murray, M., P. L. Padfield, and S. R. J. Maxwell. "Does a Hospital Formulary Influence Prescribing Practice in an Acute Medical Admissions Unit?" Scottish Medical Journal 50, no. 2 (May 2005): 76–79. http://dx.doi.org/10.1177/003693300505000212.

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Aim: To assess the extent to which prescribing of cardiovascular medications in a busy medical unit deviates from the local joint primary and secondary care drug formulary guidelines. Method: A retro spective audit of the case notes, prescription charts and discharge summaries oj 150 randomly selected emergency medical admissions overa 4 month period. Results: No patient receiving a non-formulary cardiovascular drug on admission had the choice reviewed in line with formulary recommendations. One third of new cardiovascular medications commenced in hospital were not compliant with formulary recommendations. Decisions about drug therapy were rarely justified in the written hospital record. Conclusions: Our results demonstrate that in a busy acute medical admissions' unit there is a clear jailure to amendor query non formulary prescribing at the time of admission and a tendency to exacerbate it during theinpatient period. This potentially undermines the purpose of a joint drug formulary as a guideline for safe, evidence-based and cost-effective prescribing.

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Lim, H. J., R. Robson, N. Alexander, R. Cunningham, D. Encisa, R. Jhurry, D. Owusu, and A. Remolan. "100 Frailty Hot Clinics: Rapid Cga and Speciality Diagnostics Reduces Rates of Hospitalisation and Re-Attendance." Age and Ageing 50, Supplement_1 (March 2021): i12—i42. http://dx.doi.org/10.1093/ageing/afab030.61.

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Abstract Introduction Acute hospitalisation is associated with an increased risk of progressive frailty, morbidity and subsequent institutionalisation. North Middlesex University Hospital is an Acute District General Hospital with over 550 attendances to A&E per day. Comprehensive Geriatric Assessment (CGA) is the gold standard approach for a holistic multi-disciplinary assessment (MDT) of frail patients. A rapid access daily hot clinic service for frail patients opened using quality improvement (QI) methodology to deliver rapid CGA focusing on admission avoidance and early supported discharge. Method 4 PDSA cycles were conducted. A process map identifying key moments in patient care was derived from time studies of the first 10 patients’ journeys. Patients were triaged through the Geriatrician “hotphone” for acute admissions into the Hot Clinic. Dedicated clinic and waiting rooms were placed on the acute frailty unit (Amber) staffed by a dedicated Consultant Geriatrician and Health Care Support Worker working with the Frailty Ward Clerk, Frailty Specialist Nurse, Therapies, specialities in-reach and same-day diagnostics. A shared clerking proforma and subsequent CGA Discharge Summary were completed and emailed to the referrer the same day. Qualitative and Quantitative feedback was gained from referrers, patients and relatives through a structured questionnaire. Metrics were gathered including rate of admissions, re-attendance and use of enhanced community services. Results From the first 48 Hot Clinic patients, there was a low 30-day re-attendance rate (17%—for unrelated reasons), low 30-day re-admission rates (4%) and low Did Not Attend rate (6%) for new referrals and high satisfaction scores for recommending the service (9-10/10) from patients, relatives and referrers. Conclusions Early rapid MDT can reduce re-attendances and re-admissions to hospital in frail patients. A streamlined patient journey can be delivered by frailty-trained staff and in a suitable environment. QI Methodology enables a structured measurable approach to development of the Acute Frailty Pathway.

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Temple, RM, and A. Donley. "The future hospital – implications for acute care." Acute Medicine Journal 13, no. 1 (January 1, 2014): 4–5. http://dx.doi.org/10.52964/amja.0330.

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Acute physicians are confronted daily by the relentless increase in clinical demand, inadequate continuity of care, breakdown in out of hours care and a looming crisis in the medical workforce. The scale and gravity of these factors, together with changes to patient’s needs relating to the ageing demography, were detailed in the RCP report published in September 2012 ‘Hospitals on the edge’. The top concern of RCP members and fellows was the lack of continuity of care, ahead of financial pressures and clinical staff shortages. Worryingly one in ten physicians stated they would not recommend their hospital to a family member, and a further 25% were ambivalent on this question. Concern about the provision of acute medical care is not confined to consultants and specialist registrars. Another RCP report, ‘Hospital workforce, fit for the future?’ (2013) highlighted that 37% of FT2s and CMTs considered the workload of the medical registrar on call ‘unmanageable’. The outcome of the Mid Staffs independent inquiry in February 2013 provided critical context for the launch of the Future Hospital Commission (FHC) report, which was launched seven months later in September. The report was met with an extremely positive response from patients, carers, NHS staff, healthcare leaders and politicians. Lancet Editor Richard Horton said that the Commission had ‘produced the most important statement about the future of British medicine for a generation.’ Secretary of State for Health Jeremy Hunt praised the report and its ‘buck stops here’ approach. The Daily Mirror even noted that the report was one of the few areas on which the government and the opposition could agree! ‘Future Hospital: caring for medical patients’ places the patient at the centre of healthcare. Organising healthcare delivery around the needs of the patient is at its heart and features extensively in the core principles and 50 recommendations. A series of unequivocal commitments were made to patients, on issues generating considerable patient concern: moving beds in hospital, quality of communication and arrangements to leave hospital. Patients and carers were represented in each of the Commission’s five work streams, led on the recommendations relating to building a culture of compassion and respect, and participated in launch of the report to the media. The primary focus of the FHC report is on the acute care of medical patients and the views of acute physicians were key to articulating these recommendations. However the report is clear that the solution to current acute pressures on hospitals and specifically in-patient pathways, lie across the whole health and social care system. Care must be delivered in the setting in which the patient’s clinical, care and support needs can best be met and not merely delegated to the acute hospital site. This inevitably means 7 day services in the community as well as in hospital and a consistent new level of “joined up care” with integration, collaboration and information sharing across hospital and all healthcare settings. In keeping with this the report highlights the urgent need to establish alternatives to hospital admission including the extensive use of ambulatory emergency care (AEC), the provision of secondary care services in the community and an expansion of intermediate care rehabilitation services. Many of the report’s recommendations arose from clinical staff devising innovative solutions to improve the quality of care and ameliorate clinical demand. The report showcased a range of case studies describing service developments and new patterns of care, innovations that would not have been possible without the leadership and sheer determination of physicians and their teams. Dr Jack Hawkins, Acute Physician in Nottingham Queen’s Medical Centre, described how analysis of performance data showing that 50% of acute medical patients were discharged within 15 hours, led to the starting vision for their new AEC service as “everyone is ambulatory until proven otherwise”. The case studies highlight the resources needed to implement service change and the supportive staff relationships and changes to working practices that underpin their success. The report describes the “acute care hub” as the focus of acute medical services, comprising colocation of the AMU, short stay wards, enhanced care beds and the AEC. Much of this echoes the front door configuration described by the acute medicine task force report in 2007 ‘Acute medical care: The right person, in the right setting, first time’. What the FHC adds are recommendations to co-locate AEC and a clinical co-ordination centre to provide clinicians with real time data on capacity in community-based services (rehabilitation and social services), and link to rapid access specialist clinics or community services to support pathways out of AEC and AMU. Recommendations to structure acute services to maximise continuity of care is a major theme. There should be sufficient capacity in the acute care hub to accommodate admitted patients who do not require a specialist care pathway and are likely to be discharged within 48 hours. This is supported by recommended changes to working practices of consultant led teams where they commit to two or more successive days working in the hub. This allows the consultant led team who first assess the patient in AMU to continue to manage them on the short stay ward through to their discharge – an approach familiar to acute physicians but which may be novel to GIM physicians assigned a single on call day. Striving to deliver continuity by a stable clinical team should also simplify handover, improve training, feedback and the quality and safety of the care delivered. The commission recommends designating enhanced care (level 1) and high dependency (level 2) beds in the acute care hub to improve the care of acutely ill patients requiring an increased intensity of monitoring and treatment. The RCP acute medicine taskforce made the same recommendation in 2007 but acute trusts have been slow to embed level 2 beds in particular, on AMUs. In the future hospital every effort should be made to enhance rapid access to specialist pathways that benefit patients, including entry to pathways for acute coronary disease or stroke or the frail elderly direct from the community or emergency department. Here the report is clear that the responsibility for continuity of care rests with the specialty consultant, who should review the patient on the day of admission. Patient experience should be valued as much as clinical effectiveness. Patients want “joined up care” that is tailored to their acute illness, comorbidities and requirements for social support. From a patient’s perspective, failures of information sharing between primary and secondary care, or specialist services within the same or neighbouring Trusts, are incomprehensible. The report highlights that this informatics disconnect undermines accurate clinical assessment at the time of presentation with an acute illness, when patients are most vulnerable, and this deficit will impact on patient experience, timely access to specialist staff, patient outcome and resource use. Robert Francis, in commenting on the report of the Mid Staffordshire public enquiry highlighted that the subject was ‘too important to suffer the same fate as other previous enquiries .. where after initial courtesy of welcome, implementation was slow or non existent’. The RCP shares this urgency and having accepted the recommendations of the FHC as a comprehensive ‘treatment’ for the care of patients in the future hospital, is determined that the FHC report itself will not sit on a shelf, gathering dust. The RCP is now embarking on a future hospital implementation programme. This programme gathers momentum this month with the appointment of future hospital officers and staff and the immediate priority is to identify partners to set up national development sites. The RCP is seeking enthusiastic clinical teams to investigate changes to a range of hospital and community based medical services in line with the FHC principles and to evaluate the impact on patient care. Over the next 3 years it is envisaged that the programme will also include research and new approaches to commissioning, workforce deployment, healthcare facility design and integrated working across the health economy. The evaluation of these projects, in relation to the quality and safety of patient care and patient experience, will be crucial and will be shared through the RCP and its partners. In addition, from April the RCP will publish a Future Hospital journal to help share the learning from the implementation programme and welcomes submissions of innovative best practice in acute care. The challenge now is to convert the goodwill generated by publication of the FHC principles, into an implementation programme nationally, that helps build an effective evidence base to support new ways of providing high quality, safe, patient care. Acute physicians are crucial partners in meeting this challenge.

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Draper, Brian. "The Elderly Admitted to a General Hospital Psychiatry Ward." Australian & New Zealand Journal of Psychiatry 28, no. 2 (June 1994): 288–97. http://dx.doi.org/10.1080/00048679409075641.

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In this retrospective study of 489 consecutive elderly admissions to a general hospital psychiatry ward, the main aim was to describe the stressors precipitating admission, psychiatric and medical diagnoses, physical treatments used, length of hospitalisation, and clinical and social outcome. Depression was the predominant diagnosis, with length of stay being correlated with depression severity. The main stressor associated with admissions was a change in medical status of the patient. At least two medical diagnoses were present in 70% of admissions, with many new physical illnesses being diagnosed. Significant improvement was found in 81% of admissions at discharge. Two thirds of admissions were discharged into independent living arrangements. While these outcomes suggested effective interventions, management difficulties were noted with the mix of elderly and young patients. It is recommended that acute psychogeriatric wards be developed in the general hospital and be located near geriatric medical wards.

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Dasta, Joseph F., David A. Kuhl, Olakunbi A. Agiri, and Laurie S. Mauro. "Beta-Agonists in the Treatment of Acute Exacerbation of Chronic Obstructive Pulmonary Disease." Annals of Pharmacotherapy 28, no. 12 (December 1994): 1379–88. http://dx.doi.org/10.1177/106002809402801209.

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OBJECTIVE: To critically evaluate the following issues regarding the use of beta-agonists in the treatment of acute exacerbations of chronic obstructive pulmonary disease (COPD): (1) optimal dose, (2) use of nebulizer (NEB) versus metered-dose inhaler-spacer devices (MDISs), (3) comparison with anticholinergic agents, and (4) use in mechanically ventilated patients. The patient populations addressed are limited primarily to emergency department (ED) and intensive care/acute care settings. DATA SOURCES: English-language journal articles published between 1977 and 1993. STUDY SELECTION: Nine studies were evaluated that included beta-agonists alone or in combination with other bronchodilators in the treatment of acute exacerbation of COPD. Many of the studies contained design flaws or were limited in size, making interpretation difficult. In studies containing both asthma and COPD patients, focus was restricted to analysis of COPD patients when possible. DATA EXTRACTION: Performed subjectively by the authors. Studies were evaluated for methodologic strengths and weaknesses. DATA SYNTHESIS: Dosing studies in patients with stable disease show a relationship between dose and the various pulmonary function tests (PFTs). Dose also correlates with duration of action and incidence of adverse effects. Four studies compared NEBs versus MDISs. Studies revealed significant improvement in PFTs for both treatments, with no significant difference between groups noted. Five studies compared various combinations of beta-agonists and ipratropium. Both ipratropium and beta-agonists caused statistically significant increases in PFTs from baseline. Combination therapy provided no further increase in spirometry compared with that of single-agent therapy. One study did report an early discharge from the ED with the addition of ipratropium. Most studies did not use large doses of beta-agonists or evaluate the effect of repeated doses. Many studies allowed concomitant therapy. Most did not include outcome measurements, such as ED length of stay, admission rates, hospital stay, or incidence of relapse. CONCLUSIONS: Dose—response studies in patients with stable disease suggest that doses of albuterol powder up to 1 mg may be tolerated safely, although use of repeated larger doses has not been well studied. Beta-agonists given by MDIS or NEB are equally effective in this setting. There is no apparent advantage to combined use of beta-agonist and ipratropium in the acute setting. Future research in this area should evaluate the use of larger or repeated doses of beta-agonists in the acute setting. Optimizing concurrent therapy and evaluating various patient outcomes should receive special attention in further investigations.

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Al-Bazz, Dalal, Fareeba Anwar, and Qaiser Javed. "Utilisation of mental health transfer checklist proforma from acute physical health hospitals (Liverpool University Hospitals NHS Foundation Trust) to mental health hospitals (Mersey Care NHS Foundation Trust)." BJPsych Open 7, S1 (June 2021): S307. http://dx.doi.org/10.1192/bjo.2021.812.

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AimsTesting the compliance and completion rate of a transfer checklist (proforma) created in accordance with local hospital policies.BackgroundThe proforma was developed following serious incidents where medically unstable patients were inappropriately discharged to mental health hospitals, requiring readmission to acute medical hospitals. Frequently these events reported an inadequate handover from medical to mental health teams and patients were often prematurely deemed medically fit with evidence to the contrary.Although parity of esteem between mental and physical health has been a high profile political issue in the UK since 2011, evidence indicates that parity is far from being achieved. This first ever checklist was designed to improve safety of patient transfer from acute physical health hospitals to mental health hospitals by ensuring patients are medically fit and better communication between the two trusts.MethodData were collected retrospectively over a six-month period between August 2018 and January 2019 and retrieved from patient notes available at relevant trusts. Electronic notes were obtained from medical wards, accident and emergency and Mersey Care electronic systems. Notes were specifically scrutinised for presence of the proforma, quality of completion and, number and reasons for readmission from mental health hospitals to acute physical health hospitals following their medical optimization. Readmissions were considered as admissions to physical health hospitals up to one month following discharge with evidence of ongoing concerns.Result6597 referrals were made to liaison services from Liverpool University Hospitals, of which 5–6 % were admitted to inpatient mental health units. 31% of admissions from Liverpool University Hospitals were readmitted to a physical health hospital within one month of discharge indicating inappropriate and unsafe discharges. Of all those readmitted, 10% had ongoing acute medical concerns prior to admission to a mental health hospital. The proforma was filled in 13% of admissions from Liverpool University Hospitals. None of the forms were fully complete.Conclusion10% of patient admissions to mental health hospitals were identified as inappropriate due to ongoing acute medical concerns. The proforma served as structured guidance and evidence of medical fitness at time of transfer. However poor compliance was observed, which could be secondary to lack of awareness of the proforma and inadequate dissemination of the policy. Findings were shared and discussed with the appropriate teams both in acute physical health and mental health hospitals and steps will be taken to raise awareness of the proforma before completing a second audit.

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Wilding, Daniel, and Kate Evans. "Predicting length of stay for acute medical admissions using the ALICE score: a simple bedside tool." Acute Medicine Journal 16, no. 2 (April 1, 2017): 60–64. http://dx.doi.org/10.52964/amja.0656.

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Background: Early identification of patients likely to have a short admission permits best use of limited resources to facilitate rapid discharge where possible. The ALICE score is a simple bedside tool developed in one hospital as a decision aid. This study sought to confirm its widespread applicability. Method: Retrospective review of 250 consecutive admissions at five acute hospitals. Clinical records were reviewed for a total of 1003 patients. ALICE score was calculated for each patient and compared to LoS data. Results: There was a statistically significant positive correlation between rising ALICE scores and increasing length of stay irrespective of final diagnoses. Conclusion: The ALICE score provides a simple bedside tool to predict length of stay.

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Hossain, Mohd Farid, Sailendra Nath Biswas, Masudur Rahman, Tanvir Ahmed, and Apu Karmaker. "Laparoscopic Cholecystectomy in Patients with Emphysematous and Gangrenous Cholecystitis: An Experience at Khwaja Yunus Ali Medical College & Hospital, Enayetpur, Sirajgonj." KYAMC Journal 5, no. 2 (April 27, 2017): 519–23. http://dx.doi.org/10.3329/kyamcj.v5i2.32366.

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Objective- To look for the feasibility and safety of laparoscopic cholecystectomy in patients with emphysematous and gangrenous cholecystitis.Back ground- Emphysematous and gangrenous cholecystitis are severe form of acute cholecystitis. They are considered as contraindication of laparoscopic cholecystectomy due to peri operative life threatening complications, surgical technical difficulties, frequent conversion to open procedure. This study describe our experience in terms of feasibility and safety with laparoscopic cholecystectomy in patients with emphysematous and gangrenous cholecystitis.Materials and methods- From January 2012 to December 2014,total 37 patients with clinical diagnosis of severe acute cholecystitis under went laparoscopic cholecystectomy within 72 hours of admission. Operative findings and histopathological reports were used to identify patients of emphysematous and gangrenous cholecystitis.Results- 35(94.59%)among 37 patient's laparoscopic cholecystectomy were performed successfully.29 case were emphysematous and 8 cases were gangrenous cholecystitis. Two patient's laparoscopic procedure were converted to open procedure due to various operative difficulties, of which the most common was distorted calot's triangle. Maximum operating time was up to 130 minutes(one case),Post operative major complications occurred in 2 cases(5.40%).maximum patients were discharged by 48 to72 hours. There was no mortality.Conclusion- laparoscopic cholecystectomy is feasible and safe in emphysematous and gangrenous cholecystitis. However the experience of the surgeon and his patience during surgery play key role in over all out come. Based on our experience we recommend an early laparoscopic cholecystectomy for these group of patients, provided expertise & gadgets are available.KYAMC Journal Vol. 5, No.-2, Jan 2015, Page 519-523

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Hasan, Md Mahboob, MA Baqui, Farzana Rahman, and Merajul Hasan. "Acute Large Bowel Obstruction Following Late Sequelae of Traumatic Diaphragmatic Hernia." Journal of Armed Forces Medical College, Bangladesh 15, no. 1 (August 20, 2020): 119–20. http://dx.doi.org/10.3329/jafmc.v15i1.48662.

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A 33 years old patient was admitted in a Military Hospital with the features of acute large gut obstruction. Exploratory laparotomy was done and peroperatively the obstruction was seen in the transverse colon and obstruction seemed to be carcinoma of transverse colon with involvement of left hemidiaphragm which was not negotiable. Transverse loop colostomy with decompression of bowel was done. Subsequently the patient was transferred to tertiary level hospital in Dhaka. In the tertiary hospital, the patient developed left sided massive pleural effusion. With relevant investigation the condition was diagnosed as left sided diaphragmatic hernia. Thoracotomy was done and herniorrhophy was performed after reduction of the content. Post-operative management was stormy and eventful but the condition improved gradually and the patient was discharged in proper time. The patient had history of chest trauma due to RTA he met 4 years back and he received hospital indoor management for 3½ months. The patient was asymptomatic and leading normal active military life before 2nd time admission for acute intestinal obstruction. The patient had past history of trauma to left chest wall 4 years back, presented with acute large gut obstruction and there was diagnostic dilemma. There were management difficulties and post operative events were stormy. The aim of this reporting is to highlight all of these. Journal of Armed Forces Medical College Bangladesh Vol.15 (1) 2019: 119-120

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Shammas, Nicolas W., Ryan Kelly, Jon Lemke, Ram Niwas, Sarah Castro, Christine Beuthin, Jackie Carlson, et al. "Assessment of Time to Hospital Encounter after an Initial Hospitalization for Heart Failure: Results from a Tertiary Medical Center." Cardiology Research and Practice 2018 (2018): 1–4. http://dx.doi.org/10.1155/2018/6087367.

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Background. Hospital inpatient readmissions for patients admitted initially with the primary diagnosis of heart failure (HF) can be as high as 20–25% within 30 days of discharge. This, however, does not include admissions for observations or emergency department (ED) visits within the same time frame and does not show a time-dependent hospital encounter following discharge after an index admission. We present data on time-dependent hospital encounter of HF patients discharged after an index admission for a primary diagnosis of HF. Methods. The study recruited patients from 2 hospitals within the same health system. 500 consecutive admissions with the ICD diagnosis of HF were reviewed by inclusion and exclusion screening criteria. The 166 eligible remaining patients were tracked for post hospital discharge encounters consisting of hospital admissions, observation stays, and ED visits. Only those with a primary diagnosis of heart failure were included. Demographics were recorded on all patients. Days until hospital inpatient readmissions or hospital encounters were displayed in Kaplan–Meier plots. Results. A total of 166 patients met inclusion criteria (mean age 79.3 years, males 54%). For the first 90 days following the index admission, there were a total of 287 follow-up visits (1.7 per patient), 1158 total hospitalization days (2.6 per visit, 7.0 per patient, and 8.6 per 100 days at risk), and 21 deaths (12.7%). At 30 days, 25% and 52% of patients had an inpatient readmission or a hospital encounter, respectively. The median time to inpatient readmission was 117 days and to hospital encounter was 27 days. Conclusion. Time-dependent excess days in acute care (unplanned inpatient admission, outpatient observation, and ED visit) rather than 30-day hospital inpatient readmission rate is a more realistic measure of the intensity of care required for HF patients after index admission.

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Waters, Ruairí, Robert Murphy, Edel Mannion, Laura Gaffney, Kate Donlon, Michelle Canavan, and Shaun T. O'Keeffe. "280 Acute Hospital Presentations among Nursing Home Residents: A Retrospective Observational Analysis." Age and Ageing 48, Supplement_3 (September 2019): iii1—iii16. http://dx.doi.org/10.1093/ageing/afz102.63.

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Abstract Background Nursing home residents are prone to acute illness due to their advancing age, underlying illnesses and immobility. The decision to refer a nursing home resident for acute hospital admission is a complex one, and there is no consensus among health care professionals about what constitutes an ‘appropriate admission’ to hospital from a nursing home. We aimed to explore patterns of acute nursing home patient presentations to the emergency department. Methods This was a retrospective cohort study of emergency hospital admissions to a tertiary university teaching hospital. Emergency admissions through the emergency department were included. Elective admissions, outpatient admissions, or inter-hospital transfers were excluded. Cases were validated by scrutiny of the patient medical records, and where possible an assessment of the Rockwood clinical frailty scale (CFS) was carried out. Results There were 126 nursing home residents who presented to ED over a two month period for emergency assessments. 87.3% (n=115) presented via ambulance. Just over half had a GP referral letter (53.2%). 72.3% of patients who presented to ED were admitted. 25.2% of patients were re-referred to ED within 30 days of hospital discharge. All patients were classified as frail. 21.3% of patients had died at the 90 day follow up mark. 66% of those with a CFS 8 or 9 died, in comparison to 16% of those with a CFS or either 6 or 7. Conclusion We noted high numbers of patients from nursing homes attending our emergency department. A very high proportion were admitted, along with a high number of subsequent re-presentations. Death rates were higher in those with more advanced frailty status. We would suggest advanced care planning and strategies to improve the patient experience. This study highlights the requirement for improved advance care planning in the nursing home setting. This is however a complex issue. Early discussion about end of life preferences with patients and family is required.

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Mahmood, Nazneen, Md Fazlur Rahman, Md Mostafizur Rahman, SM Hossain Shahid, and Md Mahmudur Ahman Siddiqui. "Acute Kidney Injury in Patients of Intensive Care Unit." Anwer Khan Modern Medical College Journal 8, no. 1 (February 19, 2017): 38–44. http://dx.doi.org/10.3329/akmmcj.v8i1.31656.

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Background: Acute Kidney Injury (AKI) is a common complication in patients admitted to the intensive care unit (ICU) and numerous causes are responsible for its development. The aim of the present study is to assess the incidence, risk factors, and outcome of patients who develop AKI in our ICU.Methodology: This study was conducted by the Department of Nephrology, Anwer Khan Modern Medical College Hospital (AKMMCH), a tertiary level center of Dhaka, during the period of January 2015 to December 2015. This is a Cross Sectional Descriptive type of Observational study on patients of Acute Kidney Injury (AKI) admitted to Intensive Care Unit (ICU) of AKMMCH.Result: A total number of 271 patients were admitted. Out of 271 patients, 59 (21.77%) patients with AKI who met our study requirements were included in the study and were evaluated. Among 59 patients 32 (54.23%) were males and 27 (45.77%) were females, with a male to female ratio of 1.19:1. The cause of admission were Diabetes mellitus with complication 11 (18.64%), Hepato-renal syndrome 10 (16.94%), Malignancy 7 (11.86%), Septicaemia 6 (10.18% ), Pneumonia 6 (10.18%), Intra-uterine death (IUD) 5 (8.48%) and others (Acute Myocardial Infarction, Non ST segment Elevated MI, Cerebro Vascular Disease, Gullain Burre Syndrome, Laparatomy, Type I and Type II Respiratory failure) 14 (23.72%). According to RIFLE's criteria most of the patients were from Injury group 32 (54.23%). Next to this, was Risk group 17 (28.83%) and in Failure, Loss and ESRD group were 7 (11.86%), 1(1.69%) and 2 (3.39%) accordingly. Regarding biochemical abnormality, mean Serum creatinine was 3.68 ± 2.15 and that of Urine output, HbA1C and HCO3 level ( in ABG ) were 4.57 ± 8.89, 6.91±1.4 and 17.14 ± 3.8 respectively. Out of 59 patients 10 (16.95%) needed Haemodialysis. According to RIFLE's criteria 7 (70%) were from Failure group, 1 patient from Loss group and 2 from ESRD group who received haemodialysis. 72.88% (43) patients improved, out of which 57.62% (34) got discharged from ICU after full recovery. 6.48% (4) patients expired and 3.38% (2) turned into ESRD and advised for regular haemodialysis.Conclusion: The incidence of AKI is high in patients admitted to ICU, and the development of AKI is associated with poor outcome and reduced survival. AKI significantly increases the duration of ICU stay, and this is likely to add to the healthcare burden. Age, gender or the presence of comorbidities do not appear to influence the incidence of AKI in our ICU patients.Anwer Khan Modern Medical College Journal Vol. 8, No. 1: Jan 2017, P 38-44

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Roseveare, Chris. "Editorial." Acute Medicine Journal 14, no. 1 (January 1, 2015): 2. http://dx.doi.org/10.52964/amja.0403.

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The use of early warning scores to monitor the condition of patients has been one of the biggest changes in hospital practice over the past decade. This journal has featured many papers evaluating different scoring systems for medical patients admitted to hospital in an emergency; as the mechanisms for measuring, recording and calculating these scores become more refined our ability to predict which patients will deteriorate and require higher dependency care has continued to improve. In this edition, a paper from Canada has highlighted the key importance of one component of most scoring systems. Using a weighted scoring system, the authors have identified respiratory rate as the most valuable independent predictor of patient outcome. For a large cohort of patients in Thunder Bay hospital, Ontario, respiratory rate provided a true ‘early warning’ sign of imminent deterioration – rising several days before a patient’s death, and falling for patients who survived. The authors comment that respiratory rate is often inaccurately recorded – perhaps a result of the lack of an electronic measurement device or time pressures on nursing staff combined with the need to count breaths over a one minute period. This may explain why a fall in blood pressure or rise in pulse is often perceived to be more important when reviewing the observation chart at the foot of a patient’s bed. However this paper provides strong evidence to demonstrate why variations in this this clinical sign should not be overlooked. Bed pressures in UK hospitals have regularly featured in news reports over recent months. The challenge of facilitating discharge for those patients who require increased social service support after they leave hospital has had a significant impact on our emergency departments and acute medical units. However, providing a safe and effective system of triage at the hospital ‘front door’ is also key element in improving patient flow on the AMU. Acute medicine consultants are increasingly becoming involved in identifying patients whose problem can be managed without hospital admission; the evaluation of consultant-led phone triage of medical referrals to Ipswich hospital over a 12 month period indicates that this is a cost-effective solution to reduce hospital admission. The benefit was greatest for referrals from general practitioners, for whom the authors comment that sharing of the burden of risk and uncertainty is a key component of the effectiveness of the consultant-led approach. Having provided a similar service in my own hospital over the past 15 years, I would share this view; the regular phone contact also enables building of relationships between senior primary and secondary care clinicians, which is crucial if we are going to improve integration of services in the future. Finally, hospital acquired pneumonia is generally something to be avoided – but may have proved to be serendipitous for the patient in one of this edition’s case reports. During the course of his prolonged hospital stay with back pain, an MRI scan of his brachial plexus revealed incidental consolidation in his left upper zone, prompting treatment with intravenous antibiotics. Surprisingly, this treatment resulted in a reduction in his analgesic requirements; this improvement, along with the development of a lower motor neurone 7th nerve palsy led the team to investigate the possibility of Lyme neuroborreliosis, which was confirmed by serological testing. Radicular back pain and cranial neuropathies are recognised complications of Lyme disease; acute physicians reading this article should remember this when faced with this unusual combination in the future.

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Abuzied, Yacoub, Hassan Maymani, Basim AlMatouq, and Oweida AlDosary. "Reducing the Length of Stay by Enhancing the Patient Discharge Process: Using Quality Improvement Tools to Optimize Hospital Efficiency." Global Journal on Quality and Safety in Healthcare 4, no. 1 (February 1, 2021): 44–49. http://dx.doi.org/10.36401/jqsh-20-27.

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ABSTRACT Introduction Delays in the discharging process can affect hospital efficiency. Improving patient flow in acute care hospitals is an essential issue that hospital management and research aim to achieve. Admission volume and LOS for hospitalized patients in the medical specialties department was examined at a tertiary care center in Riyadh, Saudi Arabia, to explore practical approaches to reduce the LOS. We aimed to identify and manage reasons for the delay in discharging patients from the medical specialties department at a tertiary care center in Saudi Arabia. Methods Admission and discharge data for hospitalized patients were collected from 2016–2018. In 2017, a FOCUS (find, organize, clarify, understand, select)–PDSA (plan, do, study, act) quality improvement method was used to improve the discharge processes, with specific measurable targets per year. The number of readmissions and mortality rates decreased significantly after the intervention was implemented, suggesting an improvement in the quality of treatment and the process of admission and discharge. Results Despite gradual increases in admissions from 2016 to 2018, the mean LOS decreased significantly between 2016 and 2018, from 9.16 to 7.47 days (p < 0.001). The number of readmissions and mortality rates decreased after the intervention was implemented in 2017, suggesting an improvement in the process of admission and discharge. Conclusion The LOS can be reduced by implementing a quality improvement intervention, driven by a multidisciplinary committee involving healthcare personnel, to facilitate the optimal discharge mechanism through available hospital resources and services.

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Arani, Nitkunan, Macdonald Bridget, Bhoodoo Ajay, Southam Medina, Smyth Caitlyn, Tomkins Andrew, and Schon Fred. "THUR 021 Transforming acute neurology: a 4 year study." Journal of Neurology, Neurosurgery & Psychiatry 89, no. 10 (September 13, 2018): A4.1—A4. http://dx.doi.org/10.1136/jnnp-2018-abn.13.

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We present a novel approach to acute neurological care. The key is an acute neurology triage nurse, based in the medical admission unit as well as an epilepsy specialist nurse seeing every patient referred with fits on the day of admission, a designated acute neurology consultant and acute neurophysiology and neuroradiology links. We have designated this group, a hyperacute neurology team (HANT).This study compares all admissions in 2014, the year before the team was established with 2015–2017. The total number of referrals has increased from 720 in 2014 to 1248 in 2017. The percent of patients seen on the day of referral has risen from 59% in 2014 to 92% in 2017.Average length of stay for patients with a primary diagnosis of epilepsy has gone down from 4.1 days in 2014 to 3.4 in 2017. Multiple admissions for epilepsy has reduced from 28 in 2014 to 21 in 2017. Patients suitable for early discharge are seen in consultant or nurse «outpatient hot clinics» or nurse telephone clinics.The cost of establishing this service has been relatively small (£106,000) and the service benefits enormous. We feel this model is worthy of wider debate.

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Lovell, Ben. "Editorial Volume 18 Issue 4 – Decision-making in acute medicine." Acute Medicine Journal 18, no. 4 (October 1, 2019): 206–7. http://dx.doi.org/10.52964/amja.0777.

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Acute physicians make patient-centred decisions at the start of the patient’s hospital journey. Dozens more decisions are made by the individual members of the MDT (and, of course, by the patient) during the in-patient period. Decisions are made at every level of seniority and experience and range widely in scope and impact. The original articles in this issue are connected by a common thread: phenomena that inform and influence the decisions made by acute physicians. How do you obtain adequate data to make sound decisions about individual patient care? It is often necessary to collate data around previous admissions and investigations at other healthcare institutions; a process fraught with complications. In this issue Ghelani et al1 undertook the onerous task of calling the main switchboard of all 175 acute hospitals in England on six occasions. Their aim was to identify how long it takes for an outside caller to finally contact a human operative who could put them through to the the correct person or extension. Most healthcare professionals will have some insight into the communication barriers that lie between practitioners in different hospitals, and the inordinate amount of time spent on the phone trying to gain patient information from another institution. The authors’ findings that automated messages and call steering systems impact significantly upon the time required for straightforward datagathering tasks should resonate with many for us. Hopefully, this study will provide substrate for future quality improvement efforts in the UK. How do you decide if your patient is well enough for transfer? The National Early Warning Score (NEWS) is now common currency in acute hospitals. This simple aggregate scoring system uses physiological parameters measures at the bedside and is used to inform assessments about patient acuity. There is currently significant research attention focused on the NEWS’ powers of prognostication. In a previous issues of this journal, we reported how vital sign abnormalities in the Emergency Department are predictors of poor outcomes (although not mortality) 2; monitoring of post-discharge vital signs in the community may predict readmission;3 and minor fluctuations in respiratory rate (in combination with other vital signs) may predicted clinical outcomes several days in advance.4 In this issue Subbe et all5 explore whether patients with low or unchanging NEWS scores are unlikely to deteriorate in future and could therefore be considered for transfer. How do you decide whether your patient requires intravenous fluids? In their qualitative study, Lloyd et al 6thematically analysed data from interviews with clinicians to better delineate the decision-making processes surrounding fluid therapy. They describe how doctors use vital signs, clinical presentation and their own gestalt, and – curiously – these approaches may be affected by the clinical environment and workload, and are not informed by local or national guidelines.

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Tung, J., K. Decaria, D. Dudgeon, E. Green, R. Shaw Moxam, J. Niu, and R. Rahal. "Acute-Care Hospital Use Patterns Near End-of-Life for Cancer Patients Who Die in Hospital in Canada." Journal of Global Oncology 4, Supplement 2 (October 1, 2018): 109s. http://dx.doi.org/10.1200/jgo.18.13800.

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Background: Acute-care hospitals have a role in managing the needs of people with cancer when they are at the end-of-life; however, overutilization of hospital care at the end-of-life results in poorer quality of life and can worsen the patient's experience. Early integration of comprehensive palliative care can greatly reduce unplanned visits to the emergency department, reduce avoidable admissions to hospital, shorten hospital stays, and increase the number of home deaths as well as improve the quality of life of patients with advanced cancer. Aim: To describe the current landscape of acute-care hospital utilization near the end-of-life across Canada and indirectly examine access to palliative care in cancer patients who die in hospital. Methods: Data were obtained from the Canadian Institute for Health Information. The analysis was restricted to adults aged 18+ who died in an acute care hospital in 2014/15 and 2015/16 for nine provinces and three territories. The Discharge Abstract Database was used to extract acute-care cancer death abstracts. Data on intensive care unit (ICU) admissions includes only facilities that report ICU data. Results: Acute care utilization at end-of-life remains commonplace. In Canada (excluding Québec), 43% (48,987) of deaths from cancer occurred in acute-care hospitals, with 70% admitted through the emergency department (ED). In the last six months of life, cancer patients dying in hospital had a median cumulative length of stay ranging from 17 to 25 days, depending on the province. Between 18.1% and 32.8% of patients experienced two or more admissions to the hospital in the last month of life. The proportion of cancer patients admitted to the ICU in the last 14 days of life ranged from 6.4% to 15.1%. Patient demographics (age, sex, place of residence) and clinical factors (cancer type) were often predictors of hospital utilization at end-of-life and likely point to inequities in access to palliative and end-of-life care. Conclusion: Despite previous patient surveys indicating that patients would prefer to receive care and spend their finals days at home or in a hospice, there appears to be overuse of and overreliance on acute care hospital services near the end-of-life in Canada. The high rates of hospital deaths and admissions through the ED at the end-of-life for cancer patients may signal a lack of planning for impeding death and inadequate availability of or access to community- and home-based palliative and end-of-life care services. Acute care hospitals may have a role in managing the health care needs of people affected by cancer; however, end-of-life care should be an option in other settings that align with patient preferences. Standards or practice guidelines to identify, assess and refer patients to palliative care services earlier in their cancer journey should be developed and implemented to ensure optimal quality of life.

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Mylotte, Joseph M., Robin Graham, Lucinda Kahler, B. Lauren Young, and Susan Goodnough. "Impact of Nosocomial Infection on Length of Stay and Functional Improvement Among Patients Admitted to an Acute Rehabilitation Unit." Infection Control & Hospital Epidemiology 22, no. 02 (February 2001): 83–87. http://dx.doi.org/10.1086/501868.

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AbstractObjective:To identify factors predictive of length of stay (LOS) and the level of functional improvement achieved among patients admitted to an acute rehabilitation unit for the first time, with special reference to the role of nosocomial infection.Setting:A 40-bed acute rehabilitation unit within a 300-bed, tertiary-care, public, university-affiliated hospital.Study Population:All patients admitted to the unit between January 1997 and July 1998.Design:Prospective cohort study in which demographic and clinical data, including occurrence of nosocomial infection, were collected during the entire unit admission of each patient. Multivariate linear regression analysis was used to identify factors predictive of unit LOS or improvement in functional status as measured by the change in the Functional Independence Measure (FIM) score between admission and discharge (ΔFIM).Results:There were 423 admissions to the rehabilitation unit during the study period, of which 91 (21.5%) had spinal cord injury (SCI) as a principal diagnosis. One hundred seven nosocomial infections occurred during 84 (19.9%) of the 423 admissions. The most common infections were urinary tract (31.8% of all infections), surgical-site (18.5%), andClostridium difficilediarrhea (15%). Only one patient died of infection. After controlling for severity of illness on admission, functional status on admission, age, and other clinical factors, the significant positive predictors of unit LOS were as follows: SCI (P<.001), pressure ulcer (.002), and nosocomial infection (<.001). Significant negative predictors of ΔFIM were age (P<.001), FIM score on admission (<.001), prior hospital LOS (.002), and nosocomial infection (.007).Conclusions:Several variables were identified as contributing to a longer LOS or to a smaller improvement in functional status among patients admitted for the first time to an acute rehabilitation unit Of these variables, only nosocomial infection has the potential for modification. Studies of new approaches to prevent infections among patients undergoing acute rehabilitation should be pursued.

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Vescovo, Mariavittoria. "Consensus document ANMCO/FADOI/SIAARTI/SIC/SIMG/SIMI/SIMEU: The clinical-diagnostic and therapeutic pathway of patients with acute heart failure in the Emergency Department." Italian Journal of Medicine 13, no. 4 (November 28, 2019): 247–76. http://dx.doi.org/10.4081/itjm.2019.1230.

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Acute heart failure (HF) involves hospitals throughout the world and, as well as other acute cardiac pathologies such as coronary syndromes, has markedly unfavorable outcomes: the mortality or rehospitalization rate after 3 months is 33%, mortality 1 year after admission varies between 25% and 50%. A critical factor in managing acute HF is the multiplicity of health professionals involved in the diagnostic-therapeutic pathway of this syndrome - general practitioners, emergency doctors, cardiologists, internists, anesthesiologists/resuscitators - and therefore also the need to integrate different knowledge and skills and converge on care goals that can improve clinical outcomes. This consensus document originates from the joint work of the Scientific Societies, representing various professional figures involved in assisting patients with acute HF, and has shared strategies and pathways aimed at guaranteeing both quality care levels and better outcomes. The document details the entire journey of the patient with acute HF from the onset of symptoms at home, diagnosis, home management or sending to the Accident and Emergency/Emergency Admissions Department (AandE/EAD), mode of transport, early therapy, through the instrumental clinical pathways for diagnosis in AandE/EAD and the treatment, risk stratification and discharge of the patient in ordinary hospitalization or at home. It also analyses the possible role of cardiological "fast-track", Short Intensive Observation and regional welfare taking charge through general medicine and specialist clinics for the care of HF. The growing care burden and the complex problems generated by acute HF cannot find an adequate solution without an integrated multidisciplinary approach that effectively places emergency facilities in the network along with intensive and ordinary hospitalization units and within the context of regional care. Thanks to contributions from the most qualified Scientific Societies, this document pursues this objective by proposing a structured, shared and applicable pathway which can contribute to manage a widespread problem in the country.

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O'Donovan, Claire, Steve Wright, Simon Towler, and Erin Furness. "56 Streamlining Referral Processes at a Tertiary Acute Medical Ambulatory Centre." Age and Ageing 48, Supplement_3 (September 2019): iii17—iii65. http://dx.doi.org/10.1093/ageing/afz103.32.

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Abstract Background The Acute Medical Ambulatory Centre (AMAC) was established with the goals of facilitating early discharge and preventing avoidable medical admissions. 12 months post its introduction, the service was inefficient and operating under capacity. A project aimed to improve the AMAC referral processes and increase the centre’s overall efficiency was undertaken. Methods Western Australia Department of Health Clinical Service Redesign methodology (a blend of Lean and Six Sigma methodologies) was used to complete the project. This involved process mapping, root cause analysis and solutions sessions with stakeholders, as well as a semi-structured phone interview with patients. Results Transition from a paper-based to an electronic referral system. Creation of an ‘AMAC Quick Reference Guide’ for doctors. Production of an AMAC contact card to be given to patients on discharge if they have AMAC follow up. Letters detailing the patient review are forwarded on the day of the appointment facilitating timely feedback to GPs. An AMAC information flyer for GPs is now available on the hospital website. Conclusion Redesigning the referral process to the AMAC has improved workflow and efficiency with significant improvements in staff satisfaction. The institution is aiming to become paperless and this redesign project has led to the elimination of another paper form. The success of the project is testament to the engagement of the staff involved and demonstrates the need for doctors to not only engage their medical colleagues, but also nursing and clerical staff. The redesign project has helped refocus hospital priorities and should hopefully see further support for the centre; developing the ambulatory model of care as an integral part of the service provided. Other centres can learn valuable lessons from our experience and develop similar strategies to cope with the ever-increasing demands on the public healthcare system.

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Triplett, Katherine Elizabeth, Andrew Ford, and Matthew Anstey. "Psychiatric symptoms post intensive care unit admission." BMJ Case Reports 12, no. 12 (December 2019): e231917. http://dx.doi.org/10.1136/bcr-2019-231917.

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A 53-year-old woman was admitted to a tertiary intensive care unit (ICU) with acute respiratory distress syndrome secondary to severe community-acquired pneumonia that necessitated maximum supportive care with venovenous extracorporeal membrane oxygenation. Her medical history included bipolar disorder on quetiapine and sertraline, as well as a previous ICU admission, approximately 2 years prior, for non-cirrhotic hyperammonaemic encephalopathy that was complicated by prolonged post discharge anxiety and post-traumatic stress disorder-like symptoms, consistent with post-intensive-care syndrome. Here, we present a case, and explore the outcomes for a patient who had two separate admissions with life-threatening illnesses, but had distinct differences in the psychological outcomes following each illness.

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Sullivan, Clair, Andrew Staib, Rob Eley, Bronwyn Griffin, Rohan Cattell, Judy Flores, and Ian Scott. "Who is less likely to die in association with improved National Emergency Access Target (NEAT) compliance for emergency admissions in a tertiary referral hospital?" Australian Health Review 40, no. 2 (2016): 149. http://dx.doi.org/10.1071/ah14242.

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Objective The aim of the present study was to identify patient and non-patient factors associated with reduced mortality among patients admitted from the emergency department (ED) to in-patient wards in a major tertiary hospital that had previously reported a near halving in mortality in association with a doubling in National Emergency Access Target (NEAT) compliance over a 2-year period from 2012 to 2014. Methods We retrospectively analysed routinely collected data from the Emergency Department Information System (EDIS) and hospital discharge abstracts on all emergency admissions during calendar years 2011 (pre-NEAT interventions) and 2013 (post-NEAT interventions). Patients admitted to short-stay wards and then discharged home, as well as patients dying in the ED, were excluded. Patients included in the study were categorised according to age, time and day of arrival to the ED, mode of transport to the ED, emergency triage category, type of clinical presentation and major diagnostic codes. Results The in-patient mortality rate for emergency admissions decreased from 1.9% (320/17 022) in 2011 to 1.2% (202/17 162) in 2013 (P < 0.001). There was no change from 2011 to 2013 in the percentage of deaths in the ED (0.19% vs 0.17%) or those coded as in-patient palliative care (17.9% vs 22.2%). Although deaths were not associated with age by itself, the mortality rate of older patients admitted to medical wards decreased significantly from 3.5% to 1.7% (P = 0.011). A higher mortality rate was seen among patients presenting to ED triage between midnight and 12 noon than at other times in 2011 (2.5% vs 1.5%; P < 0.001), but this difference disappeared by 2013 (1.3% vs 1.1%; P = 0.150). A similar pattern was seen among patients presenting on weekends versus weekdays: 2.2% versus 1.7% (P = 0.038) in 2011 and 1.3% versus 1.1% (P = 0.150) in 2013. Fewer deaths were noted among patients with acute cardiovascular or respiratory disease in 2013 than in 2011 (1.7% vs 3.6% and 1.5% vs 3.4%, respectively; P < 0.001 for both comparisons). Mode of transport to the ED or triage category was not associated with changes in mortality. These analyses took account of any possible confounding resulting from differences over time in emergency admission rates. Conclusions Improved NEAT compliance as a result of clinical redesign is associated with improved in-patient mortality among particular subgroups of emergency admissions, namely older patients with complex medical conditions, those presenting after hours and on weekends and those presenting with time-sensitive acute cardiorespiratory conditions. What is known about the topic? Clinical redesign aimed at improving compliance with NEAT and reducing time spent within the ED of acutely admitted patients has been associated with reduced mortality. To date, no study has attempted to identify subgroups of patients who potentially derive the greatest benefit from improved NEAT compliance in terms of reduced risk of in-patient death. It also remains unclear as to what extent non-patient factors (e.g. admission practices and differences in coding of palliative care patients) affect or confound this reduced risk. What does this paper add? The present study is the first to reveal that enhanced NEAT compliance is associated with lower mortality among particular subgroups of emergency patients admitted to in-patient wards. These include older patients with complex medical conditions, those presenting after hours or on weekends or those with time-sensitive acute cardiorespiratory conditions. These results took account of any possible confounding resulting from differences over time in emergency admission rates, deaths in the ED, numbers of short-stay ward admissions and coding of palliative care deaths. What are the implications for practitioners? Efforts aimed at improving NEAT compliance and efficiencies at the ED–in-patient interface appear to be worthwhile in reducing in-patient mortality among particular subgroups of emergency admissions at high risk. More research is urgently needed in identifying patient- and system-level factors that predispose to higher mortality rates in such populations, but are potentially amenable to focused interventions aimed at optimising transitions of care at the ED–in-patient interface and increasing NEAT compliance for patients admitted to in-patient wards from the ED.

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Cader, Fathima Aaysha, M. Maksumul Haq, Sahela Nasrin, and CM Shaheen Kabir. "Presentation, Management Practices and In-hospital Outcomes of Patients with Acute Coronary Syndrome in a Tertiary Cardiac Centre in Bangladesh." Bangladesh Heart Journal 32, no. 2 (April 10, 2018): 106–13. http://dx.doi.org/10.3329/bhj.v32i2.36097.

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Background: There is no large-scale data on the management practices and in-hospital outcomes of acute coronary syndromes (ACS) in Bangladesh. This study aimed to document the presentation characteristics, treatment practices and in-hospital outcomes of ACS patients presenting to a specialized tertiary cardiac care institute in Bangladesh.Methods: This retrospective observational study included all ACS patients presenting to Ibrahim Cardiac Hospital & Research Institute (ICHRI), Dhaka, Bangladesh, over the period of January 2013 to December 2013. Data were collected from hospital discharge records and catheterization laboratory database, and analysis was carried out using Statistical Package for Social Sciences (SPSS) version 16.0 (Chicago, Illinois, USA).Result: A total of 1914 ACS patients were included. The mean age was 57.8 ± 12.1 years. 71.4% were male. 39.8% presented with ST-elevation myocardial infarction (STEMI), 39.7% with non- ST-elevation myocardial infarction (NSTEMI) and 20.5% presented with unstable angina (UA). 68.91% were diabetic, 74.24% hypertensive, 53.23% were dyslipidaemic, 25.75% were smokers and 20.72% had chronic kidney disease (CKD).1022 (53.4%) of all admitted ACS patients underwent coronary angiography, among whom 649 (33.9%) were advised percutaneous coronary intervention (PCI), and 198 (10.3%) and 207 (10.8%) were advised coronary artery bypass graft (CABG) surgery and medical management respectively. PCI was performed in 509 patients (26.6%)during the index admission. The majority of these patients were those of STEMI (39.23%), among whom 47 (6.2%) underwent primary PCI. 146 (7.6%) of the patients presenting with ACS expired during hospital stay. Mortality was highest among STEMI (10.5%), followed by NSTEMI (8.3%) and UA (1%). 501 (26.2%) patients developed left ventricular failure, 108 (5.6%) patients developed shock and 265 (13.8%) developed acute kidney injury.Conclusion: This study represents one of the larger single-centre analyses of ACS patients in Bangladesh thus far. Our patients have high prevalence of cardiovascular risk factors, particularly diabetes and hypertension. There is room for further improvement in terms of guideline-directed medical and interventional treatment modalities, in order to improve outcomes.Bangladesh Heart Journal 2017; 32(2) : 106-113

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Busingye, Doreen, Monique F. Kilkenny, Tara Purvis, Joosup Kim, Sandy Middleton, Bruce C. V. Campbell, and Dominique A. Cadilhac. "Is length of time in a stroke unit associated with better outcomes for patients with stroke in Australia? An observational study." BMJ Open 8, no. 11 (November 2018): e022536. http://dx.doi.org/10.1136/bmjopen-2018-022536.

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ObjectiveSpending at least 90% of hospital admission in a stroke unit (SU) is a recommended indicator of receiving high-quality stroke care. However, whether this makes a difference to patient outcomes is unknown. We aimed to investigate outcomes and factors associated with patients with acute stroke spending at least 90% of their admission in an SU, compared with those having less time in the SU.DesignObservational study using cross-sectional data.SettingData from hospitals which participated in the 2015 Stroke Foundation National Audit: Acute Services (Australia) and had an SU. This audit includes an organisational survey and retrospective medical record audit of approximately 40 admissions from each hospital.ParticipantsPatients admitted to an SU during their acute admission were included.Outcome measuresHospital-based patient outcomes included length of stay, independence on discharge, severe complications and discharge destination. Patient, organisational and process indicators were included in multilevel logistic modelling to determine factors associated with spending at least 90% of their admission in an SU.ResultsEighty-eight hospitals with an SU audited 2655 cases (median age 76 years, 55% male). Patients who spent at least 90% of their admission in an SU experienced: a length of stay that was 2 days shorter (coefficient −2.77, 95% CI −3.45 to –2.10), fewer severe complications (adjusted OR (aOR) 0.60, 95% CI 0.43 to 0.84) and were less often discharged to residential aged care (aOR 0.59, 95% CI 0.38 to 0.94) than those who had less time in the SU. Patients admitted to an SU within 3 hours of hospital arrival were three times more likely to spend at least 90% of their admission in an SU.ConclusionSpending at least 90% of time in an SU is a valid measure of stroke care quality as it results in improved patient outcomes. Direct admission to SUs is warranted.

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Einsiedel, Lloyd J., Eileen van Iersel, Robert Macnamara, Tim Spelman, Malcolm Heffernan, Linda Bray, Hamilton Morris, Brenda Porter, and Anthony Davis. "Self-discharge by adult Aboriginal patients at Alice Springs Hospital, Central Australia: insights from a prospective cohort study." Australian Health Review 37, no. 2 (2013): 239. http://dx.doi.org/10.1071/ah11087.

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Objective. To determine rates and risk factors for self-discharge by Aboriginal medical inpatients at Alice Springs Hospital. Methods. Prospective cohort study. Interviews were conducted in primary language by Aboriginal Liaison Officers, from July 2006 to August 2007. Topics included understanding of diagnosis, satisfaction with services and perceptions of staff and environment. Risk factors for self-discharge were then determined prospectively. Results. During the study period 202 (14.7%) of 1380 patients admitted to general medical units at Alice Springs Hospital, were interviewed. Self-discharge rates for all admissions were significantly lower during the study period than they had been previously (pre-study, mean 22.9 ± standard error 0.3%; study, 17.0 ± 0.2%) (P < 0.001). Most interviewees (73.4%) did not know their reason for admission (73.4%) or estimated length of stay (82.3%). Forty interviewees (19.8%) self-discharged. Mean monthly self-discharge rates differed between the three medical units (Unit A, 13.9 ± 0.3%; Unit B, 17.3 ± 1.37%; Unit C, 20.0 ± 0.4%) (P = 0.005). Multivariable predictors of self-discharge included male sex (hazard ratio (HR) 2.4; 95% confidence interval (CI) 1.1, 5.2), a past history of self-discharge (HR 3.2; 95%CI 1.5, 6), planned transfer to a tertiary referral centre (HR 3.8; 95%CI 1.3–7.4) and a desire to drink alcohol (HR 4.5; 95%CI 1.8–10.2). Conclusions. Physician, institutional and patient factors all contribute to self-discharge. Improving cultural safety may be the key to lowering self-discharge rates. What is known about the topic? Rates of self-discharge by Aboriginal adults in Central Australia are the highest reported worldwide. Previous studies have been retrospective and focussed on patient demographics without addressing the environmental and cultural contexts in which self-discharge occurs. What does this paper add? In this acute care setting, we found a pervasive failure to communicate effectively with Aboriginal patients. Consequently, most patients were unaware of their diagnosis or length of stay. Self-discharge was a common practice; nearly half of all previously admitted patients had self-discharged in the past. We demonstrate that physician, hospital and patient factors all contribute to this practice. Prospectively determined risk factors included the treating medical team, the need for transfer outside Central Australia, and patient factors such as male gender and alcohol dependence. Self-discharge rates fell significantly with Aboriginal Liaison involvement. What are the implications for practitioners? Cross-cultural communication skills must be markedly improved among medical staff caring for this marginalised population. Critical to reducing rates of self-discharge are improvements in institutional cultural safety by involving Aboriginal Liaison Officers and family members. However, persistently high self-discharge rates suggest a need to redirect medical services to a more culturally appropriate community-based model of care.

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Kim, Roger Y., Xiaopan Yao, Peter Longley, Joan Rimar, Chryssanthi Kournioti, and Alfred Ian Lee. "Using the Rothman Index to Predict Discharge and Readmission Rates in an Inpatient Hematology Unit." Blood 124, no. 21 (December 6, 2014): 1302. http://dx.doi.org/10.1182/blood.v124.21.1302.1302.

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Abstract BACKGROUND: Limited data exists regarding predictors of discharge (DC) disposition and readmission (RA) rates for hematology-oncology patients who are hospitalized. The Rothman Index (RI) is a single numerical score ranging from -91 to 100 derived from 26 data elements including vital signs, laboratory results, and nursing assessments. It is automatically calculated and displayed in real-time in the electronic medical record by a commercial software system. A previous analysis at our institution revealed a significant association between RI and DC disposition, and between RI and RA rates, for patients with solid tumors who were hospitalized in a dedicated inpatient oncology unit. We sought to determine the effectiveness of RI in predicting DC disposition and RA rates for hospitalized patients with hematologic malignancies. METHODS: Medical records of patients with hematologic malignancies admitted to Yale Cancer Center between 3/1/13 and 2/28/14 were reviewed. Admissions for elective chemotherapy were excluded. DC disposition was categorized as home (Hm), nursing home (NH), hospice (Hp), or death (D). RI at DC was examined as a predictor of DC disposition, overall RA rate, and RA rate of patients discharged to Hm. As an individual patient might have several admissions, generalized estimating equation models were used to assess the effect of RI at DC on DC disposition and the possibility of RA by controlling the within subject correlation. RESULTS: A total of 281 patients comprising 520 admissions were included in the final analysis. The median age was 59 (range: 19-93; age 70 or older: 21%), and 53% of patients were male. The most common hematologic malignancies were non-Hodgkin lymphoma (33%), acute myeloid leukemia (25%), and multiple myeloma (19%). Among all admissions, DC disposition was as follows: Hm, 439 (84%); NH, 53 (10%); Hp, 18 (4%); and D, 10 (2%). RI at DC was a significant predictor of DC disposition (p = 0.0001), with median RI at DC as follows: Hm, 82.1; NH, 61.4; Hp, 38.7; and D, -1.3. Patients with lower RI at DC were significantly more likely to be readmitted (p = 0.0006), even when the analysis was restricted to patients who had been discharged to Hm (p = 0.0131). Among Hm patients, RA rate was 61% for those whose RI at DC was < 60 and 46% for RI at DC > 60. CONCLUSIONS: The RI at DC significantly correlated with patient DC disposition and RA rates and may assist health care providers in DC planning with the goal of reducing hospital RA rates and ultimately health care costs. Disclosures Lee: Pfizer: Consultancy.

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Hull, Russell, Duane Bates, Cynthia Brocklebank, Nelly Komari, and Tazmin Merali. "Rate of Late Venous Thromboembolism Events In High-Risk Medical Patients." Blood 116, no. 21 (November 19, 2010): 82. http://dx.doi.org/10.1182/blood.v116.21.82.82.

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Abstract Abstract 82 Background: Current guidelines recommend that venous thromboembolism (VTE) prophylaxis should be given to high-risk medical inpatients based on evidence of reduced VTE events and reduced mortality. However, current guidelines do not specify the appropriate length of VTE prophylaxis in this population, especially after discharge. The EXCLAIM study showed a 90 day VTE incidence of 4.2% in those patients who received enoxaparin for 10 days in the hospital, with 1.1% being symptomatic VTE. However, real world data is needed to understand the risk of VTE for this patient population after they are discharged from acute care and the prevalence of symptomatic VTE. Objective: To determine the incidence of late VTE events in high-risk medical patients in every day clinical practice and in the absence of systematic screening for VTE. Methods: Charts from 1134 consecutive high-risk medical patients who were hospitalized in the Calgary region and discharged between January and February 2008 were abstracted using standardized case record forms. All hospitals in the region use a common unique patient identifier number, thus enabling the tracking of subsequent patient visits to the emergency room, inpatient admissions or outpatient visits occurring anywhere in the region's acute care system. High-risk medical patients were defined as age > 60 years and having at least one of the following risk factors: malignancy, respiratory illness, neurological illness, inflammatory bowel disease, previous VTE, acute infection or heart failure. Records excluded were those of patients who were admitted for VTE or to rule out VTE, those receiving chronic anticoagulation, those with acute coronary syndromes, patients whose hospital stay was ≤ 3 days, surgical patients, orthopedic patients, and pregnant patients. Data was collected on patient risk factors, thromboprophylaxis received in hospital and at discharge, VTE related events for up to 100 days post discharge. Results: 989 patients met criteria over the review period. 74% (733/989) of all patients received mechanical or pharmacological prophylaxis in hospital: 28% (281) received unfractionated heparin, 28% (281) received LMWH and 4% (40) received mechanical prophylaxis and 13% (131) received a combination of modalities. The prevailing medical risk factors were malignancy (46%), respiratory illness (44%), neurological illness (15%), inflammatory bowel disease (6%), previous VTE (4%), acute infection (17%), heart failure (9%). Only 2% (95% CI, 1.6% to 3.6%) of all patients received anticoagulation prophylaxis at discharge. Twenty one percent of patients in the population studied received medical care for symptoms associated with VTE. Of these, 4% (95% CI, 2.7% to 5.2%) had confirmation of VTE by diagnostic testing while the other 17% (95% CI, 15.0% to 19.8%) had diagnostic tests that were negative or inconclusive. The mean length of time to confirmed VTE was 34.1 days post hospital admission. Conclusion: This study demonstrates that in a real life setting 21% of high-risk patients would develop symptoms of VTE requiring a health professional's attention with 4% having VTE confirmed by diagnostic testing. These events occurred despite prophylaxis in hospital and suggest that the risk of symptomatic VTE could be higher in real life compared to that reported in randomized clinical trials where patients are screened for asymptomatic VTE. These findings show that the prevalence of VTE warrants consideration of extended thromboprophylaxis in selected high-risk medical patients, as the benefits of extended prophylactic therapy may outweigh the risks in this population. Disclosures: Hull: sanofi-aventis Canada Inc: Consultancy, Research Funding. Brocklebank:sanofi-aventis Canada Inc: Honoraria; Bayer, Inc.: Honoraria; Leo Pharma: Honoraria. Komari:sanofi-aventis Canada Inc: Employment. Merali:sanofi-aventis Canada Inc: Consultancy, Research Funding.

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Rudilosso, Salvatore, Carlos Laredo, Víctor Vera, Martha Vargas, Arturo Renú, Laura Llull, Víctor Obach, et al. "Acute Stroke Care Is at Risk in the Era of COVID-19." Stroke 51, no. 7 (July 2020): 1991–95. http://dx.doi.org/10.1161/strokeaha.120.030329.

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Background and Purpose: The purpose of the study is to analyze how the coronavirus disease 2019 (COVID-19) pandemic affected acute stroke care in a Comprehensive Stroke Center. Methods: On February 28, 2020, contingency plans were implemented at Hospital Clinic of Barcelona to contain the COVID-19 pandemic. Among them, the decision to refrain from reallocating the Stroke Team and Stroke Unit to the care of patients with COVID-19. From March 1 to March 31, 2020, we measured the number of emergency calls to the Emergency Medical System in Catalonia (7.5 million inhabitants), and the Stroke Codes dispatched to Hospital Clinic of Barcelona. We recorded all stroke admissions, and the adequacy of acute care measures, including the number of thrombectomies, workflow metrics, angiographic results, and clinical outcomes. Data were compared with March 2019 using parametric or nonparametric methods as appropriate. Results: At Hospital Clinic of Barcelona, 1232 patients with COVID-19 were admitted in March 2020, demanding 60% of the hospital bed capacity. Relative to March 2019, the Emergency Medical System had a 330% mean increment in the number of calls (158 005 versus 679 569), but fewer Stroke Code activations (517 versus 426). Stroke admissions (108 versus 83) and the number of thrombectomies (21 versus 16) declined at Hospital Clinic of Barcelona, particularly after lockdown of the population. Younger age was found in stroke admissions during the pandemic (median [interquartile range] 69 [64–73] versus 75 [73–80] years, P =0.009). In-hospital, there were no differences in workflow metrics, angiographic results, complications, or outcomes at discharge. Conclusions: The COVID-19 pandemic reduced by a quarter the stroke admissions and thrombectomies performed at a Comprehensive Stroke Center but did not affect the quality of care metrics. During the lockdown, there was an overload of emergency calls but fewer Stroke Code activations, particularly in elderly patients. Hospital contingency plans, patient transport systems, and population-targeted alerts must act concertedly to better protect the chain of stroke care in times of pandemic.

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Journal articles on the topic 'Acute medical admissions ; Patient journey ; Patient discharge'

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