Teses / dissertações sobre o tema "Acute medical admissions"

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.

Health information technology (HIT), which includes electronic health record (EHR) systems and clinical data analytics, has become a major component of all health care delivery and care management. The adoption of HIT by physicians, hospitals, post-acute care organizations, pharmacies and other health care providers has been accepted as a necessary (and recently, a government required) step toward improved quality, care coordination and reduced costs: “Better coordination of care provides a path to improving communication, improving quality of care, and reducing unnecessary emergency room use and hospital readmissions. LTPAC providers play a critical role in achieving these goals” (HealthIT.gov, 2013). Though some of the impacts of evolving HIT and EHRs have been studied in acute care hospitals and physician office settings, a dearth of information exists about the deployment and effectiveness of HIT and EHRs in long-term and post-acute care facilities, places where they are becoming more essential. This dissertation examines how and to what extent health information technology and electronic health record implementation and use affects certain measurable outcomes in long term and post-acute care facilities. Monthly data were obtained for the period beginning January 1, 2016 through June 30, 2017, a total of 18 months. The level of EHR adoption was found to positively impact hospital readmission rates, employee engagement, complaint deficiencies, failed revisit surveys, staff overtime (partial EHR), staff turnover rate (full EHR) and United States Centers for Medicare and Medicaid Services (CMS) Five Star Quality score. The level of EHR adoption was found to negatively impact CMS Five Star Total score, staff retention rate (full EHR) and staff overtime (full EHR group higher than partial EHR).

Hospital admissions for patients close to the end of life are considered ‘inappropriate’ in contemporary English health policy. Hospitals are supposedly unable to offer a ‘good’ death for patients, and dying there is thought to contradict patient choice, since patients are assumed to want to die at home. However, almost half of all deaths in England in 2015 occurred in hospital, and of these, nearly a third died within three days of admission. This thesis seeks to explore why these admissions are considered to be a problem and how they occur. Through a systematic review of UK literature I found that it cannot be stated that most patients want to die at home, because of the extent of missing data (preferences not asked, expressed, reported or absent). This finding challenges the justification that admissions are inappropriate because they contravene patient choice. Similarly inconclusive evidence about the undesirability, cost, and lack of need for patients to be in hospital were also found in a review of policy. Together with analysis of historical trends in hospital and hospice provision, it is apparent that attitudes towards end-of-life admissions reflect existing tensions about the role of hospital as an acute provider, and as a place of death. An analysis of interviews conducted with healthcare staff and next-of-kin involved in the admission of patients (case-patients) who died shortly after being admitted to Meadowbridge, a large English hospital explored these tensions further. I found that whilst hospital was not recognised as a place where ‘good’ deaths typically occurred, it was acknowledged as an emergency place of care. In this context, patients without obvious need for hospital care were nevertheless admitted to the hospital and the environment was subsequently recognised to offer distinct benefits. The need for emergency care reflected the difficulties of providing end-of-life care in the community. For dying to occur appropriately, home had to be adapted and care organised by healthcare staff. Both tasks were complicated by the unpredictability of dying, and family carers helped to absorb much of the uncertainty and support patients to die at home. Ambulance staff became involved when patients had care needs that exceeded care quickly and easily available in the community. When called to the case-patients, ambulance staff instituted familiar practices in transferring them to hospital. Hospital was recognised as a default place of care because ambulance staff struggled to facilitate alternative care and lacked sufficient professional authority to keep patients at home. The admissions of the case-patients represent the best attempts of staff to navigate the tangled practices of end-of-life care. These practices are the result of the actions of the staff, which in turn both constrained and enabled their action in providing care to patients. The term ‘inappropriate’ to describe admissions does not encompass these attempts, and moreover, devalued the significant care provided by healthcare staff in the community and hospital.

Fundamentação: O tromboembolismo pulmonar (TEP) é uma doença freqüente no ambiente hospitalar e com significativa mortalidade. A investigação diagnóstica envolve uma série de etapas e o desfecho dos pacientes investigados para TEP, mas cuja investigação não confirmou nem excluiu TEP, não está bem documentado. Objetivo: Comparar a mortalidade intra-hospitalar nos casos com suspeita de TEP agudo entre aqueles com diagnóstico confirmado, diagnóstico excluído e investigação inconclusiva. Métodos: Estudo observacional, comparado, retrospectivo (coorte histórica), de pacientes adultos ( 18 anos) com suspeita de TEP internados no HCPA de 1996 a 2000 que realizaram testes diagnósticos para TEP (cintilografia pulmonar perfusional, angio-TC ou arteriografia pulmonar convencional) ou com CID-9 413/CID10 I26 (embolia pulmonar) na ficha de admissão ou na nota de alta/óbito. Resultados: Dos 741 pacientes selecionados, 687 constituíram a amostra final (54 excluídos). A média de idade foi 61,53 ± 16,75 anos, sendo 292 homens (42,5%). Ocorreu início dos sintomas de TEP no domicílio em 330 casos (48%) e no hospital em 357 (52%). Em 120 pacientes (17,5%) TEP foi objetivamente confirmado, em 193 (28,1%) foi objetivamente excluído e em 374 (54,4%) a investigação foi não conclusiva. A mortalidade intra-hospitalar da amostra foi de 19,1% (n=134). Na análise univariada, sexo masculino, hipotensão, TEP nosocomial, neoplasia maligna, investigação não conclusiva, ausência de tratamento para TEP, investigação em 1996-1997 foram associados à maior mortalidade. Na análise multivariada, hipotensão (beta 2,49, IC95% 1,35-4,63), TEP objetivamente confirmado (beta 2,199, IC95% 1,15-4,21), investigação não conclusiva (beta 1,70, IC95% 1,00 – 2,87), neoplasia maligna (beta 2,868, IC95% 1,80-4,45), TEP nosocomial (beta 1,57, IC95% 1,02-2,41), ano de inclusão 1996- 1997 (beta 1,71, IC95% 1,15-2,67) e infecção torácica ou abdominal (beta 1,71, IC95% 1,08-2,71) foram independentemente associados à maior mortalidade intrahospitalar (p<0,05). Conclusões: Pacientes com TEP agudo objetivamente confirmado tiveram mortalidade intra-hospitalar significativa-mente maior que pacientes nos quais TEP foi excluído. A investigação não conclusiva para TEP foi um fator independente para mortalidade intra-hospitalar em pacientes com suspeita desta doença.
Background: Pulmonary thromboembolism (PE) is frequent in hospital setting and has significant mortality. Diagnostic approach of PE has many steps and follow-up of patients with non-confirmed PE is unknown. Purpose: To compare the inhospital mortality in cases with suspected acute PE among those with confirmed diagnosis, excluding diagnosis and inconclusive diagnostic workup. Methods: Historical cohort including adult patients ( 18 years) with clinically suspected PE that performed perfusion lung scan, CT-angiography, pulmonary arteriography or had PE ICD-9 413/ICD-10 I26 at admission or in discharge charts, from 1996 to 2000. We excluded patients with incomplete or lost medical records. Medical records were reviewed using a standardized form. Statistical analysis was done by chi-square-test, Student’s t test and logistic regression, with statistical significance of 5% (bilateral). Results: Of 741 patients, 687 were included (54 were excluded). Mean age was 61.53 ± 16.75 years, 292 patients were men (42.5%). Primary PE was identified in 330 cases (48%) and secondary PE in 357 (52%). In 120 patients (17.5%), PE was objectively confirmed, in 193 (28.1%) was objectively excluded, and in 374 cases (54.4%) the diagnostic approach was non-conclusive. In-hospital mortality was 19.1% (n=134). In univariate analysis, male gender, hypotension, secondary PE, cancer, non-conclusive approach, untreated PE, inclusion in 1996- 1997 were associated to the highest mortality. In multivariate analysis, hypotension (beta 2.49, 95% confidence interval [CI] 1.35-4.63), PE objectively confirmed (beta 2.199, 95%CI 1.15-4.21), non-conclusive approach (beta 1.70, 95%CI 1.00-2.87), cancer (beta 2.87, 95%CI 1.80-4.45), secondary PE (beta 1.57, 95%CI 1.02-2.41), inclusion in 1996-1997 (beta 1.71, 95%CI 1.15-2.67) and thoracic or abdominal infection (beta 1.71, 95%CI 1.08-2.71) were associated with the highest in-hospital mortality (p<0.05). Conclusions: Patients with acute PE objectively confirmed had significantly higher in-hospital mortality than patients in whom PE was excluded. Non-conclusive approach of PE was an independent factor for in-hospital mortality in patients with suspected disease.

Despite several investigations and interventions aimed at decreasing the time from symptom onset to medical care seeking in acute myocardial infarction patients, the delay time is still too long for best treatment outcomes. In this thesis, investigations aimed at improving our understanding of the factors influencing delay time are evaluated, as well as attitudes to medical care seeking in patients, relatives and the general public. Additionally, an evaluation was performed to examine whether health-related quality of life had any influence on delay time and re-admissions. Participating patients, relatives and representatives of the general public were generally knowledgeable about acute myocardial infarction (AMI) and its symptomatology. The majority of participants knew about the importance of receiving fast treatment when an AMI occurs. Despite people’s knowledge, several patients and relatives felt uncertain of symptom origin and how to act at symptom onset. Patients commonly consulted an additional person when symptoms did not disappear. However, people appeared to act more appropriately if someone else had chest pain compared to self-experienced symptoms. In patients who had suffered from more than one AMI, poor total health status increased the risk of delaying for more than two hours, but no independent association was found between total health status and re-admissions within the first year post-AMI.

The main purpose of this study was to examine empirically the trends and reasons for rising acute adult medical admissions at two major public hospitals in Auckland from 1997 to 2004. According to recent national and international literature published on the topic, there has been unsustainable growth in the adult medical admissions both in NZ and most of the other developed countries. Overall, the causes of this increase have not been explored sufficiently in the literature reviewed. The NZ research has largely focused on the macro-analysis of hospital throughput data from health policy points of view. Methodology: A mixed methodology research design was applied to address the problem. Phase 1 quantitatively analysed adult medical hospital admission data (N = 277,416) obtained from the two hospitals (Middlemore and Auckland Public Hospitals), and phase 2 qualitatively explored the responses and views of the health professional expert panel (n = 16) in relation to the findings of phase 1 of the study. Findings: Overall, the crude number of admissions and age-standardised admission rates at both hospitals increased more rapidly than actual population increases. Approximately 1/3 of the patients accounted for 2/3 of the total admissions. Five major diagnostic categories accounted for 70%-80% of total acute admissions, with circulatory and respiratory system disorders being the leading causes of medical admissions. There was a strong relationship between age and increased admissions. MMH hospital overall, and its ethnic groups separately, had significantly higher admission rates than APH. Comparison of ethnic groups highlighted significant variations in the admission rates at the two hospitals despite adjusting for age, morbidity and deprivation. Conclusions: Overall the increase and variation in admission rates between the hospitals and ethnic groups was dependent on factors such as the characteristics of the population and patients, hospital admission and administration processes, availability of hospital beds, medical management at the hospital, and availability of primary and community care services. By making changes to those factors in the control of hospitals and District Health Boards, hospitals can potentially influence the trajectory of rising medical admissions. These factors include systems for managing patients with chronic illness, and pathways from community services to hospital. Finally, a number of future research areas, such as a large-scale study to explore the health service utilisation of the 55+ age groups, have been proposed.

A research report submitted to the University of the Witwatersrand, in fulfilment for the requirements of the degree of Master of Medicine in the branch of Internal Medicine. Johannesburg 2018.
Background A Medical Acute Care Unit (MACU) was established at Chris Hani Baragwanath Academic Hospital (CHBAH) to provide comprehensive medical specialist care to the patients presenting with acute medical emergencies. Improved standards of health care delivery systems at the MACU may result in shorter hospital stay, better outcomes and less mortality. Objectives The objective of the study was to describe the demographics, diagnoses, pattern of diseases and the outcomes, including mortality of patients admitted to the MACU at the Chris Hani Baragwanath Academic Hospital (CHBAH). Methods A record review of 200 patients admitted to the MACU at CHBAH was performed from March 2015 to August 2015. The records were analysed for patient demographics, diagnosis at admission and duration of stay in MACU. The outcome was defined as transfer to the medical ward, Intensive Care Unit (ICU) or discharged home. The main causes of mortality were also recorded. Results Of the 200 patients, 59% were females. The mean age of the patients was 46 ± 17.2 years and the mean duration of stay at the MACU was 1.45 ± 1.25 days. Noncommunicable diseases accounted for 76% of admissions. The most frequently diagnosed conditions included: diabetic ketoacidosis acidosis (DKA) and hyperosmolar non-ketotic (HONK) (17.5%), non-accidental self-poisoning (16%), hypertensive emergencies (9.5%), decompensated cardiac failure (8%) and ischemic v heart disease (7%). Infectious diseases comprised 14% of the diagnoses of which pneumonias were the most common (5%). Most patients (77.5%) were transferred to medical wards, 12% to ICU, while 10% demised at the MACU. The main causes of death included sepsis (25%), DKA/HONK (20%), non-accidental self-poisoning (10%) and cardiac failure (10%). Conclusion Non-communicable diseases particularly diabetic emergencies were the main causes of admission to the MACU at CHBAH. During the study period, high rates of case improvement, patient discharge, shorter hospital stay, and less mortality were observed. The main cause of mortality was sepsis related.
LG2018

Yes
Background: Hospital-acquired Acute Kidney Injury (H-AKI) is a common cause of avoidable morbidity and mortality. Aim: To determine if the patients’ vital signs data as defined by a National Early Warning Score (NEWS), can predict H-AKI following emergency admission to hospital. Methods: Analyses of emergency admissions to York hospital over 24-months with NEWS data. We report the area under the curve (AUC) for logistic regression models that used the index NEWS (model A0), plus age and sex (A1), plus subcomponents of NEWS (A2) and two-way interactions (A3). Likewise for maximum NEWS (models B0,B1,B2,B3). Results: 4.05% (1361/33608) of emergency admissions had H-AKI. Models using the index NEWS had the lower AUCs (0.59 to 0.68) than models using the maximum NEWS AUCs (0.75 to 0.77). The maximum NEWS model (B3) was more sensitivity than the index NEWS model (A0) (67.60% vs 19.84%) but identified twice as many cases as being at risk of H-AKI (9581 vs 4099) at a NEWS of 5. Conclusions: The index NEWS is a poor predictor of H-AKI. The maximum NEWS is a better predictor but seems unfeasible because it is only knowable in retrospect and is associated with a substantial increase in workload albeit with improved sensitivity.
The Health Foundation

Yes
Objectives There are no established mortality risk equations specifically for emergency medical patients who are admitted to a general hospital ward. Such risk equations may be useful in supporting the clinical decision-making process. We aim to develop and externally validate a computer-aided risk of mortality (CARM) score by combining the first electronically recorded vital signs and blood test results for emergency medical admissions. Design Logistic regression model development and external validation study. Setting Two acute hospitals (Northern Lincolnshire and Goole NHS Foundation Trust Hospital (NH)—model development data; York Hospital (YH)—external validation data). Participants Adult (aged ≥16 years) medical admissions discharged over a 24-month period with electronic National Early Warning Score(s) and blood test results recorded on admission. Results The risk of in-hospital mortality following emergency medical admission was 5.7% (NH: 1766/30 996) and 6.5% (YH: 1703/26 247). The C-statistic for the CARM score in NH was 0.87 (95% CI 0.86 to 0.88) and was similar in an external hospital setting YH (0.86, 95% CI 0.85 to 0.87) and the calibration slope included 1 (0.97, 95% CI 0.94 to 1.00). Conclusions We have developed a novel, externally validated CARM score with good performance characteristics for estimating the risk of in-hospital mortality following an emergency medical admission using the patient’s first, electronically recorded, vital signs and blood test results. Since the CARM score places no additional data collection burden on clinicians and is readily automated, it may now be carefully introduced and evaluated in hospitals with sufficient informatics infrastructure.
The Health Foundation, National Institute for Health Research (NIHR) Yorkshire and Humberside Patient Safety Translational Research Centre

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 lead 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](1). 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.
Doctor of Philosophy (PhD)