Dissertations / Theses on the topic 'Admission and discharge'

The rising cost of unplanned hospital readmissions has sparked calls for identifying medical system failures, best practices, and interventions in order to reduce the incidence of avoidable readmission. Readmissions currently account for 18% of total hospital admissions among Medicare patients in the United States. Distinguishing avoidable from unavoidable readmissions is a complex problem, but tackling it can shed light on readmission determinants and contributing factors. The objective of this thesis is to gain knowledge about the role that dispensed drugs, medical procedures, and diagnostic information play in predicting the chance of readmission within thirty days from a hospital discharge, using machine learning techniques. The prediction of hospital readmission is formulated as a supervised learning problem. Two supervised learning models, Naïve Bayes and Decision Tree, are used in the thesis to predict the chance of readmission based on patients' demographic information, prescription drugs, diagnosis and procedure codes extracted from hospital discharge summaries. The empirical analysis improves the understanding of hospital readmission prediction and identifies patient subpopulations for which the readmission prediction is naturally more difficult. Comparing the performance of different methods, using AUC as the measure of performance, we found that the combination of Naïve Bayes classifier and Gini Index feature selection performs slightly better than other methods on this dataset. We also found that some diagnostic features play an important role in distinguishing outliers. Removing outliers from the entire data results in significant performance gains in the prediction of readmission.
La hausse des côuts associés avec les re-admissions non-planifiées à l'hôpital suggère que c'est très important d'identifier les détérminants de ces événements. Les re-admissions causent 18% des côuts de Medicare aux États-Unis, ce qui fait l'identification des re-admissions qui peuvent être évitées très importante. Nous formulons ce problème comme une tâche d'apprentissage supervisé. Nous utilisons deus méthodes, Naive Bayes et les Arbres de Décision, pour la prédiction des patients qui vont être re-admis, en fonctions de leurs données démographiques, les médicaments de préscription, et les codes de diagnostique et des procédures que les patients ont subis en hôpital. Nôtre analyse ameliore nos connaissances sur les facteurs détérminants pour les re-admissions non-planifiées et identifie de sous-populations de patients pour lesquelles la prédiction est plus difficile. Nous performons des comparaisons de différentes méthodes de prédiction. La combinaison de Naïve Bayes et séléction d'attributes basée sur l'index Gini donne les meilleurs résultats sur nos données. Nous avons aussi trouvé que certains attributs sont utiles pour distinguer les patients pour lesquels la prédiction est difficile. Si on élimine ces patients du jeu de données, les résultats de l'aprentissage sont meilleurs. La hausse des côuts associés avec les re-admissions non-planifiées à l'hôpital suggère que c'est très important d'identifier les détérminants de ces événements. Les re-admissions causent 18% des côuts de Medicare aux États-Unis, ce qui fait l'identification des re-admissions qui peuvent être évitées très importante. Nous formulons ce problème comme une tâche d'apprentissage supervisé. Nous utilisons deus méthodes, Naive Bayes et les Arbres de Décision, pour la prédiction des patients qui vont être re-admis, en fonctions de leurs données démographiques, les médicaments de préscription, et les codes de diagnostique et des procédures que les patients ont subis en hôpital. Nôtre analyse ameliore nos connaissances sur les facteurs détérminants pour les re-admissions non-planifiées et identifie de sous-populations de patients pour lesquelles la prédiction est plus difficile. Nous performons des comparaisons de différentes méthodes de prédiction. La combinaison de Naïve Bayes et séléction d'attributes basée sur l'index Gini donne les meilleurs résultats sur nos données. Nous avons aussi trouvé que certains attributs sont utiles pour distinguer les patients pour lesquels la prédiction est difficile. Si on élimine ces patients du jeu de données, les résultats de l'aprentissage sont meilleurs.

It has consistently been documented in many countries and sectors that there are difficulties in implementing public policy effectively. A priori, the Australian health care system is no exception to this general proposition. While governments issue directives with particular goals in mind these goals are not always met, because of the modifications, interpretations or lack of uptake by targeted populations. However it is not clear the extent to which these difficulties occur in the public hospital sector, and we lack clear empirical data on this phenomenon. This thesis investigates the effects of a state government directive on the development and implementation of elective admission policies in New South Wales public hospitals. It did this by three separate but related studies that examined the impact of the directive at the hospitals??? management and staff levels. The first two studies were quantitative and qualitative surveys of hospital managers and admission staff. The management survey aimed to ascertain the extent to which managers responded to the directive in terms of developing and implementing hospital policies. The staff survey sought to investigate staff awareness and knowledge of the developed policies. The third study was a qualitative analysis of the policy contents to determine the extent to which they reflected the aims and objectives of the government directive guidelines. All three studies found a general lack of relevance and applicability of the government directive and its guidelines to individual hospital organisations. The manager survey showed a disconnection between the central government office responsible for implementing the directive and hospital managers??? perspectives. This was apparent by the lack of response to the directive by many hospitals and the fact that managers often passed on the task of implementing the directive and its guidelines to other hospital staff. The findings of the qualitative analysis of policies showed evidence of hospital strategies to manage pressures created by the directive. These difficulties were corroborated by the surveyed staff that reported difficulties in translating the directive???s requirements (as reflected by the hospital policy), into the reality of their daily work; a lack of organisational commitment to policy enforcement; and a suspicion regarding the directive???s political motives. The findings of this thesis show that, as with other public service sectors effective policy implementation in the public hospital arena is problematic, with government agendas frequently not aligned with the requirements of stakeholders, and inadequate understanding of implementation barriers. Recommendations are made regarding methods to improve the synchronicity of political directives with organisational realties in the public hospital sector.

Abstract A study is made of the volume of hospital treatment provided for cases of pneumonia in Finland from 1972 to 1993, employing as a source the National Hospital Discharge Register. The results are used to predict changes in the utilization of hospital resources in this respect up to the year 2020. A total of 452 474 treatment periods and 5 935 615 hospitalization days attributable to pneumonia were recorded for the total population over the given period, of which just under 20% applied to children aged under 15 years, over 30% to persons of working age, 15-64 years, and over 50% to elderly persons aged 65 years and over. The mean duration of hospitalization was reduced from 18.4 days to 14.3 days for males and from 19.6 days to 17.5 days for females over the period in question. The number of treatment periods for pneumonia in children per year relative to population decreased by 28.3%, the greatest reduction being in the group under one year of age, 5.7% for boys and 5.5% for girls. The mean duration of treatment decreased from 9.6 days to 4.1 days for boys and 9.7 days to 4.3 days for girls. The numbers of treatment periods and hospitalization days were consistently greater for men than for women in the working-age population, the difference between the sexes being most pronounced in the age group 15 - 24 years, where the number of treatment periods for men was 7.2 times that for women. Likewise, the number of treatment periods for men began to increase with age from 40 years onwards and that for women from 50 years onwards. The mean treatment time for patients of working-age decreased over the period studied, from 10.5 days to 8.2 days for men and from 9.9 days to 8.2 days for women. The duration of treatment similarly increased with advancing age. The absolute numbers of treatment periods increased by 139% among the elderly population, even when standardized for age, whereas the number of hospitalization days diminished. The clearest increase in treatment periods of all was recorded for men aged over 84 years, 3.16%. The mean duration of treatment increased with age in both sexes, being significantly longer for women than for men in each age group. The forecast for changes in the utilization of hospital services for the treatment of pneumonia up to the year 2020 was examined by methods based on both an age structure model and a time series model. Both predicted an increase of over 50% in the total number of treatment periods for the population as a whole, being of the order of 70% for men and 30% for women. The predicted increase in the age group over 64 years was in excess of 90% with both models. The use of hospital services for the treatment of childhood pneumonia decreased significantly over the period examined here, while the majority of the treatment periods recorded for the working-age population concerned young men or persons aged over 40 years. The most significant increase was seen in treatment periods for persons aged over 64 years, and this figure is also predicted to increase in the future, on account of the frequent use made of hospital services by the elderly in general. Preparations should be made for dealing with this increase in demand by improving treatment methods, developing the treatment system and undertaking preventive measures.

A descriptive quantitative study was conducted to determine what factors nurses considered when discharge planning, and how these factors compared with factors identified in the literature as being effective in planning for discharge. This study was undertaken because with the intended Prospective Payment System (PPS) of funding to hospitals, it is essential that Western Australian Clinical Registered Nurses are able to prepare patients for discharge effectively to prevent the financial burden of cost outliers and re-admissions. Anderson and Steinberg ( 1984) in their studies of factors that influence the cost of hospital care for the elderly, found that the results of inappropriate and premature discharges resulted in a 22% readmission rate within 60 days of discharge for all Medicare hospitalisation. Their (1988) study of readmission rates of Medicare beneficiaries between 1974 and 1977 showed that the added costs associated readmissions cost the U.S. government more than US$2.5 billion per annum. It would seem probable that such a system introduced into the Australian health:care system will have the potential to produce similar effects for Western Australian patients, nurses and nursing.

The purpose of this study was to explore the experiences and needs of families during the admission of a child to a paediatric ward in an acute care hospital. Qualitative research methods were used to access the caregivers' and professionals' perceptions of the culture that families experience in a paediatric in-patient setting. For this project, data collection methods included a review of the literature in the area, individual interviews with caregivers, and focus groups with paediatric health care professionals.
In the study, both parents and paediatric professionals described a multitude of experiences and needs of families during a child's admission to a paediatric ward in an acute care setting. Understanding the experiences and needs of families is important for professionals. The information collected in this study provides some insight into the culture that families experience when their child is admitted to a paediatric ward in an acute care hospital.

This thesis aimed to explore systematic health service problems that are related to frequent readmission of persons suffering from severe mental illnesses to Valkenberg Hospital. Reduction of acute and chronic beds in the Associated Psychiatric Hospitals, Western Cape over the past decade has led to increasing pressure for beds and rapid inpatient turnover, many of these inpatients being "
revolving door"
patients. Integration of mental health service into general health services, an intrinsic part of the comprehensive primary health care approach in South Africa, is supposed to make mental health care more accessible the public, therefore research into why patients are being frequently readmitted at secondary specialist level is indicated.

The purpose of this descriptive study was to describe the evaluation of a 'Patient Management Program'. This managed care type of program combined a Pre-Admission Clinic and an Early Discharge Program. It was established as a twelve month pilot program at a major Western Australian public teaching hospital in January 1995. It aimed to provide a more efficient health service by replacing part of elective surgical patients' inpatient care with outpatient services. The first component of the Program was the Pre-Admission Clinic, which allowed patients to undergo pre-operative assessment and testing prior to admission to hospital, thus facilitating same day of surgery admission and reducing hospitalisation by at least one day. It also enabled identification of patients unfit for surgery, allowed discharge planning to be initiated, and patient education to be undertaken. The second component of the Program was the Early Discharge Program, which aimed to facilitate patient discharge from hospital, and to provide acute post discharge care and support. The significance of it’s component was the continuity of care, as the same nursing staff who provided pre-admission assessment, education and discharge planning also provided inpatient discharge co-ordination, post discharge support, and the delivery of domiciliary nursing care.

Advances in neonatology have led to increased numbers of high-risk neonates surviving and intensified interest in the developmental outcomes of this population. In the South African context prematurity and low birth weight are the most common causes of death in the perinatal period and the same risk factors that contribute to infant mortality also contribute to the surviving infants’ increased risk for developmental delays. As a result of the interacting biological and environmental risk factors of prematurity, low birth weight, poverty and HIV and AIDS in the South African context Kangaroo Mother Care (KMC) has been developed as best practice to promote infant survival and to facilitate mother-infant attachment. Mother-infant attachment may lead to synchronous interaction patterns between the mother and infant which forms the basis of early communication development. Early communication intervention (ECI) services are recommended as early as possible as high-risk infants are especially at risk for feeding difficulties and communication developmental delays. It is, however, not clear what the content of an ECI programme should be and how it should be implemented according to the changing communication and feeding developmental needs of the infant while receiving KMC. There appears to be a dearth of research on the earliest stages of communication development in high-risk neonates, which should form the foundation of such a programme. A descriptive survey was conducted to describe the development of 25 high-risk infants and their mothers’ changing needs from admission to discharge from a KMC unit. Each participant and mother dyad was followed up over an average of 11 days of data collection with three to four data collection sessions. Data was collected by means of direct observation during routine care-giving activities. The different developmental subsystems of the participants’ feeding, communication, neuro-behavioural organization and mother-neonate interaction were described. The results demonstrated that subtle, but definite changes could be observed in the participants’ development. Development in all the different areas occurred over time as the participants progressed through the three developmental states of the in-turned state, coming-out state and reciprocity state. As the participants progressed during the 11 days of data collection and were increasingly able to attend to their environment, they also developed the ability to regulate and organize their own behaviour in order to develop more complex communication, feeding and interaction skills with their mothers. The functioning of the participants’ sensory systems developed in a specific order namely tactile, auditory and then visual. Although the participants developed consistently throughout their stay in the KMC unit, mother-neonate interaction never reached optimal levels. The importance of an individualized training programme for each mother is reflected in the finding that the neonate’s developmental level and progress needs to be considered when implementing the ECI programme. The need for speech-language therapy involvement in KMC is emphasized in the light of a shortage of practicing speech-language therapists in South Africa. It is therefore imperative that the prevention of communication delays and feeding difficulties in high-risk neonates as well as parent training assume priority.
Dissertation (MCommunication Pathology)--University of Pretoria, 2008.
Speech-Language Pathology and Audiology
unrestricted

The purpose of this study was to determine the impact of a public smoking ban on the hospital admissions due to acute myocardial infarction in Delaware County, Indiana. The study population consists of all the patients admitted to Ball Memorial Hospital during three 22-month periods with a primary or secondary discharge diagnosis code of acute myocardial infarction (ICD-9-CM) immediately prior to the implementation of the ordinance. Chi-square was conducted for the three 22-month periods of hospital admissions. A significant drop occurred in the number of admissions among nonsmoking patients in Delaware County. The changes in the number of smoking-patient admissions before and after the ban were not significant.
Access to thesis and accompanying PDF permanently restricted to Ball State community only
Department of Physiology and Health Science

Nursing is developing a science for explaining our interventions_ Hormones play a vital role in the female response pattern and that must be assessed in order for nursing to justify its actions. This descriptive design studied 30 women between the ages of 30 and 45 examining psychiatric addmissions and premenstrual syndrome (PMS). Two hypotheses were considered: 1) There is no difference in the incidence of admission to psychiatric facilities of women for depression, schizophrenia, or other psychiatric crises during the paramenstruum of their menstrual cycle and 2) There is no difference in the incidence of premenstrual syndrome symptoms among women admitted to psychiatric facilities during their paramenstruum.Data was obtained by questionnaire and chart review. The nominal data was analyzed using chi-square. No significant results were found statistically. The practical significance of the study is that 20 of the 30 women were admitted during their paramenstruum.
School of Nursing

Thesis (MSc) Stllenbosch University, 2001.
ENGLISH ABSTRACT: A prospective study was conducted in 1999 to establish the incidence and nature of acute poisonings in the Cape Town / Western Cape region. This study was based on an analysis of Poison Centre queries and acute poisoning admissions to Tygerberg Hospital over a period of 1 year (1999). Summary of findings for Hospital admissions (1010 cases): Acute poisonings were more common in adults (83%) than in children (17%) and drug overdose was by far the most common clinical entity in adult Hospital admissions (89% of cases). Most overdoses in adults were intentional (97%). Seventy five percent of these cases were female, predominantly in the 20-40 year age group. The incidence of non-drug chemical exposures in adults was relatively low (11%). In children, on the other hand, there was much less of a discrepancy between drug and non-drug chemical exposures (41% and 59% respectively). Paracetamol was the drug most commonly used in overdose in both adults and children. In adults ethanol featured in 17% of cases. Ingestion of paraffin and related volatile hydrocarbons were the most important cause of acute poisoning in children. Acute poisoning admissions due to drugs of abuse, excluding ethanol, were minimal in both age groups (1%). Toxic exposures to non-drug chemicals in the agricultural and industrial settings were low (3%). The number of exposures to biological toxins was also minimal (2%). Summary of findings for Poison Centre inqueries (3744 consultations): In 1999 the Tygerberg Poison Information Centre received 3744 calls, of which 2690 were related to acute human exposures to poisonous substances. The remainder of the calls (1054) was either about drug therapy, or general non-patient related toxicological matters. There were more calls regarding poisoning in adults (61%) than in children (39%). Most of the paediatric poisonings were accidental (97%), whereas in adults 55% were deliberate and 45% accidental. Forty four percent of the children and 52% of adults were female. In children, inqueries about exposures to potentially harmful non-drug household chemical products comprised 56% of poison calls, while drug overdose was 28% and exposures to biological toxins 16%. In adults 44% of inqueries were with regard to household products, 40% about drugs and 16% biological toxins. A comparison of Hospital admissions versus Poison Centre consultations: In order to make a valid comparison between Hospital admissions and Poison Centre consultations, acute poisoning cases originating from the same area were compared. Eight hundred and thirty four (90%) of patients admitted to Tygerberg Hospital and 592 (25%) of Poison Centre consultations originated from the same region, the Tygerberg catchment area. Several differences were noted when comparing poisoning cases reported to the Poison Centre and Hospital admissions. Six hundred and eighty eight (83%) adults and 145 (17%) children were admitted to Hospital in contrast to Poison Centre inqueries, where 322 (54%) were adults and 270 (46%) children. In adults, 99% of Hospital admissions versus 59% of Poison Centre consultations were regarded as self-inflicted. Ninety three percent of adults admitted to Hospital were drug overdoses, whereas only 48% of adult Poison Centre consultations involved ingestion of medicines. In adult overdoses with paracetamol and other analgesics, tricyclic antidepressants, antiepileptics, theophylline and ethanol were significantly higher in Hospital admissions than in Poison Centre consultations. In contrast, exposures to pesticides e.g. pyrethroids, misuse of recreational drugs e.g. cannabis and biological toxin exposures e.g. spider bites, were significantly higher in Poison Centre consultations than in Hospital admissions. In children, poisoning exposures to volatile hydrocarbons, especially paraffin, were significantly higher in Hospital admissions compared to Poison Centre enqueries. As is evident from the disparity in the results above, inqueries to the Tygerberg Poison Information Centre cannot be regarded as a reflection of the true incidence of acute poisonings in the community. Poison Information Centre statistics are distorted because of two factors: 1. Under-reporting to the Poison Information Centre. Healthcare providers are familiar with how to manage drugs commonly used in overdose (e.g. paracetamol) and certain household non-drug chemicals (e.g. paraffin), and often do not consult the Poison Centre for poison cases involving these substances. The number of inqueries received by the Poison Information Centre regarding these substances is, therefore, an under representation of actual incidence. 2. Over-reporting to the Poison Information Centre. The Tygerberg Poison Information Centre is well known for its expertise in biological toxins (e.g. spider and snake bites, scorpion stings, plant and mushroom ingestions, and marine toxins). Therefore, the number of inqueries received by the Centre with regard to these exposures is far higher than actual incidence of exposures. It is clear from this study that one cannot use data derived from a poison centre alone as an indicator of true incidence of poisoning in the community. A more accurate estimate of incidence of acute poisoning could be obtained by including data from hospital admissions, as well as those from primary health care facilities. Another prominent finding in this study was the high incidence of self-inflicted drug overdose in adult females, with paracetamol being the drug of choice. Poison prevention should therefore not be limited to children. Adult prevention programs need urgent attention.
AFRIKAANSE OPSOMMING: ‘n Prospektiewe studie om die insidensie en aard van akute vergigtigings in die Wes-Kaap vas te stel, is gedurende 1999 in Tygerberg Hospitaal uitgevoer. Die studie is gebaseer op ‘n analise van oproepe wat deur die Tygerbergse Vergifinligtingsentrum ontvang is en pasiente wat gedurende dieselfde tydperk met ‘n diagnose van akute vergiftiging by die Hospitaal toegelaat is. Qpsomming van Hospitaal toelatinqs (1010 qevalle): Toelatings van akute vergiftigings was meer algemeen by volwassenes (83%) as by kinders (17%). Die meeste hospitaal toelatings (83%) by volwassenes is a.g.v. geneesmiddeloordoseing. By 97% van volwassenes was gifstowwe doelbewus ingeneem, met vroue in die meerderheid (75%). Die insidensie van vergiftigings met nie-geneesmiddel verwante gifstowwe by volwassenes was laag (11%). By kinders was daar egter ‘n meer eweredige verspreiding tussen geneesmiddel (41%) en nie-geneesmiddel verwante (59%) gifstowwe. By beide volwassenes en kinders, was parasetamol die middel wat by die meeste oordoserings betrokke was. Alkohol was by 17% van vergiftigings by volwassenes betrokke. Paraffien en verwante vlugtige substanse was die belangrikste gifstowwe betrokke by akute vergiftigings by kinders. Akute vergiftigings as gevolg van die gebruik van dwelmmiddels was laag in alle ouderdomsgroepe (1%). Vergiftigings in die landbou en industriele sektore was laag (3%). Dit was ook die geval ten opsigte van blootstelling aan biologiese toksienes (2%). Opsomminq van Tyqerberq Verqifinliqtinqsentrum konsultasies (3744 qevalle): Gedurende 1999 het die Tygerberg Vergifinligtingsentrum 3744 oproepe ontvang waarvan 2690 as gevolg van akute vergiftigings was. Die ander 1054 oproepe het gehandel oor geneesmiddel terapie of algemene, nie-pasient verwante navrae. Daar is aangetoon dat oproepe ten opsigte van akute vergiftigings by volwassenes meer algemeen was as by kinders (61% en 39% respektiewelik). By kinders was die meeste vergiftigings per ongeluk (97%), terwyl by volwassenes die meeste doelbewus (55%) was. By kinders was 44% van die vroulike geslag teenoor 52% by volwassenes. By kinders was nie-geneesmiddel gifstowwe by 56% van akute vergiftigings betrokke en geneesmiddels by 44%. By volwassenes was dit 60% en 40%, respektiewelik. ‘n Verqelvkinq ten opsigte van Hospitaal toelatinqs en Verqifsentrum konsultasies: Om ‘n geldige vergelyking tussen Hospitaal toelatings en Vergifinligtingsentrum konsultasies te maak is gevalle van akute vergiftigings afkomstig uit dieselfde geografiese gebied.vergelyk. Toelatings tot Tygerberg Hospitaal 834 (90%) en 592 (25%) oproepe wat deur die Tygerbergse Vergifsentrum ontvang is, kom uit dieselfde opvangsgebied, naamlik die Tygerbergse substruktuur. Verskeie verskille tussen die twee instansies ten opsigte van die tipe vergiftigings is aangetoon. Volwassenes 688 (83%) en 145 (17%) kinders is met ‘n diagnose van akute vergiftiging by Tygerberg Hospitaal toegelaat in teenstelling met die Inligtingsentrum konsultasies waar 322 (54%) volwassenes en 270 (46%) kinders by betrokke was. By volwassenes was 99% van die toelatings die gevolg van doelbewuste vergiftiging (paraselfmoord), terwyl dit 59% van die Inligtingsentrum se navrae was. Drie en negentig persent van die volwassenes was in die Hospital toegelaat met geneesmiddel oordosering. Heelwat minder geneesmiddel oordosering (48%) was deur die Inligtingsentrum hanteer. Parasetamol en ander analgetika, trisikliese antidepressante, anti-epilepsie middels, alkohol en teofillien oordoserings by volwassenes was beduidend hoer by Hospitaal toelatings as by Vergifsentrum konsultasies. Akute vergiftiging deur paraffien en verwante vlugtige substanse by kinders was beduidend hoer by Hospitaal toelatings as wat gevind is by Inligtingsentrum navrae. Navrae ten opsigte van pestisied vergiftiging, gebruik van dwelmmiddels en blootstelling aan biologiese toksiene was beduidend hoer as by Hospitaal toelatings. Hierdie duidelike kontrasterende data dui daarop dat die tipe navrae wat deur die Tygerberg Vergifinligtingsentrum hanteer word nie noodwendig ‘n weerspieeling van die ware insidensie van akute vergiftiging in die gemeenskap is nie. Daar is 2 hoofredes hiervoor. 1. Onderrapportering by die Inligtingsentrum. Gesondheidverskaffers (dokters, verpleegsters, aptekers ens.) is vertroud met die behandeling van sekere algemene vergiftigings soos byvoorbeeld parasetamol oordosering en paraffien inname. Hulle ag dit derhalwe onnodig om die Sentrum hieroor te konsulteer. Dit lei dus tot onderrapportering. 2. Oorrapportering by die Inligtingsentrum. Die Tygerbergse Vergifinligtingsentrum is bekend vir sy vakkundigheid ten opsigte van blootstelling aan biologiese toksiene (spinnekopbyte, slangbyte, skerpioensteke, plante-en sampioen vergiftigings, ens). Dit is om hierdie rede dat vergiftigings deur biologiese agense, geraporteer aan die Sentrum, ‘n hoer syfer verteenwoordig as wat die werklike insidensie ten opsigte van die vergiftigings is. Hierdie studie toon dat vergifinligtingsentrum data nie noodwendig ‘n indikator van die ware insidensie van akute vergiftigings in die gemeenskap is nie. Dit is dus belangrik dat hospitaaltoelatingsdata asook data van primere gesondheidsklinieke ingesluit word om sodoende ‘n beter beeld te verkry van die ware insidensie van akute vergiftigings. ‘n Opmerklike bevinding tydens die studie was die hoe insidensie van doelbewuste geneesmiddel oordosering by volwasse vroue, met veral parasetamol as die middel van keuse. Programme wat fokus op die voorkoming van akute vergiftigings in volwassenes het dringende aandag nodig.

The purpose of this study was to investigate how men, 18 years or older, who had been admitted to inpatient psychiatric hospitalization differed as to their level of aggression, locus of control, and the degree of androgyny at admission and at discharge. The sample consisted of 61 males. The males were evaluated with a demographic questionnaire, the Adjective Check List, the Internal Control Index, and the Bem Sex-Role Inventory within 24 hours of admission and again at discharge. The research indicated that there were no statistically significant differences in these sensitive male qualities. The data indicated a possibility that androgyny could be a catalyst in reducing the level of aggression and developing a more internal locus of control. The research also indicated a positive correlation between age and a more internal locus of control, but the correlation only accounted for 22% of the variance. There was no correlation found between the subjects' relationships to the father figure and the three male qualities.

The purpose of the present study was to test the theoretical relationship of the concepts of informational support and threat appraisal with a sample of surgical cardiac patients twenty-four hours after discharge from the hospital. These discharged patients were adjusting to the transition of hospital to home environment while still recovering from a life threatening illness. They may need varying informational supports to reduce their threat perception of the magnitude of the illness. A convenience sample of thirty-six surgical cardiac patients was assigned to three groups. The groups received the standard discharge preparation as stated by the hospitals' policy and procedure manual. The experimental group received a supportive and informational telephone call approximately twenty-four hours after discharge. The second group was the placebo group, these participants were given a telephone call at the end of the twenty-four hours to remind them to return the questionnaire. The third group was the control group, received no telephone call and were instructed to complete the questionnaire at the specified time. All groups were instructed at the time of initial contact to complete the questionnaire at approximately the end of the first twenty-four hours after discharge. The placebo group and control group were then pooled for data analysis due to the low return rate of the two groups. The two groups were compared with a t-test. The demographic data compared age and educational level to the perceived level of threat. Reliability of the tool was determined using a Cronbach's Alpha.
School of Nursing

This thesis explored the experience of inpatient mental health care from the perspective of individuals diagnosed with Borderline Personality Disorder (BPD). The literature review synthesised the findings from 11 qualitative studies that reported on experiences of inpatient stays. The process elicited five main themes; (1) positions of control; (2) a volatile environment; (3) negative attitudes and responses; (4) the impact of negative attitudes and responses; (5) the absence but importance of talking. The findings suggest that inpatient services can provide the safety, security and support people with a diagnosis of BPD desire. However, they can also repeat unpleasant experiences of the past and therefore trigger distress and contribute to several difficulties associated with this personality disorder. The research study employed a qualitative Interpretative Phenomenological Analysis design to investigate the experiences of discharge from inpatient services. The aim was to explore how and why these experiences have an impact on this client group. Four superordinate themes emerged: (1) from a protective to an isolated space; (2) tensions around accessing support; (3) withholding the truth and guarding the true self; (4) a perpetuation of previous loss. The findings suggest that the transition from hospital to the community can be difficult for people with a diagnosis of BPD. Further difficulties can occur following discharge as a result of experiencing tension between wanting and resisting support. An unwillingness to share true thoughts and feelings can lead to distress and this can be made worse by the overall discharge experience that seems to remind some of previous experiences of loss. The critical review detailed a number of important issues that arose during the completion of this thesis. It also included an evaluation of the research study and discussions that arose from personal reflections.

The full abstract for this thesis is available in the body of the thesis, and will be available when the embargo expires.
Medicine, Faculty of
Anesthesiology, Pharmacology and Therapeutics, Department of
Graduate

This study examined the effect of interdisciplinary discharge planning rounds on timing of social work intervention, length of stay (LOS), and readmission for patients aged 65 and over. Data sources were the medical charts of 449 patients discharged during two corresponding 28 day periods (one before end one after the implementation of rounds) supplemented by Discharge Planning Committee minutes (DPCM) and interviews with four key informants. No significant differences in the timing of social work intervention, LOS, or readmissions were found between the two samples. Qualitative research revealed that essential components were either missing (physician participation), or not uniformly included (family participation) in rounds, and that staff felt that rounds improved communication among the disciplines and contributed to improved efficiency in planning hospital and posthospital services. These findings highlight the need to further study all aspects of the complex discharge planning process to identify factors that would reduce LOS and readmissions.

Mental health is a growing concern for adolescents. Billions of dollars are spent annually on mental services for youth. Many adolescents experience abuse, suicidal ideations, psychotic disorders, substance abuse, and other challenges. Recurring inpatient psychiatric hospitalizations are increasing among adolescents. The recurring admissions impact adolescents significantly socially, psychologically, and financially. Social workers are a vital part of this treatment process from admission to discharge. The research question asked what were the issues and challenges social workers encounter when conducting discharge planning with adolescents receiving recurring inpatient psychiatric treatment. The purpose for this doctoral project was to carefully examine the discharge planning process while identifying ways social workers can positively impact the process. Key concepts for this project were adolescent, inpatient hospitalization, recurring hospitalization, and discharge planning. Systems theory was used to inform the project. This action research study allowed social workers to share their experiences and perspectives about the role of social workers in discharge planning. Seven participants were identified using purposive sampling. One focus group provided data for project. Data analysis consisted of in vivo and process coding. Four participant-inspired themes identified related to issues and challenges in discharge planning include (a) adequate resources, (b) insurance restrictions, (c) rapport with adolescents, and (d) parental participation. Social work practice and positive social change implications include establishing follow-up protocol for all adolescent discharges from inpatient settings and increasing the use of encouragement and engagement strategies for rapport building with adolescents.

Bakgrund: Personer över 80 år har ökat med nästan 22 % under åren 1992 – 2005. Under samma tid har vårdplatserna inom hela akutsjukvården nästan halverats. Detta har lett till ökat vårdbehov och större belastning på framför allt akutmottagningar, medicinkliniker, primärvården och kommunen. Tidigare studier har visat att inadekvata akutmedicinska inläggningar sker ofta runtom i Europa. Syfte: Syftet med studien var att studera inskrivning och utskrivning av patienter vid akutmedicinska avdelningar på ett sjukhus i Sverige. Metod: Studien genomfördes under 2007 på en akutmedicinsk klinik i Sydöstra Sverige. 411 akutmedicinska patientinläggningar bedömdes med Appropriateness Evaluation Protocol (AEP). Lika många hade möjlighet att besvara en enkätfråga, riktad till patienter, sjuksköterskor och läkare, om bedömning av utskrivningen. Resultat: Studien visar att 28,7% av patientinläggningarna inte uppfyllde AEP’s kriterier. De flesta patienter hade bröstsmärta som inskrivningsorsak oavsett adekvat eller inadekvat inläggning. Nära 30 % av patienterna, sjuksköterskorna och läkarna bedömde möjlig utskrivning ett dygn tidigare. Slutsats: Studien visar att inadekvata akutmedicinska inläggningar, enligt instrumentet AEP utgör en betydande del av beläggningen på en medicinklinik som är potentiellt påverkbar. Studien visar också att beläggningen kan påverkas genom tidigarelagd utskrivning enligt bedömningar av såväl patienter som sjuksköterskor och läkare. Resultatet talar för att en bättre kommunikation mellan patienter, sjuksköterskor och läkare skulle kunna optimera längden för akuta medicinska vårdtillfällen.
Background: Persons aged over 80 has increased by almost 22% during 1992-2005. In that time, bed occupancy throughout the emergency medical services has almost decreased to the half. This has led to increased care needs and greater burden, especially on emergency wards, medical clinics, primary care and community. Previous studies have shown that inadequate emergency medical admissions are frequently around Europe. Aim: The aim was to study admission and discharge of patients in acute medical wards at a hospital in Sweden. Method: The study was conducted in 2007 at an acute medical clinic in Southeast Sweden. 411 acute medical patient admissions were assessed with the Appropriateness Evaluation Protocol (AEP). Just as many were able to answer a survey question, directed to patients, nurses and doctors, on the assessment of discharge. Results: The study shows that 28.7% of patients' admissions did not meet AEP's criteria. Most patients had chest pain that enrollment cause any adequate or inadequate curing. Almost 30% of patients, nurses and doctors thought that discharge of the patient was possible one day earlier. Conclusion: The study shows that inadequate emergency medical admissions, with the instrument AEP, are an important part of the hospital bed occupancy of a medical clinic that is potentially impressionable. The study also shows that the hospital bed occupancy can be influenced by earlier discharge according to assessments by both patients, nurses and doctors.

Objectives: This thesis addresses patients’ conceptualising of the experience of admission to and discharge from an inpatient mental health unit, and the role of measurable psychosocial constructs in this conceptualisation. Design: An embedded mixed-methods design was employed. Themes developed using thematic analysis were compared and contrasted with standardised assessment ratings. Methods: Twelve adult patients of an acute mental health unit took part in two separate interviews about their experience of admission and discharge, and completed standardised measures of anxiety and depression, social support, attachment style and illness beliefs. Interview data were analysed using social constructionist thematic analysis. Relationships between participants’ contribution to constructed themes and their responses to standardised assessments were discussed in the context of extant literature. Results: A total of fourteen themes were constructed, organised around a central theme of choices, planning and decision making. Many themes were comparable to existing constructs in attachment theory and the literature addressing illness appraisal, including mentalisation, the safe haven, internal working models, self as illness and shame. Standardised assessments supported and enhanced these interpretations. Conclusions: Understanding of the process and adaptation to the inpatient experience can be enhanced by reference to the concepts of attachment theory and social cognition. Incorporation of these concepts into current care practices and future service development may improve the inpatient experience.

Introduction - Maximising efficient and effective use of resources without compromising quality of care is essential in the current healthcare climate. Intensive care unit services are one of the most resource intensive and therefore expensive services within a hospital. Because intensive care unit services comprise a significant portion of hospital costs and resources, appropriate utilisation of intensive care units is imperative. The occurrence of delayed discharges and the reason for the delays is important as they impact on the efficiency and effectiveness of intensive care unit services. Patients who no longer need intensive care unit care block beds for impending admissions, unnecessarily utilise the costly and often scarce resources and by remaining in a stressful environment may experience negative psychological and social effects detrimental to their well being. Study objectives - To determine to what extent delayed discharge from the intensive care unit occurs and ascertain the reasons for these delays. Design - A prospective cross sectional design to determine the number of delayed discharges from the intensive care unit and reasons causing the delay. A discharge was considered to be delayed if the patient was not discharged from the intensive care unit within 8 hours of being deemed suitable for discharge by intensive care unit medical staff. Setting - A level III intensive care unit with 22 beds (12 general and 10 surgical beds in 2 adjacent areas) in a metropolitan tertiary teaching hospital of 955 beds located across two campuses. Sample - A prospective convenience sample of consecutive patients admitted over a 6-month period from September 2000 to March 2001. Exclusions were patients who died whilst in the intensive care unit and those patients who could be discharged prior to commencement of the study. Method. - Intensive care unit medical staff informed nursing shift coordinators when patients could be discharged. The nursing shift coordinators completed the data collection tool on all patients discharged from intensive care unit. Admission and discharge times and APACHE-11 data (a predictive scoring system for ICU patient outcome) were recorded from intensive care unit records. Results - There were 652 discharges, 468 patients were not delayed (71.8%), 176 were delayed (27.0%, 95% CI 23,9%-30.7%) and 8 (1.2%) patients had no delay information available. There were substantial delays in discharging patients from the intensive care unit; for every 5 discharges that were not delayed, 2 patients would be delayed. Unavailable ward beds (81 %) were cited as the main reason for delay in discharge. Delay time from the intensive care unit ranged from 0.2 hours (1 0 minutes) to 617.5 hours (3 weeks, 4 days, 17.5 hours). Mean delay time was 42 hours (I day, 18 hours) and median delay time 21.3 hours. There was a statistical significance difference between-non delayed and delayed patients for APACHE II score on admission (Ɩ = -3.824 {642), p <0.0001) and worst APACHE 11 score in first 24 hours e (Ɩ = -5.123 (642), p <0.0001 ). There was also a statistically significant difference between delay from the intensive care unit and non delayed discharge by admitting diagnosis (Chi sq (12) = 43.235, p < 0.0001); primary organ system failure (chi sq (6) = 14.231, p = 0.027); ward destination (chi sq (7) = -51.486, p < 0.0001 ); specialty (chi sq (23) = -43.371, p = 0.006) and day of eligible discharge (chi sq (6) = 34.008; p < 0.0001 ). Conclusion - Discharge from the intensive care unit is delayed on average by 27% in the study hospital. These delays can be related to how sick the patient was, principle admitting diagnosis, discharge destination and weekend discharge. Reducing these delays would free up beds for other admissions, may result in a cost saving for the health care facility through more efficient resource utilisation and ultimately benefit patients by better managing the discharge process.

Valvular disorders can be corrected by means of surgery, after which very comprehensive discharge planning should be implemented to prevent the occurrence of post-operative complications. Advances in medical technology and intellect instigate earlier discharge for patients after they have undergone valvular surgery. The aim of this research study is to establish the extent of discharge planning by nurses for patients who have undergone valvular surgery, so that practice guidelines in the form of an in-service educational framework can be compiled for nurses in the management of these patients post-operatively. Patients, many of whom are from rural areas, are discharged without an adequate referral system. There are, currently, no set guidelines or referral persons to direct these patients during their rehabilitation period. Based on the researcher’s personal observations, it is evident that many patients suffer from bacterial endocarditis or clotted valves due to poor post-surgery management. However, both of these conditions could be avoided if proper health education was given to these patients. The study will take the form of a quantitative, exploratory, descriptive and contextual survey. Data will be collected by means of a structured questionnaire that will be completed by the nurses working in the cardiac general ward and the cardiac clinic. Findings of the research study will be used to assist the researcher in developing an in-service educational framework for staff that are both nursing and preparing post valvular surgery patients for discharge. The goal is to prevent complications such as clot formation and endocarditis and to enable patients to deal effectively with their rehabilitation period.

Background: Spinal cord injury (SCI) is defined as a low incidence, high cost condition, however there is little information in the UK regarding the incidence, prevalence or associated costs of SCI. Additionally there is little evidence identifying outcomes or issues associated with delays in referral, admission or discharge from an SCIC or the impact of delays in provision of resources on reintegration outcomes. Research Aim: This novel study aims to determine factors and timings which may facilitate or limit successful rehabilitation and community reintegration for individuals with SCI. Map timescales and key indicators in the SCI injury and rehabilitation and reintegration pathways. Establish the impact of delays in provision of required resources on reintegration outcomes. Methods: An observational longitudinal study, collecting data regarding individuals from injury to one year post-discharge. Rehabilitation, reintegration and healthcare systems outcome measures to be evaluated were identified and included: community participation, quality of life, residential situation, readmission rate and vocational activity. Results: Delays in accessing services occur for a variety of issues and can have lasting impact. Many issues can affect progress and may have a more profound effect at particular points of the injury and rehabilitation pathway. At one year post discharge some subjects have fallen short of the identified outcomes; potential reasons for this are discussed in addition to issues that may have facilitated improved outcomes in some subjects. Conclusion: Some assumptions in SCI rehabilitation and reintegration have been challenged and some partially or fully supported. Novel findings have been identified in relation to physical social and psychological barriers or facilitators of outcomes following SCI. Potential areas for further research to increase our knowledge of issues for SCI individuals, SCIC services, acute hospital services and community services are identified.

En les últimes dècades un moviment internacional provinent de diversos països ha desenvolupat diferents recursos comunitaris per l’atenció de persones grans amb crisis complexes de salut a partir d’intervencions complexes. En la primera part de la tesi s’ha realitzat una revisió de la literatura per tal d’analitzar les principals característiques de diversos models d’hospitalització domiciliària en les persones grans, basada en dues modalitats/estratègies principals: Evitació d’Ingrés (per tal de proveir atenció substitutiva a l’hospitalització i prevenir complicacions relacionades amb l’hospitalització) i Facilitació d’Alta (per tal d’escurçar la durada de l’hospitalització i facilitar la reinserció comunitària després d’un ingrés hospitalari agut). Després de comprovar que disposem de sòlides evidències en intervencions d’hospitalització domiciliària en poblacions d’edat avançada, tant per la modalitat de Facilitació d’Alta com per la d’Evitació d’Ingrés, es va dissenyar, en base a la literatura revisada, una intervenció complexa centrada en la persona a partir de l’Avaluació Geriàtrica Integral (AGI), per a la provisió d’atenció de crisis de salut en persones grans vulnerables que necessitin atenció hospitalària. Un programa integrat d’atenció, anomenat d’Hospitalització Domiciliària Integral (HDI), es va pilotar i avaluar en una àrea urbana del nord del Barcelona, per un equip multidisciplinari de base geriàtrica. El programa va ser analitzat per mitjà d’un disseny quasi experimental, amb comparació dels resultats de la intervenció realitzada en una unitat d’hospitalització domiciliària vinculada a un servei de geriatria, amb els dels pacients aparellats atesos contemporàniament pel mateix servei en la trajectòria convencional d’hospitalització, en diferents processos de salut (mèdics, ortopèdics i ictus). En les dues modalitats, Facilitació d’Alta i Evitació d’Ingrés, el programa domiciliari es va comprovar que era eficient en la consecució de resultats clínics de resolució de crisis i de recuperació funcional, per les diferents trajectòries (mèdica, ortopèdica i ictus). Globalment, els resultats clínics foren comparables als de la trajectòria d’hospitalització convencional. En rehabilitació de processos aguts discapacitants la intervenció s’associà a favorable resolució de la crisi, comparant-la amb l’atenció habitual. En la modalitat de Facilitació d’Alta, en crisis mèdiques i ortopèdiques, la intervenció es va associar amb una estada hospitalària més curta. En la modalitat d’Evitació d’Ingrés en crisis mèdiques, es van evidenciar millors resultats al finalitzar la intervenció, a més d’una tendència no significativa a tenir taxes més reduïdes de reingrés als 30 dies. En l’atenció dels processos ortopèdics, es va evidenciar una reducció significativa en els costos directes de l’atenció. La creació del programa integrat d’HDI va suposar l’adaptació dels models d’hospitalització domiciliària geriàtrics a una població local adulta en el Sud d’Europa. Van identificar-se diversos factors clínics, provinents de l’AGI feta a l’ingrés a la unitat d’hospitalització domiciliària, com a relacionats amb resolució favorable de les crisis de salut ateses, com ara que el diagnòstic principal sigui ortopèdic, presentar una puntuació de més de 40 en l’índex de Barthel d’ingrés, o no presentar nafres per pressió. La recerca clínica presentada en aquesta tesi pretén contribuir a la implementació d’un model d’hospitalització domiciliària geriàtric, adaptat al sistema d’atenció integrat català, a partir de diferents consideracions de recerca futures que es descriuen en la discussió.
In the last decades, an international movement worldwide has developed different schemes in the community to provide care to older adults in complex health crises based on complex interventions. In the first part of this thesis, a literature review was done in order to analyse the main characteristics of several models of hospital-at-home care in older adults, based on two main modalities/strategies: Admission Avoidance (for providing hospital admission substitution and preventing hospital-related morbidities) and Early Supported Discharge (for shortening length of hospitalisation and facilitating community reinsertion after an acute admission). After knowing that there is a strong international evidence on hospital-at-home interventions for several processes of care in older populations, both on Early Supported Discharge and Admission Avoidance modalities, we designed a patientcentred complex intervention, by using Comprehensive Geriatric Assessment (CGA), based on the reviewed literature, to provide care of health crises in vulnerable older patients in need of hospital care. The Hospital-at-Home Integrated Care Programme (HaH-ICP) was piloted and evaluated in an urban area in the north of Barcelona, by a geriatrician-led multidisciplinary team. The programme was analysed using a quasi-experimental design, by comparing the results of the intervention provided in a hospital-at-home unit, linked to a department of geriatrics, with the results of contemporary matched patients that were attended by the same department in a hospital-based trajectory for several disabling health processes (medical, orthopaedics and stroke). In both, Early Supported Discharge and Admission Avoidance modalities, the homebased scheme was found efficient based on clinical outcomes of health crisis resolution and functional resolution, in several trajectories (medical, orthopaedic and stroke processes). Overall, the clinical results were comparable to the hospital-based trajectory. In the rehabilitation process of the disabling health crises, the intervention was found associated with favourable crisis resolution, compared to usual care. In the Early Supported Discharge trajectory, in medical and orthopaedics crises, the intervention led to shortening of acute stay. In Admission Avoidance in medical crises, better functional results at discharge were evidenced, and a non significant trend in lower readmission rates up to 30-day follow-up was observed. In orthopaedic processes, a significant reduction in direct costs was evidenced. The HaH-ICP was an adaptation of geriatrician-led hospital-at-home models of care to a local older adult population in Southern Europe. Several clinical factors from CGA at admission, such as suffering an orthopaedic process, having Barthel Index score higher than 40 points at admission, and not having pressure ulcers at admission, were found factors related with favourable crisis resolution. The clinical research presented in this Doctoral Thesis pretends to contribute to future implementation of the geriatrician-led multidisciplinary hospital-at-home model in the Catalan integrated care system, based on future research lines summarised in the discussion section.

Background: A key innovation in the provision of inpatient services to facilitate the care and treatment of women with severe postnatal mental illness was the introduction of joint mother and baby psychiatric hospitalisations, where both the mother and baby are admitted to hospital together. This study examined the history of the practice of joint mother and baby admissions across the UK and critically explored the processes relevant to the diffusion of joint admissions and patterns of service development to identify the possible and probable causes for significant differences in service provision across the United Kingdom (UK). Aims: The study examined the documented history of the development of practice of joint mother and baby psychiatric hospital admissions across the UK and in doing so, a) Identified the pattern of service and practice development and the likely reasons for the pattern of the chronology. b) Identified the processes involved in the diffusion of joint mother and baby admissions in the UK, and explored why the practice was sustained (or not). c) Contributed new information to the continued development of innovation diffusion theory and research, and its application to health care service and practice development. Methods: A historical method was used in the study and was reported through the use of historical narrative and analysis. Data was collated from primary and secondary sources of documented evidence which was used to inform the history of joint mother and baby admissions across the UK. Data was analysed using the theoretical framework of diffusion of innovation (Rogers, 2003). Findings: Two versions of the same innovation were identified: joint admissions to side rooms of general adult psychiatric wards or annexed areas of the wards and joint admissions to specialist mother and baby units. Neither version of the practice followed the normal S-curve pattern of adoption in terms of frequency and rate of adoption. After a period of approximately 63 years there are 24 facilities for the provision of joint admissions in the NHS in the UK. The main influencers to the adoption of the practice was perception of risk, social networks internal and external to the NHS, the presence of clinical and political champions to drive the adoption and implementation of the innovation and policy entrepreneurship by clinicians working in the clinical field of perinatal mental health. The development of specific policy, guidelines and in Scotland, legislation, has resulted in a move during the last decade from joint admissions being diffused naturally to side room admissions being actively withdrawn and specialist psychiatric mother and baby units actively being disseminated. There is strong evidence that the diffusion process for specialist mother and baby units is still in motion at the time of reporting. Conclusion: Two competing versions of the same innovation had unusual patterns of diffusion. The influencers identified as relevant to the diffusion patterns of each version of the innovation were essentially the same influencers but they were used in different ways to affect change: rejection of one version of the innovation in favour of adoption of the other. The main influencers on the diffusion of joint admissions changed over the time line of the adoption pattern. Barriers to diffusion included the absence of evidence of effectiveness, the absence of economic evaluation, the position in service divisions of perinatal mental health as a field of practice and the absence of succession planning across professional groups. Recommendations are made for future research.

This project offers evidence and data to measure how progressive and sustained mobilization strategies that are implemented by nurses impact early discharge on a single stay Cardiothoracic Intensive Care Unit for patients undergoing first-time Coronary Artery Bypass Surgery (CABG) surgery.

Heart failure (HF) affects 6 million Americans, has an expected increasing prevalence in the next 20 years, and has a 5-year mortality rate of 50%. It represents the number one reason for hospitalization in patients older than 65 years. Recent legislation has increased the accountability of care of patients with HF, specifically readmission rates for HF in less than 30 days. This increased focus on HF readmission rates has led many health care organizations to reassess transition-of-care issues (i.e., from home to hospital, from hospital to home) and possible interventions to positively impact these readmission rates. During this process, home health care providers play an integral role and should be aware of possible issues to ensure optimum care for patients.

In recognition of the inherently inflationary nature of retrospective reimbursement, the Reagan Administration enacted legislation that substantially changed Medicare's hospital reimbursement system. The Prospective Payment System (PPS) mandated paying hospitals a fixed payment, set in advance, based on the patient's diagnosis rather than retrospectively paying for all services delivered to a patient. Critics contend that PPS introduces incentives for hospitals to conserve resources during the hospital stay and to shift care to less costly settings, both potentially affecting quality of care to the elderly. The question addressed by this dissertation is whether there were changes in the discharge health status and post-hospital placement of Medicare beneficiaries as a result of the implementation of PPS. Using a quasi-experimental time-series PRE/POST design, data was collected from the medical records of 2,619 Medicare beneficiaries (1,258 in the PRE-PPS period; 1,361 in the POST-PPS period) hospitalized between 1981 and 1986. Two large (300+ beds) and two medium-sized (100-300 beds) hospitals, representative of hospitals in the Portland metropolitan area, served as data collection sites. Medical records were selected from five Diagnosis Related Groups (DRGs): three medical DRGs (stroke, heart failure, and pneumonia) and two surgical DRGs (hip replacement and major joint pinning). Analysis of the data show that overall length of stay declined from 11.3 days in the PRE-PPS period to 8.6 days in the POST-PPS period, a reduction of 2.7 days and significant at the p = $<$.001 level and a significant increase in Dependency between the PRE and POST periods for four of the five DRGs studies (Stroke, Pneumonia, Heart Failure, and Hip Replacement). Finally, an analysis of differences in post-hospital placements shows a significant increase in POST-PPS placements to home alone (p = $<$.05), home health (p =.01), and for hospital transfers (p = $<$.001). Though limited in its generalizability, the data presented in this dissertation support the contention that Medicare patients are leaving the hospital sooner, in more dependent states of health than before PPS, and that greater numbers of potentially high care patients are being discharged to home and to home health.

Relatório de Trabalho de Projeto apresentado para cumprimento dos requisitos necessários à obtenção do grau de Mestre em Enfermagem Médico-Cirúrgica
Este relatório de trabalho de projeto contém, tendo por base as competências do enfermeiro especialista em EMC e de mestre em enfermagem, um Projeto de Intervenção em Serviço subordinado ao tema: Protocolo de atuação de admissão e alta de doentes num recobro cirúrgico: precioso ou prescindível? O mesmo surgiu pelo facto de exercermos no Serviço de Urologia/Cirurgia Vascular de um Hospital da Margem Sul, onde se verifica a inexistência de critérios estabelecidos de entrada e saída dos doentes do recobro e da sistematização de cuidados, sendo que o próprio recobro não é visto como uma unidade de cuidados pós-cirúrgicos diferenciada, mas como uma extensão da "enfermaria". Para o diagnóstico da situação, realizámos uma análise SWOT dos critérios existentes de entrada e de saída dos doentes do recobro. Recorreu-se à escala modificada de Aldrete, utilizada para a alta do doente nas unidades de cuidados pós-anestésicos, e à Escala de Etxebarria, utilizada no transporte de doente crítico. As principais conclusões a que chegamos prendem-se com a constatação de que a existência de um Protocolo com critérios de admissão e alta de doentes do recobro proporcionam a melhoria da qualidade dos cuidados prestados aos doentes no recobro de um Serviço de Urologia/Cirurgia Vascular, num Hospital da Margem Sul.
Abstract: This report contains, based on the master’s skills, one Intervention Project in service the subject of the admission of action Protocol and high of patients in a surgical recovery room: Precious or dispensable? The same came in that we exercise in the Urology Service / Vascular Surgery Hospital in Region of Lisbon of the South Rim, where he observed a lack of established criteria for entry and exit of patients in the recovery room and the systematization of care, and the recovery room itself is not seen as a unit of differentiated post-surgical care, but as an extension of "nursery". To assess the situation, we conducted a SWOT analysis of the existing criteria for entry and exit from the recovery room patients. Resorted to scale modified Aldrete, used for high patient in the post-anesthesia care units, and Etxebarria Scale, used in the transport of critically ill patients. The main conclusions reached relate to the finding that the existence of a Protocol to the criteria for entry and recovery room of patients output are based on improving the quality of care provided to patients in the recovery room of a Urology / Surgery Service Vascular, a Hospital of the South Rim.

Bipolar disorder is the sixth leading cause of disability in the world among people aged 15-44. Bipolar disorder is a chronic psychiatric disorder with a significant impact on patients’ social, occupational, and general functioning well-being. Patients who are diagnosed with bipolar type 1 disorder are usually admitted to a psychiatric hospital as an involuntary patient which means that they will be cared for in a closed unit. In a critical analysis of the literature it was noted that not much is known of the experiences of patients in psychiatric wards. The researcher used a qualitative approach, with a phenomenological research strategy. An explorative, descriptive and contextual design was utilized to gain more insight into female patients’ lived experiences during their admission and stay in a tertiary level psychiatric institution. The research population was female patients who were diagnosed with bipolar disorder and who had recently experienced being admitted to and treated at a tertiary level psychiatric facility where they were treated for this condition. Purposive sampling was utilised to obtain the sample for the study. A pilot study was conducted before the study commenced to ensure the trustworthiness of the findings. The researcher obtained the data via semi-structured interviews as well as field notes and reflective journals. Data was analysed by using Tesch’s method as adopted by Creswell. Once the data had been analysed, a literature control was done in accordance with the findings. Guba’s model of trustworthiness was utilized to ensure that this study was trustworthy and credible. The researcher implemented ethical principles to ensure that no harm was done to the participants during the research study. Finally, guidelines were developed to assist professional nurses to manage patients optimally during their admission and stay in a closed unit of a tertiary psychiatric facility.

Medication safety and improving communication at care transitions are an international priority. There is vast evidence on the scale of error associated with medicines reconciliation and some evidence of successful interventions to improve reconciliation. However, there is insufficient evidence on the factors that contribute towards medication error at transitions, or the roles of those involved. This thesis examined current UK medicines reconciliation practice within primary and secondary care, and the role of HCPs and patients. Using a mixed-method, multi-centre design, the type and severity of discrepancies at admission to hospital were established and staff undertaking medicines reconciliation across secondary and primary care were observed, using evidence-informed framework, based on a narrative literature review. The overall processes used to reconcile medicines were similar; however, there was considerable inter and intra-organisational variation within primary and secondary care practice. Patients were not routinely involved in discussions about their medication, despite their capacity to do so. Various human factors in reconciliation-related errors were apparent; predominantly inadequate communication, individual factors e.g. variation in approach by HCP, and patient factors e.g. lack of capacity. Areas of good practice which could reduce medicines reconciliation-related errors/discrepancies were identified. There is a need for increased consistency and standardisation of medicines reconciliationrelated policy, procedures and documentation, alongside communication optimisation. This could be achieved through a standardised definition and taxonomy of error, the development of a medicines reconciliation quality assessment framework, increased undergraduate and post-graduate education, improved patient engagement, better utilisation of information technology and improved safety culture.

Medication safety and improving communication at care transitions are an international priority. There is vast evidence on the scale of error associated with medicines reconciliation and some evidence of successful interventions to improve reconciliation. However, there is insufficient evidence on the factors that contribute towards medication error at transitions, or the roles of those involved. This thesis examined current UK medicines reconciliation practice within primary and secondary care, and the role of HCPs and patients. Using a mixed-method, multi-centre design, the type and severity of discrepancies at admission to hospital were established and staff undertaking medicines reconciliation across secondary and primary care were observed, using evidence-informed framework, based on a narrative literature review. The overall processes used to reconcile medicines were similar; however, there was considerable inter and intra-organisational variation within primary and secondary care practice. Patients were not routinely involved in discussions about their medication, despite their capacity to do so. Various human factors in reconciliation-related errors were apparent; predominantly inadequate communication, individual factors e.g. variation in approach by HCP, and patient factors e.g. lack of capacity. Areas of good practice which could reduce medicines reconciliation-related errors/discrepancies were identified. There is a need for increased consistency and standardisation of medicines reconciliationrelated policy, procedures and documentation, alongside communication optimisation. This could be achieved through a standardised definition and taxonomy of error, the development of a medicines reconciliation quality assessment framework, increased undergraduate and post-graduate education, improved patient engagement, better utilisation of information technology and improved safety culture.

In a stroke-certified 500-bed acute care hospital, the 30-day readmission rates for patients discharged to rehabilitation centers or skilled nursing facilities were higher than the rates for patients discharged to home. A review of data by the stroke team showed 44 patients readmitted within 30 days of initial stroke discharge between October 2016 and January 2017. The rate of re-admission for those discharged home was 41% (18 patients), whereas the rate for those discharged to acute inpatient rehabilitation, long-term acute care, or skilled nursing facilities was 59% (26 patients). The practice-focused question for this project assessed whether using a re-admission risk-assessment tool and implementing interventions during the initial acute-care admission, would help to identify and improve risk for 30-day re-admissions for patients diagnosed with stroke. The goal of this research project was to adopt, test, and recommend the implementation of a readmission risk assessment tool to enable discharge planners to identify stroke patients at risk for readmission and implement interventions to help reduce this risk. Lewin’s theory of change was used to inform the project. A stroke re-admission risk-assessment tool in use at a similar hospital was adopted and tested for 1 week on the hospital’s 28-bed stroke unit by nurse case managers. The test was conducted among 5 patients with confirmed diagnosis of stroke. A re-admission data review was performed 30 days after their discharge, which showed no readmissions for the 5 patients involved in the trial. The tool helped to improve case manager awareness of increased risk for readmissions, guide interventions, and improve patient transition and outcomes. The implications of this project for positive change include the potential to improve risk for patients with stroke in the acute-care facility.

The mentally ill who have been found not guilty of a crime by reason of insanity (NGRI), appear to be at risk in several areas when confronted with the judicial system. The purpose of this study is to determine whether the factors which predict recidivism of NGRI patients in Community Out-patient Treatment (COT) also inhibit a patient's release into a conditional release program (CONREP).

Thesis (MMed)--Stellenbosch University, 2014.
ENGLISH ABSTRACT: BACKGROUND Post anesthesia discharge criteria scoring systems have been used successfully to aid discharge from the post anesthetic care unit (PACU) for over 40 years. They do not replace, but rather act in conjunction with good clinical judgment, and provide concise, standardized documentation of a patient’s readiness for discharge. 1,2,3,4,5 In order to improve patient safety, provide clear documentation and to aid future audit, a discharge criteria scoring system was developed for use in our PACU (Addendum A). It is a modification of the Aldrete Scoring System and the modified Post Anesthetic Discharge Scoring System (PADSS) proposed by Chung.1 There is a steadily increasing patient burden on the existing medical infrastructure in South Africa. Tygerberg Academic Hospital is no exception, and because of the high demand on our theatre services, optimal efficiency is essential. We speculated that our discharge criteria scoring system might increase the efficiency of our PACU when compared to the traditional time based system. The more healthy patients, undergoing minor procedures, could potentially spend less time in PACU, allowing the nurses to focus on problem cases. Increasing the speed of transit might also help prevent delays in theatre due to lack of bed space in PACU. Our primary endpoint was to compare the duration of time spent by patients in the PACU at Tygerberg Academic Hospital, from the moment they are admitted, to the time they are discharged to the ward, before and after the introduction of a discharge criteria scoring system. While planning the audit, one of the factors that staff identified as contributing to delayed discharge from PACU, was the time it took for the wards to collect their patients. A secondary objective, therefore, was to assess the amount of time that elapsed between calling the ward to collect the patient, and the patient leaving PACU. METHODS AND MATERIALS Prior to commencing the audit, approval was obtained from the Human Research Ethics Committee of the Faculty of Health Sciences of the University of Stellenbosch and Tygerberg Academic Hospital. The Audit, its purpose and possible benefits, was discussed with representatives of the nurses working in PACU, and written consent was obtained from those who would be involved in the data collection (Addendum B). Audit forms (Addendum C), collection boxes, and posters reminding staff to participate in the audit were prepared. Our first audit was performed over approximately a week in August 2012. During this period, the traditional time-based discharge system was still in operation. Data was captured from 327 patients. Audit forms were placed in a collection box, which was cleared daily by the primary investigator. The discharge criteria scoring system was introduced to the PACU staff in January 2013. The nurses were trained in its use, and a one month period was allowed for all involved to become accustomed to the new system. A second audit was performed in February 2013, again over a week, during which we gathered data from 313 patients. RESULTS The median value of the time spent by patients in the PACU decreased from 1 hour 25 minutes, to 1 hour 15 minutes, after introduction of the discharge criteria scoring system. This was statistically significant (p-value = 0.003). The median time between calling the ward to collect a patient, and the patient leaving recovery, was 15 minutes. CONCLUSION The main finding of the study was that the introduction of a discharge criteria scoring system decreased the median duration of time spent by patients in the post anesthetic care unit at Tygerberg Academic Hospital.
AFRIKAANSE OPSOMMING: AGTERGROND Puntestelsels as ontslag kriteria na narkose, word vir die afgelope 40 jaar suksesvol gebruik as maatstaf om pasiënte uit die herstelkamer te ontslaan. Hierdie kriteria vervang nie goeie kliniese oordeel nie, maar is ’n addisionele hulpmiddel om te bepaal of die pasiënt gereed is vir ontslag en om noukeurige, gestandardiseerde dokumentasie te verseker. 1,2,3,4,5 'n Nuwe puntestelsel vir ontslag is vir die herstelkamer van Tygerberg Akademiese Hospitaal ontwikkel om pasiëntesorg en dokumentasie te verbeter, asook om ouditering in die toekoms te vergemaklik (Addendum A). Hiervoor is die Aldrete Scoring System en die gemodifiseerde PADSS, voorgestel deur Chung, aangepas. 1 Die bestaande mediese infrastruktuur in Suid-Afrika beleef tans ‘n geleidelike toename in die getal pasiënte. Tygerberg Akademiese Hospitaal is geen uitsondering nie en as gevolg van die hoë aanvraag na ons teaterdienste, is uiterste doeltreffendheid noodsaaklik. Ons vermoede was dat hierdie aangepaste puntestelsel doeltreffendheid in die herstelkamer sou verbeter in vergelyking met die meer tradisionele tyd-gebaseerde sisteem. Gesonde pasiënte wat kleiner prosedures ondergaan, sal waarskynlik na ’n korter periode ontslaan kan word wat die verpleegpersoneel in staat sal stel om meer aandag aan probleem gevalle te gee. Bespoediging van die pasiëntvloei behoort onnodige vertragings van teatergevalle weens 'n tekort aan beddens in die herstelkamer, te beperk. Die primêre doel van die studie was om te bepaal of die gebruik van die aangepaste puntestelsel as ontslag kriteria in Tygerberg Akademiese Hospitaal, die tydperk wat die pasiënt in die herstelkamer deurbring, verkort. Die herstelkamer verpleegsters het beweer dat die saal personeel ‘n lang tyd gevat het om hulle pasiente in herstelkamer te kom haal. Vervolgens is 'n sekondêre doelwit ingesluit om die tydperk te bepaal vandat die saalpersoneel in kennis gestel word, totdat die pasiënt die herstelkamer verlaat. METODE Goedkeuring is verkry van die Menslike Navorsing en Etiese Komitee van die Gesondheidswetenskap Fakulteit van die Universiteit van Stellenbosch en Tygerberg Akademiese Hospitaal voor die aanvang van die studie. Die studie, asook die doel en moontlike voordele daarvan is vooraf bepsreek met verteenwoordigers van die herstelkamer verpleegpersoneel en skriftelike toestemming is verkry van al die deelnemers wat betrokke sou wees by die data versameling (Addendum B). Oudit vorms (Addendum C), versamelhouers en inligtingsplakkate vir die betrokke personeel is voorberei. Die aanvanklike oudit is in Augustus 2012 oor 'n periode van ongeveer een week uitgevoer. Tydens hierdie oudit is die tradisionele tydgebaseerde sisteem gebruik. Inligting van 327 pasiёnte is versamel. Die oudit vorms is in die versamelbokse geplaas en is daagliks deur die primêre navorser verwyder. Die aangepaste puntestelsel as ontslag kriteria, is in Januarie 2013 in die herstelkamer geïmplementeer. Die verpleegpersoneel het opleiding ontvang waarna die aangepaste puntestelsel vir een maand gebruik is om te verseker dat die personeel vertroud is daarmee. In Februarie 2013, is ‘n tweede oudit oor ‘n tydperk van een week uitgevoer, waartydens inligting van 313 pasiёnte versamel is. RESULTATE Na die implementering van die aangepaste puntestelsel as ontslag kriteria, het die mediane tyd wat pasiënte in die herstelkamer deurbring afgeneem van 1 uur en 25 minute tot 1 uur en 15 minute. Hierdie afname is statities betekenisvol (p-waarde = 0.003) Die mediane tyd vandat die saal in kennis gestel is totdat die pasiënt die herstelkamer verlaat, was 15 minute. GEVOLGTREKKING Die hoof bevinding van die studie is dat die mediane tydperk wat die pasiënte in die herstelkamer deurbring verminder is deur die implementering van die aangepaste puntestelsel as ontslag kriteria in Tygerberg Akademiese Hospitaal.

Contends that poor discharge planning for elderly patients in American hospitals is the result of reduced lengths of stay which do not give medical social workers adequate time to assess patients' needs. A survey methodology was used to assess social service and community resource needs of hospitalized elderly patients and their family members at Riverside Community Hospital in California. Argues that the results of the survey can be used to improve discharge planning and lead to a more client-centered practice in hospitals.

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Economics from the NOVA – School of Business and Economics
This project tries to assess whether hospitals react to random demand pressure by discharging patients earlier than expected. As a matter of fact, combining an unpredictable demand for medical services with limited and, to some extent, fixed medical resources, generates strong incentives to discharge patients earlier than expected when demand is high - increasing the risk of readmission and decreasing the benefit from treatment. This work was conducted as a way to determine whether those incentives actually affect discharging decisions. Analysis of Portuguese hospitals data shows that hospital utilization levels at the time of admission, prior to the admission and post admission do have a negative impact over the length of stay in hospital, although this impact is quantitatively irrelevant. More than that, larger utilization levels have a positive impact over the probability of being discharged at certain days of the week, indicating that an early discharges problem may exist.

This thesis explores the role of the nurse on an Acute Medical Admissions Unit (AMAU). AMAUs provide a dedicated area for the assessment, treatment, and subsequent transfer or discharge of patients who are medical emergencies. Despite increasing numbers of AMAUs across the UK they are an under researched area and, in particular, there is limited research that has explored the role of the nurse in the AMAU setting. Data were generated through the use of ethnography that entailed participant observation over an eighteen-month period, semi-structured interviews with a purposive sample of doctors, nurses, paramedics, and patients (n= 19), and examination of documentary evidence. Drawing on the concept of communities of practice (Wenger 1998) and the demand-control-social support model of occupational stress (Baker et al., 1996) the key themes of the study were identified as: The AMAU nurse's role in co-ordinating patients ' transition; Professional skills and attributes o f the AMAU nurse; 7 love the buzz': the AMAU nurses' work place stresses and balances; and Organisational constraints and practice boundaries for AMA U nursing The findings from the study indicate that a key aspect of the AMAU nurse's role was the facilitation of rapid patient transition. In addition the study has identified the distinctive and locally negotiated working practices developed by the nurses to coordinate this transition. Another important claim arising from this study was the identification of this nursing role as an evolved construction within a community of practice. This study makes a significant contribution to the limited body of knowledge regarding AMAU nursing practice by aiding understanding of the complexity of this nursing role. Additionally, the application of the concept of community of practice provides a unique perspective and insight into this under explored role. Recommendations are offered for practice, education, management and future research.

Background. Reducing unplanned hospital admissions and achieving timely discharge are key issues for healthcare systems worldwide. Policymakers have focussed on admissions for ambulatory care sensitive conditions (ACSCs) as they are potentially avoidable. Exploring geographic variation could identify variable care pathways. Aims. To investigate the magnitude and causes of geographic variation in unplanned ACSC care. To explore key methodological issues pertinent to small-area variation studies and how this data can inform local decisions. Methods. I conducted a systematic review exploring the magnitude and causes of geographic variation. I estimated geographic variation in ACSC admission rates, length of stay and.readmission rates between PCTs and general practices. I investigated what might be driving these differences. I contrasted geographic variation across patient subgroups. I examined how methodological issues impacted the conclusions of small-area variation studies. I explored how benchmarking is used locally. Results. ACSCs are a large and growing problem. Care processes were highly variable for most, although not all, conditions. Admissions for younger patients, or those with low illness severity, were consistently more variable. Areas with greater bed availability, reduced care continuity and increased A&E proximity had consistently higher admission rates. A range of methodologies were used to quantify geographic variation which can impact conclusions and hinder comparisons. Benchmarking is widely used locally however perceptions of poor data reliability sometimes undermined its utility. Conclusions. There are important differences in ACSC care processes across England. Further work is needed to understand the causes of these differences and should initially focus on the most variable conditions and patient subgroups. Several factors are strongly associated with admission rates; where possible the causal effect of these should be tested using more robust study designs. Improvements in the reliability of routinely collected data, and the methodological rigor of small-area variation studies, is needed to improve their utility.

Patient flow from ICU to the wards has been found to be problematic in many countries. It has been found that many discharges from ICU to ward were unsuccessful at the first attempt. Although after-hours ICU discharges have been found to be associated with increased mortality, after-hours discharges still take place in Australian ICUs. Refused and delayed ICU admissions have been associated with increased mortality, however statistics showed that there were still many patients unable to be admitted into ICUs in Australian hospitals. These findings indicate a resource constraint in Australian ICUs. Many researchers have implemented interventions to address these issues. The engagements of an ICU liaison nurse and an ICU outreach team to provide care to patients after ICU discharge were found to shorten ICU discharge delays and increase patient hospital survival. It is against this context this study was carried out. The aim of this study was to explore and describe the patient discharge process from ICU to the wards in a metropolitan hospital in Australia. Distributed cognition and activity theory were used as theoretical frameworks and cognitive ethnography was used as the research method. Ethnographic data collection techniques including informal interviews, direct observations, and collecting existing documents were used. A total of 56 one-on-one interviews were conducted with 46 participants; 28 discharges were observed; and numerous documents were collected during a three-month period. A triangulated technique was used in both data collection and data analysis to ensure the research rigour.
Thesis (PhD Doctorate)
Doctor of Philosophy (PhD)
School of Nursing and Midwifery
Griffith Health
Full Text

Globally the population is ageing and as a consequence people are living longer with multiple chronic conditions. A range of factors, including decreased lengths of hospital stay and a greater focus on community based care, has led to an increasing acuity of patients admitted to acute care settings, many with complex care needs. To date, models of nursing care in acute settings have been configured to focus on acute, procedural care and do not meet the unique needs of the older person. In order to ensure optimal health outcomes of older hospitalised people, nursing care needs to be responsive to the priorities and needs of patients and their families. This study sought to collaboratively develop a model of nursing care with nurse clinicians to improve the care of older people in the acute care setting. Model development was driven by an action research framework, using evidence-based principles and a comprehensive needs assessment. A three phased, mixed method design was embedded within the overarching conceptual and philosophical framework of action research. The first phase of the study comprised a needs assessment and allowed appraisal of the needs of patients as perceived by patients, carer’s and nurses, this was performed using the Caring Activity Scale [CAS]. Qualitative data and semi-structured interviews added depth to the survey data and qualified responses by confirming that patients thought that nurses did the best they could within a culture of busyness, while patients strived to maintain and sustain their own independence. Managing the discharge process and carer burden arose mainly from the carer semi-structured interviews only. Data revealed significant differences between patients, carer’s and nurses in relation to priority and satisfaction with care. Patients did not place a large importance on discharge care which contrasted with the focus of nursing initiatives. During the subsequent phases of the study a collaborative approach, using action research principles, was used to develop and implement a model of nursing care. A key feature of this model was the introduction of a team structure with a focus on patient centred care. Significant differences were identified in the pre model and post model patient groups in relation to satisfaction with care, with the post model group more satisfied than the pre group model group. Further, improvements in functional status and medication knowledge were demonstrated among patients cared for under the new model. This study has demonstrated that developing a model of care appropriate to the needs of patients, carer’s and nurses can be achieved through the use of action research principles. Study data illustrates the importance of collaboration, empowerment and change management principles in driving clinical improvement and patient satisfaction with care. The findings also underscore the importance of promoting and educating patients and carers as well as nurses about the importance of discharge planning to optimise post-discharge health outcomes.

The Ottawa Hospital cancels hundreds of elective surgeries every year due to a lack of beds, and has an average weekday occupancy rate above 100%. Our approach to addressing these issues, by way of informing administrators of resource needs, was to model the flow of patients coming and going from the hospital. We used administrative data from the Ottawa Hospital to build a time-series model of emergency department admissions, and studied models that would predict next-day discharge of patients currently taking up hospital beds. In the latter, we considered population-averaged models for groups of patients based on their primary medical condition, as well as subject-specific models. We included the random effects from subject-specific variation to improve on predictive accuracy over the population- averaged approach. The result was a model that provided more realistic probabilities of discharge, and stable predictive accuracy over patient length of stay.