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Comprehensive surveillance of surgical wound infections in outpatient and inpatient surgery.

A surgeon-specific computer-generated monthly questionnaire was used to improve surveillance of surgical wound infections in outpatients as well as inpatients following discharge. From July 1988 through June 1989, 20,536 surgical procedures were performed at our medical center, of which 53% were for outpatients. The total wound infection rate was 0.63%: 0.13% in outpatients and 1.2% in inpatients (p less than .005). Of the infected wounds, 20% were reported by the survey alone and would have gone undetected by conventional surveillance methods (71.4% of outpatient and 13.8% of inpatient wound infections). As a whole, clean and clean-contaminated wounds in outpatients were much less likely to become infected than those in inpatients. Wound cultures were not obtained in 85% of infections reported by the survey alone, and were less likely to be obtained in outpatients. The average time spent by the infection control department on the survey was approximately two hours per week.

Ambulatory Surgical Procedures↗

Psychopharmacological treatment of child and adolescent psychiatric inpatients in Finland.

OBJECTIVE: The objective of this study was to investigate the use of psychopharmacological treatment in child and adolescent psychiatric inpatient treatment in Finland. METHODS: The study is a cross-sectional study conducted in January 2000. The psychiatrist responsible for the inpatient treatment was asked to fill in a questionnaire for every inpatient who occupied a child or adolescent psychiatric bed during the chosen study day (n = 504 patients). Information on psychopharmacological treatment was obtained for 475 patients. RESULTS: Forty-three percent had scheduled medication and 28% had "as required" medication. Of those with scheduled medication, 56% had neuroleptics and 45% antidepressants. In multivariate analysis, older age (13-18 years), involuntary treatment, and psychotic disorder were independently associated with scheduled medication, neuroleptic treatment, and as required medication prescription. Neurolepic treatment was also associated with a very low general functioning level (Children's Global Assessment Scale < 41). A diagnosis of depression and older age were associated with antidepressant treatment. Almost all patients with antidepressant treatment were treated with selective serotonin reuptake inhibitors. CONCLUSIONS: Compared with data from a similarly conducted study in 1988, there is an increase especially in the use of antidepressant medication in inpatient care. Considering the increasing use of psychopharmacotherapy during the last 10 years as shown in the present study, the lack of research-based data on the efficacy and safety supporting their clinical use is a major problem in the treatment of disabling childhood mental health problems.

Adolescent↗

Phenotypic and genotypic characterization of clinical and intestinal enterococci isolated from inpatients and outpatients in two Brazilian hospitals.

The phenotypic and genotypic characteristics of clinical and intestinal enterococcal isolates recovered from inpatients and outpatients of two Brazilian hospitals, located in Niterói city, Rio de Janeiro, Brazil, were compared. A total of 601 strains were studied, including 253 isolated from different clinical sources and 348 intestinal strains (205 isolated from inpatients and 143 from outpatients) recovered from fecal specimens. Isolates were identified by using conventional physiological tests and evaluated for high-level resistance to aminoglycosides (HLR-A) and resistance to vancomycin and ampicillin by the agar screening technique. Susceptibility to several antimicrobial agents was evaluated by the disk diffusion method. The genetic diversity of Enterococcus faecalis strains presenting HLR-A was assessed by pulsed-field gel electrophoresis of chromosomal DNA after SmaI digestion. E. faecalis was the most frequent species among clinical isolates (90.1%) and intestinal strains from inpatients (53.6%). E. casseliflavus was the prevalent species among intestinal isolates from outpatients (35.0%). Clinical isolates were shown to be resistant to erythromycin (53.0%), tetracycline (52.2%), ciprofloxacin (36.4%), gentamicin (36.4%), streptomycin (30.4%), chloramphenicol (34.4%), norfloxacin (32.0%), imipenem (3.2%), and ampicillin (2.8%). Vancomycin resistance was only detected in intrinsic vancomycin-resistant enterococcal species. The overall prevalence of HLR-A was 52.2% among clinical isolates and 40.5% among intestinal strains. However, HLR-A was significantly more frequent among intestinal strains obtained from inpatients (56.6%) than among strains from outpatients (17.5%). Three major clonal groups were found among E. faecalis strains exhibiting HLR-GE or HLR-GE/ST (clonal groups GE-A and GE-B), and strains exhibiting HLR-ST (clonal group ST-A). HLR-A, particularly HLR-GE, was most frequently associated with enterococcal strains of nosocomial origin. Isolates included in the major clonal groups were recovered from clinical and intestinal sources from patients in both hospitals, indicating both intrahospital and interhospital spread of strains.

Brazil↗

Factors affecting total hospital charges and utilization for South Carolina inpatients with HIV/AIDS in 1994-1996,.

This study's analysis addresses trends in hospital utilization and costs for patients with human immunodeficiency virus acquired immunodeficiency syndrome (HIV/AIDS) from 1994 through 1996 in South Carolina, as well as the effect of patient sociodemographics, referrals, and provider characteristics. This is a population-based study of all emergency department visits and hospitalizations occurring during that time period. The total hospital charge per patient significantly increases over time, while the total inpatient days per patient decreases significantly, and the charge per day increases significantly. The proportion of patients with public insurance or who are indigent is increasing, and the proportion of those with private insurance is decreasing. Other variables that have a significant impact on total hospital charges, total inpatient days, and charges per day are types of insurance, physicians specialty, discharge status, and number of diagnoses (severity). Persons who are Medicare eligible are sicker and have higher hospital costs and more inpatient days when compared to those with Medicaid. Intensity of services (hospital charges per day) is associated with private insurance and self-pay patients. Persons with terminal illness stay longer and have higher costs. When HIV/AIDS is the primary admitting diagnosis, there are higher hospitalization costs. Increasing severity of illness (number of diagnoses) leads to higher total hospital charges and days. With the introduction of new AIDS treatments in 1996, further study is required to determine the effects of new drugs, physician specialties, and other provider characteristics on the cost and utilization of health care services, both inpatient and outpatient.

Costs and Cost Analysis↗

Overview of inpatient coding.

The main classification-based and nomenclature-based coding systems used in the United States, as well as the process and importance of documenting in the patient record, are discussed. Hospital pharmacists usually have limited knowledge of and exposure to coding and reimbursement in the inpatient system. Coding allows for reporting of mortality data to the World Health Organization (WHO), reporting morbidity data in the U.S., and providing data for reimbursement from third-party payers to hospitals for services provided. Coded information is also the primary source for administrative management of medical services and a source of epidemiologic and statistical data from inpatient stays. In order to better understand inpatient coding and reimbursement, this article will discuss the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding system; the Healthcare Common Procedure Coding System (HCPCS); the process and importance of appropriate chart documentation; and the development of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) coding system. Coding in the inpatient setting enables hospital billing and provides statistical data for epidemiology and financial planning. The ICD-9-CM is a clinically modified version of the international ICD-9 system used for coding both diagnoses and procedures in the United States. Coding is derived from documentation found in the patient's chart. Appropriate documentation is key for quality and continuity of care and compensation for resources utilized. In the future the ICD-9-CM will be replaced by the 10th revision, ICD-10, which is already in use in many countries in Europe.

Abstracting and Indexing↗

Feasibility of dialectical behavior therapy for suicidal adolescent inpatients.

OBJECTIVE: To evaluate the feasibility of dialectical behavior therapy (DBT) implementation in a general child and adolescent psychiatric inpatient unit and to provide preliminary effectiveness data on DBT versus treatment as usual (TAU). METHOD: Sixty-two adolescents with suicide attempts or suicidal ideation were admitted to one of two psychiatric inpatient units. One unit used a DBT protocol and the other unit relied on TAU. Assessments of depressive symptoms, suicidal ideation, hopelessness, parasuicidal behavior, hospitalizations, emergency room visits, and adherence to follow-up recommendations were conducted before and after treatment and at 1-year follow-up for both groups. In addition, behavioral incidents on the units were evaluated. RESULTS: DBT significantly reduced behavioral incidents during admission when compared with TAU. Both groups demonstrated highly significant reductions in parasuicidal behavior, depressive symptoms, and suicidal ideation at 1 year. CONCLUSIONS: DBT can be effectively implemented in acute-care child and adolescent psychiatric inpatient units. The promising results from this pilot study suggest that further evaluation of DBT for adolescent inpatients appears warranted.

Adolescent↗

Daytime outpatient versus inpatient video-EEG monitoring for presurgical evaluation in temporal lobe epilepsy.

Video-EEG monitoring documentation of seizure localization is one of the most important aspects of a presurgical investigation in refractory temporal lobe epilepsy (TLE) patients. The objective of this study was to evaluate the efficacy of inpatient versus daytime outpatient telemetry. The authors evaluated prospectively 73 patients with medically intractable TLE. Ninety-one telemetry sessions were performed: 35 as inpatients and 56 as outpatients. Outpatient monitoring was performed in the EEG laboratory. They used 18-channel digital EEG. Medications were not changed in the outpatient group. For analysis of the data, time was counted in periods (12 hours = 1 period). Statistical analyses were performed using Student's t-test and the chi2 test. There were no differences between the two groups (outpatient versus inpatient) with respect to age and mean seizure frequency before monitoring, mean time to record the first seizure (1.1 versus 1.4 periods), mean number of seizures per period (0.6 for both groups), lateralization by interictal spiking (46% versus 57%), and lateralization by ictal EEG (59% versus 77%). Daytime outpatient video-EEG monitoring for presurgical evaluation is efficient and comparable with inpatient monitoring. Therefore, the improved cost benefit of outpatient monitoring may increase the access to surgery for individuals with intractable TLE.

Adolescent↗

Determinants of antipsychotic polypharmacy in psychiatric inpatients: a prospective study.

A recent survey of clinicians' opinions suggested that antipsychotic polypharmacy is reserved for particularly severe cases, and that it is intended to avoid high doses of a single drug. In the present study, we tested these clinicians' reasons for antipsychotic polypharmacy in a sample of Italian psychiatric inpatients. During a 6-year recruitment period, all psychiatric patients receiving antipsychotic therapy at discharge from an inpatient facility were included. Sociodemographic and clinical data were collected, and the 18-item version of the Brief Psychiatric Rating Scale was administered on admission and before discharge. At discharge, data on length of inpatient stay, psychotropic drug therapy and treatment adherence were collected. Prescribed daily doses were converted into multiples of the defined daily doses. A total of 354 inpatients receiving antipsychotic treatment at discharge were included. Of these, 100 (28%) were discharged with two or more antipsychotic drugs. After background group differences were controlled for, positive symptoms, manic/hostility symptoms and polypharmacy on admission were predictors of polypharmacy at discharge. The risk of high-dose antipsychotics in patients receiving polypharmacy at discharge was 10-fold higher than that in patients receiving one antipsychotic (odds ratio 10.70, 95% confidence interval 4.78-23.97, P<0.001). The perception of clinicians is to reserve antipsychotic polypharmacy for severe, persistent and difficult-to-treat cases, and this was confirmed by the finding that patients discharged on two or more antipsychotic agents were more severely ill on admission. Conversely, the theoretical advantage of avoiding a high dose of a single drug is counterbalanced by the documented disadvantage of administering high total doses.

Adolescent↗

Classifying psychiatric inpatients: seeking better measures.

BACKGROUND: Use of case-mix reimbursement in psychiatric inpatients has been limited as a result of a lack of systems which effectively group patients according to required resource needs. In recognition of the fact that many patient factors, in addition to diagnosis influence delivery of care in psychiatry, new measures of patient need are emerging. OBJECTIVE: This study compared improvement realized by using a multidimensional measure of patient severity, the Computerized Severity Index (CSI), to predict length of stay (LOS) in psychiatric inpatients over that achieved by using patient variables routinely collected in the discharge abstract. METHOD: Through retrospective chart review, severity ratings were made on 355 psychiatric discharges with primary diagnoses of psychotic or major depressive disorders. Those ratings were combined with demographic and diagnostic data available in discharge abstracts and were then entered into multivariate regression analyses to model LOS. RESULT: CSI ratings significantly contributed to prediction models, which accounted for an additional 9% to 11% of variation in LOS over discharge abstract data. Among patients with psychotic disorders, maximum severity during hospitalization was the best predictor of LOS, whereas among patients with depressive disorders, it was an increase in severity following admission. CONCLUSION: Severity ratings, based on chart review, improved prediction of LOS over discharge abstract variables for psychiatric inpatients in two diagnostic groups. Further research is needed to estimate the impact of incorporating severity ratings into a grouping system for all psychiatric inpatients. Estimation of predictive accuracy is important to determine the amount of risk passed on to providers in a payment system based on psychiatric case mix.

Comorbidity↗

Inpatient rehabilitation outcomes in primary and revision total knee arthroplasty patients.

UNLABELLED: Inpatient rehabilitation is an effective means of improving physical function and independence following total knee arthroplasty (TKA). Revision TKA (TKAR) is becoming increasingly more prevalent and it is unclear if revision TKAR patients attain similar improvements following inpatient rehabilitation compared to primary TKA (TKAP) patients. This investigation compared functional outcomes following interdisciplinary inpatient rehabilitation in 286 TKAP and 138 TKAR consecutive male and female patients. Functional Independence Measure (FIM) scores improved from admission to discharge for the TKAP (81.6 to 110.5) and TKAR (74.4 to 101.4) groups (p = 0.015). TKAP patients had shorter length of stay (LOS) compared to TKAR (9.2 and 11.3). FIM efficiency (FIM/LOS) was greater for the TKAP compared to TKAR (3.6 and 2.6). Total hospital charges were 11,399 dollars and 13,407 dollars for the TKAP and TKAR groups, respectively. TKAP patients were more likely to be discharged home compared to the TKAR patients (97.6 vs. 78.3%). Both TKAP and TKAR patients demonstrate gains in FIM scores during inpatient rehabilitation. However, the amount of FIM efficiency is lower, and LOS and hospital charges are greater when comparing TKAR and TKAP. In addition, discharge disposition may be influenced by the type of TKA, primary and revision. LEVEL OF EVIDENCE: Prognostic study, level II-1 (retrospective study). See Guidelines for Authors for a complete description of levels of evidence.

Aged↗

Depression and other mental health diagnoses after stroke increase inpatient and outpatient medical utilization three years poststroke.

OBJECTIVE: Poststroke depression (PSD) has been linked to negative outcomes, including mortality and decreased functioning. However, the effect of PSD and other mental health conditions on inpatient and outpatient healthcare utilization after stroke has not been examined. The primary objective of this study was to evaluate the relationship between PSD and healthcare utilization after stroke. The secondary objective was to evaluate the relationship between other mental health diagnoses and medical utilization after stroke. METHOD: We examined 3 years of poststroke healthcare utilization data in a national cohort of veterans with ischemic stroke. Mental health diagnoses were identified with inpatient International Classification of Diseases, 9th Revision codes. Multivariate analysis of variance was used to compare patient characteristics and multivariate linear regression to model utilization in: 1) patients with PSD, 2) patients diagnosed with other mental health conditions poststroke, and 3) patients with no mental health diagnosis. RESULTS: Of 51,119 veterans identified, 2405 (5%) received a PSD diagnosis and 2257 (4%) received a diagnosis of another mental health condition after their stroke. Patients with PSD had significantly more inpatient hospitalization days and outpatient visits than those without any mental health diagnosis, even after adjusting for the number of mental health clinic visits. Likewise, patients diagnosed with other mental health diagnoses had greater medical utilization than patients without any mental health diagnosis. Both PSD and other mental health diagnoses independently predicted medical utilization. CONCLUSION: Mental health diagnosis after stroke increases inpatient and outpatient healthcare utilization in the first 3 years poststroke. Additional biologic and psychosocial factors should be investigated.

Aged↗

Chinese inpatients' subjective experiences of the helping process as viewed through examination of a nurses' focused, structured therapy group.

AIMS AND OBJECTIVES: This study examined Chinese inpatients' views on what aspects of a nurses' focused, structured therapy group worked to help their psychological and interpersonal problems and what traditional Chinese cultural values influenced their viewpoints. METHODS: Nine Chinese inpatients with mental illness participated in the four-session nurses' focused, structured therapy group. After they completed the last session of therapy, they were invited to participate in a structured interview and a semi-structured interview regarding their perceptions of the change mechanisms in nurses' focused, structured group therapy. The semi-structured interviews were recorded and transcribed to be further analysed according to the principal of content analysis. RESULTS: The results indicate that (i) all patients believed that a nurses' focused, structured group psychotherapy enhanced their interpersonal learning and improved the quality of their lives, (ii) traditional Chinese cultural values--those emphasizing the importance of maintaining harmonious interpersonal relationships--influenced the Chinese inpatients' expression of negative emotions in the group and their motivation on interpersonal learning. CONCLUSION: In conclusion, we found that transcultural modification for applying Western group psychotherapy in Chinese culture was needed. The modification included establishing a 'pseudo-kin' or 'own people' relationship among group members and the therapists, organizing warm-up exercises and structured activities, applying projective methods and focusing on the issues of interpersonal relationships and interpersonal problems. RELEVANCE TO CLINICAL PRACTICE: The small sample size of the present study raises questions regarding how representative the views of the sample are with respect to the majority of Chinese inpatients. Nevertheless, this preliminary study revealed a cultural aspect in nursing training that requires significant consideration in order to work effectively with Chinese patients.

Cultural Characteristics↗

Beliefs about using consumer consultants in inpatient psychiatric units.

A key recommendation of consumer organizations and governments has been the employment of consumer consultants in inpatient psychiatric facilities, but the attitudes of mental health clinicians towards this measure remain inconsistent. The aims of this study were to examine mental health clinicians' attitudes about the role of mental health consumer consultants in inpatient psychiatric units, and to ascertain if participants' age, type of inpatient unit, or grade of staff influenced their attitudes towards consultants. The Consumer Participation and Consultant Questionnaire was used, which was adapted from the Mental Health Consumer Participation Questionnaire. A convenience sample of 47 mental health professionals from two adult inpatient psychiatric units located in a large Australian public general hospital participated in the study. The findings, overall, showed that participants supported the inclusion of consumer consultants in psychiatric units in areas that indirectly impinged on their current roles. Age, level of nurses, and place of employment did not affect their beliefs, but type of occupation was influential. Nurses were less supportive of aspects of consumer consultants' roles that overlapped with the traditional roles of the nurse. The findings have implications for clinical practice, education, and further research, and these are discussed.

Adult↗

Effects of race and poverty on the process and outcome of inpatient rehabilitation services among stroke patients.

BACKGROUND AND PURPOSE: The greater mortality and residual physical impairments among black stroke patients may be attributable to differential utilization of rehabilitation services. This report examines, within an equal-access healthcare system, racial differences in time to initiation of stroke rehabilitation services and in the trajectory of physical function recovery. METHODS: This study was a secondary analysis of data from an inception cohort of 1073 stroke patients hospitalized between April 1995 and March 1997 and followed up for up to 1 year. Inpatient data came from medical record reviews; follow-up data came from telephone interviews at 1, 6, and 12 months after stroke. The study included consecutive acute ischemic or intracerebral hemorrhagic stroke patients from 9 VA medical centers. The main outcome measures were time to initiation of inpatient rehabilitation services and ability to perform activities of daily living. RESULTS: There were no racial differences in receipt of inpatient rehabilitation services (blacks, 76%; whites, 70%) or in the proportion of patients referred within 3 days of admission (blacks, 43.5%; whites, 42.0%). Among patients who experienced delay in initiation of rehabilitation, only low-income blacks experienced worse functional recovery over 12 months. CONCLUSIONS: Low-income black stroke patients who experience delay in initiation of inpatient rehabilitation have a worse trajectory of functional recovery in the first year after stroke. Poverty-associated factors in the postdischarge setting may explain this phenomenon.

Activities of Daily Living↗

Incidence of stroke among inpatients in a large Italian hospital.

BACKGROUND AND PURPOSE: The incidence of stroke among inpatients is not known. The aim of our study was to investigate the incidence of stroke not preceded by evident iatrogenic factors such as surgical or medical procedures in a cohort of inpatients in a large Italian general hospital. METHODS: From January 1, 1992, to December 31, 1992, we evaluated patients referred to our neurology department with a suspected diagnosis of stroke that occurred during hospitalization. Patients presenting with stroke as a complication of iatrogenic causes were excluded. We calculated the incidence rate of first-ever stroke in our cohort (crude and among patients aged older than 50 years), thereafter adjusting these rates for age to the general population of the city district of Bologna (Italy). RESULTS: In 1992, 22 inpatients had a first-ever stroke with no evidence of iatrogenic factors. The crude stroke incidence rate was 11.08/1000 per year (95% confidence interval, 6.95 to 16.73). The age-adjusted rate was 5.46 (95% confidence interval 3.42 to 8.24). CONCLUSIONS: The incidence rate of first-ever stroke among hospitalized patients is higher than those reported in community-based studies. Higher frequency of coronary artery disease among our patients could explain our findings. Further studies are needed to identify possible predisposing factors (individual or environmental) for stroke among inpatients.

Adult↗

Risk factors and correlates of violence among acutely ill adult psychiatric inpatients.

OBJECTIVE: The purpose of the study was to identify risk factors and correlates of violence committed by patients in an acute adult psychiatric inpatient unit in a district general hospital of the United Kingdom's National Health Service. METHODS: Incidents of violence committed by inpatients over a one-year period in 1997-1998 were retrospectively analyzed. The clinical characteristics of 49 violent patients were compared with those of all patients admitted to the unit during the study period (N=474) and with a random sample of nonviolent patients (N=140). Logistic regression analysis was used to identify clinical variables that predicted violent behavior. RESULTS: Violence was not positively associated with schizophrenia or negatively associated with depression. Frequent medication change, high use of sedative drugs, past violent behavior, an ICD-10 diagnosis of dissocial personality disorder or emotionally unstable personality disorder (DSM-IV antisocial personality disorder or borderline personality disorder), and long hospitalization were the most powerful predictors of violence. Together these variables had a sensitivity of 76 percent, a specificity of 97 percent, and a positive predictive value of 90 percent in predicting which patients became violent. Compulsory (involuntary) admission, comorbid diagnoses, past self-harm, and nonalcohol drug abuse were also associated with violent behavior. CONCLUSIONS: Clinicians' judgment about an inpatient's potential for violence may be augmented by knowledge of the risk factors identified in this study. Medication variables could be especially useful predictors, particularly when information about other risk factors is not available. Factors other than mental illness per se may be crucial determinants of violence in acute inpatient settings.

Acute Disease↗

Community violence and inpatient assaults: neurobiological deficits.

The goals of this study were to examine the relationship between community violence and inpatient assaults and to identify neurological and neuropsychological deficits underlying violent behavior. Thirty-three inpatients with a history of community violence were compared with 69 patients who did not have such a history. Inpatient assaults were recorded for 4 weeks; a neurological/neuropsychological battery was then administered. Patients without community violence were more likely to show transient or no violence while in the hospital. Patients with community violence performed more poorly on the Wisconsin Card Sorting Test and on psychomotor tasks, impairments that are consistent with frontal lobe dysfunction. Inpatient assaults were not associated with these neuropsychological impairments. They were related, however, to impairment on frontal motor programming tasks and a history of community violence.

Adolescent↗

The effect on diagnostic rates of assigning patients to ethnically focused inpatient psychiatric units.

OBJECTIVE: The authors examined whether assigning patients from three ethnic groups-blacks, Latinos, and Asians-to three psychiatric inpatient units that provided culturally appropriate treatment to those groups would affect rates of diagnosis of various psychiatric disorders. METHODS: Retrospective administrative data for 5,983 inpatients at a large urban community hospital with several ethnically focused units were examined. The data represented 10,645 admissions between 1989 and 1996. Chi square analyses and Stuart-Maxwell tests of symmetry and homogeneity were used to assess the relationship between matching patients to ethnically focused units and the rates of major psychiatric illnesses among Asian, black, and Latino patients compared with whites. RESULTS: Ethnic differences in diagnostic rates were consistent with the results of previous studies. Black patients had more diagnoses of psychotic disorders and fewer diagnoses of affective disorders than other ethnic minorities or whites, and Latino patients had more nonspecific diagnoses. Matching inpatients to ethnically focused units did not have a marked effect on patterns of diagnoses among black patients, but an association was observed for Latino patients, particularly those who had only one admission. No significant diagnostic differences were found between Asian patients and whites, irrespective of whether the Asian patients had been ethnically matched to a specialty focus unit. CONCLUSIONS: The effect of referring inpatients with serious mental illnesses to an ethnically focused psychiatric unit varied by ethnic group, probably because each specialty unit functioned differently, depending on the needs of its particular patient population.

Adult↗