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PubMed2005

Overcoming barriers to establishing an inpatient vaccination program for pneumococcus using standing orders.

OBJECTIVES: To identify and classify barriers to establishing a standing orders program (SOP) for adult pneumococcal vaccination in acute care inpatient facilities and to provide recommendations for overcoming these roadblocks. Vaccination rates in hospitals with SOPs are generally higher than those in hospitals that require individual physician orders. The array of solutions drawn from our experience in different hospital settings should permit many types of facilities to anticipate and overcome barriers, allowing a smoother transition from initiation to successful implementation of an inpatient pneumococcal vaccination SOP. DESIGN: Descriptive study of barriers and solutions encountered during implementation of a pneumococcal vaccination SOP in three hospitals of the University of Pittsburgh Medical Center Health System (UPMC) and in the scientific literature. SETTING: As of 2004, two UPMC tertiary-care hospitals and one UPMC community hospital had incorporated SOPs into existing physician order-driven programs for inpatient vaccination with pneumococcal polysaccharide vaccine. RESULTS: Barriers were identified at each step of implementation and categorized as patient related, provider related, or institutional. Based on a process of continual review and revision of our programs in response to encountered barriers, steps were taken to overcome these impediments. CONCLUSIONS: A strong commitment by key individuals in the facility's administration including a physician champion; ongoing, persistent efforts to educate and train staff; and close monitoring of the vaccination rate were essential for successful implementation of a SOP for pneumococcal vaccination of eligible inpatients. Legal statutes and evaluations of external hospital-rating associations regarding the effectiveness of the vaccination program were major motivating factors in its success.

Aged↗
PubMed2001

Development of a French inpatient satisfaction questionnaire.

OBJECTIVE: To develop a brief French-language, generic, self-administered questionnaire to measure inpatient satisfaction. DESIGN: Issues relevant to patients were identified using three open-ended questions designed in accordance with the disconfirmation paradigm. The content of patients' responses was analysed and then supplemented by items taken from published instruments in order to generate a pool of 93 items. Twenty-nine items were selected following a strict procedure. Content validity was judged by comparing the questionnaire to existing instruments. Construct validity was supported by testing specific hypotheses derived from the literature and by performing principal component analysis. Reliability was estimated by calculating Cronbach's alpha. SETTING: A 2200-bed French teaching hospital. SUBJECTS: A mail survey was carried out on a random sample of 1000 inpatients within 2-4 weeks of discharge. Eligible subjects were medical, surgical and obstetrics inpatients who had stayed in the hospital for more than 24 hours. RESULTS: The participation rate (71%) and the completion rate (95%) were indicators of acceptability. There were modest differences between the questionnaire and published instruments (financial aspects, amenities). Construct representation by principal component analysis consisted of six scales which accounted for 58% of the variance in total satisfaction scores. The reliability estimates of internal consistency ranged from 0.67 to 0.86. CONCLUSION: We propose that the self-administered multidimensional inpatient satisfaction questionnaire provided encouraging preliminary psychometric information. This instrument is intended to involve patient feedback in a continuous quality health care improvement strategy.

Adult↗
PubMed2002

The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay.

UNLABELLED: To evaluate the possible effects of outpatient preoperative evaluation (OPE) for new surgical patients who will be inpatients, we conducted an observational study at a university hospital in The Netherlands. Various outcomes before and after the introduction of an OPE clinic were compared. The study population comprised all 21,553 elective adult inpatients operated on between January 1, 1997 and December 31, 1999. Cardiac surgery, obstetric and pediatric patients, and patients operated on in same-day surgery were excluded. The main outcome measures were surgical cases canceled for medical reasons, rate of same-day admissions (who were expected to increase), and length of hospital stay. After introduction of OPE, the rate of cancellations for medical reasons decreased from 2.0% to 0.9% (adjusted odds ratio 0.7, 95% CI, 0.5--0.9). The rate of same-day admissions increased from 5.3% before to 7.7% after OPE introduction (adjusted odds ratio 1.2, 95% CI, 1.01--1.39), and the total hospital length of stay (in days) significantly decreased by a factor of 0.92 (0.90--0.94), which was partly the result of a reduction in preoperative admission time. We concluded that, although smaller than anticipated, the use of OPE for potential inpatients leads to a significant reduction of cancelled cases and of length of admission. Further increase of these benefits from OPE requires changes in institutional policy, such as forcing surgical departments to increase their number of same-day admissions. IMPLICATIONS: An observational study was conducted to compare various outcomes before and after the introduction of outpatient preoperative evaluation (OPE). Although smaller than anticipated, OPE for potential inpatients leads to a significant reduction of canceled cases and of length of admission.

Adult↗
PubMedDate not supplied

Complicated mild traumatic brain injury on the inpatient rehabilitation unit: a multicenter analysis.

OBJECTIVE: To determine characteristics of patients with complicated mild traumatic brain injury (CMTBI) on the inpatient rehabilitation unit and to accentuate limits of current classification systems for patients with mild TBI. DESIGN: Multicenter analysis of individuals with a Glasgow Coma Scale (GCS) score of 13 to 15 (lowest score in 24 h) and positive computed tomography findings admitted to inpatient rehabilitation for TBI. SETTING: 16 TBI Model System centers funded by the National Institute on Disability and Rehabilitation Research. PARTICIPANTS: 373 adults with CMTBI. MAIN OUTCOME MEASURES: Functional Independence Measure (FIM) and Disability Rating Scale (DRS) scores, length of stay, and medical complications. RESULTS: 16% of the sample experienced serious cranial complications (eg, cerebrospinal fluid leak, intracranial hypertension), with seizures being the most common during the course of inpatient rehabilitation. Most patients demonstrated substantial improvements on functional outcome measures during rehabilitation (mean admission FIM 68.2, discharge FIM 100.6; admission DRS 9.1, discharge DRS 4.8). Age, acute length of stay, and FIM score on rehabilitation admission were significant predictors of rehabilitation length of stay. Factors not predictive of rehabilitation duration were GCS score, ethnicity, gender, incidence of fractures, and incidence of cranial/noncranial complications. CONCLUSION: Despite favorable GCS scores, some patients with CMTBI suffer a variety of serious cranial and noncranial complications. Such patients appear to benefit from additional brain injury services offered in inpatient rehabilitation. Further study of the unique treatment needs of these patients is warranted.

Activities of Daily Living↗
PubMed2002

Functional changes during inpatient rehabilitation for children with musculoskeletal diagnoses.

PURPOSE: The purpose of this study was to describe functional self-care and mobility changes of children with musculoskeletal diagnoses during inpatient rehabilitation. METHODS: A retrospective record review was completed for 50 children and youth aged three to 20 years admitted to inpatient rehabilitation after a traumatic musculoskeletal injury or after orthopedic surgery because of a preexisting musculoskeletal or neuromuscular disorder. Admission to discharge changes in summary scaled scores on the Pediatric Evaluation of Disability Inventory's (PEDI) Functional Skills and Caregiver Assistance Self-Care and Mobility scales for the total group and two diagnostic subgroups were examined using paired t tests and effect-size coefficients. Independent t tests were used to determine differences between change scores for the subgroups. RESULTS: Mean PEDI Functional Skills Self-Care and Mobility scaled scores were significantly higher at discharge for the total group. For the subgroups, both Functional Skills and Caregiver Mobility scaled scores were significantly higher at discharge, but only the trauma group made a significant change in Self-Care, on the Caregiver Assistance scale. Effect-size coefficients ranged from 0.23 to 1.76. The trauma group demonstrated significantly greater changes than the postsurgical group on both scales in both domains. CONCLUSIONS: During inpatient rehabilitation, children with musculoskeletal diagnoses demonstrated significant functional improvements. Children with traumatic injuries made greater gains than children with preexisting conditions after orthopedic surgery. These results support the PEDI as a responsive measure of change during inpatient rehabilitation for children with musculoskeletal diagnoses.

Journal Article↗
PubMed1991

Inpatient education for fiberoptic/videoptic diagnostic and therapeutic procedures for gastroenterology.

The purpose of this study was to evaluate the educational needs of the inpatient undergoing gastroenterology or pulmonary diagnostics or therapeutics using fiberoptic or videoptic technology. This study provided a mechanism to increase nursing, patient and family understanding of fiberoptic/videoptics diagnostics and treatment modalities. Interviews and surveys were used to evaluate the educational preparation of inpatients. These data revealed a significant difference in the educational preparation of inpatients compared to outpatients, which was a concern for quality standards in the preparation of gastroenterology/bronchoscopy patients. Teaching methods and tools were implemented in the inpatient environment with a measurable increase in patient preparation for gastroenterology/bronchoscopy procedures. This article will outline the findings, implementation methods and outcomes reported in a procedural gastroenterology laboratory performing approximately 2,000 procedures per year.

Bronchoscopy↗
PubMed2002

The relationship between nurses' job satisfaction and inpatient satisfaction: an exploratory study in a Taiwan teaching hospital.

This exploratory study sought to test the relationship between nurses' job satisfaction and inpatient satisfaction with quality of nursing care in Taiwan. Patient and nurse data were collected from six inpatient care wards in a teaching hospital. Statistical results showed that nurses' general job satisfaction, general feelings of happiness when they are doing their jobs, and their job satisfaction are significantly correlated with at least one of the inpatient satisfaction factors studied, except for the factor of patient education. The results provide partial support for a linkage between nurses' job satisfaction and inpatient satisfaction with nursing care.

Adult↗
PubMed1994

Evaluation of clinical teaching by general internal medicine faculty in outpatient and inpatient settings.

PURPOSE: To determine the measurement characteristics of a form used to evaluate teaching in outpatient settings, and to compare ratings received by general internists in outpatient and inpatient settings. METHOD: The physicians evaluated were 29 faculty who taught in both outpatient and inpatient settings affiliated with the Department of Medicine, University of Washington School of Medicine, over a five-year period (from 1985-86 through 1989-90). Residents completed 639 evaluations, using a six-point Likert-type scale (from 1, very poor, to 6, excellent) to rate instructors in eight categories and to provide an overall assessment of each instructor's teaching effectiveness. In addition, each evaluation contained an indication of the resident's perceived degree of involvement with the instructor. Statistical analysis involved two-tailed t-tests, analysis of variance and covariance, intraclass correlation coefficients, and the Spearman Brown prophecy formula. RESULTS: When more than ten raters of teaching in outpatient settings were available, the reliabilities ranged from .58 to .81. The outpatient-setting ratings were significantly lower than the inpatient-setting ratings for seven categories, overall teaching effectiveness (5.01 versus 5.35, p < .05), and perceived degree of involvement of the instructor with the resident. When controlled for perceived degree of involvement, differences remained in only two categories: demonstration of clinical skills, rated higher for outpatient settings, and instructor accessibility, rated lower. CONCLUSION: The evaluation form provides reliable ratings of teaching in outpatient settings when more than ten raters are available. The differences found in the ratings between the inpatient and outpatient settings may be explained by the factor of the resident's perceived degree of involvement with the instructor.

Evaluation Studies as Topic↗
PubMed1989

Administrative issues in inpatient child and adolescent psychiatry.

There has been a dramatic increase in the number of inpatient child and adolescent psychiatric inpatient beds within the past 5 to 10 years. Child psychiatrists have not been trained to play a leadership role in the development and management of these units. Important issues facing the administrative child psychiatrist include the role of the medical director, the development of the clinical program, staffing of the inpatient unit, the design of the physical plant, financing of inpatient care, promotion of the services, and relationship with medical staff.

Child Psychiatry↗
PubMed1993

Use of inpatient services by a national population: do benefits make a difference?

This study describes changes in the use of inpatient mental health services by children and adolescents under age 18. The data were insurance claims from the Blue Cross and Blue Shield Federal Employees Program. The study focused on a cut in inpatient benefits that occurred between 1978 and 1983. The rate of inpatient hospitalization dropped significantly, and the average number of days also decreased significantly from 45.8 to 27.0 days. This study is among the first to demonstrate that the rate and amount of inpatient care provided for children and adolescents is responsive to variations in benefit coverage.

Adolescent Psychiatry↗
PubMed2003

Correlates of suicide risk in juvenile detainees and adolescent inpatients.

OBJECTIVE: To compare correlates of risk for suicidal behavior in juvenile detainees with those in another high-risk group, adolescent psychiatric inpatients. METHOD: Eighty-one adolescents in a short-term juvenile detention center were contrasted with a matched group of 81 adolescent psychiatric inpatients on a clinical assessment battery of established instruments including a measure for risk of suicidal behavior. RESULTS: Juvenile detainees and adolescent psychiatric inpatients reported similar levels of distress on measures of suicide risk, depression, impulsivity, and drug abuse. After controlling for depression, impulsivity and drug abuse remained significantly associated with suicide risk scores in the juvenile detention group, but did not in the psychiatric contrast group. For depressed female inpatients, hopelessness added significantly to the prediction of suicide risk scores. CONCLUSIONS: Correlates of risk for suicidal behavior in juvenile detainees may differ from those in other high-risk groups. Results suggest that it may be helpful to examine impulsivity and history of drug abuse when assessing suicide risk for detained adolescents. Further study of juvenile detainees as a separate high-risk group is warranted to better determine the nature and extent of risk.

Adolescent↗
PubMedDate not supplied

Management of an inpatient-outpatient clinic an eight-year review.

Healthcare organizations have historically separated outpatient from inpatient facilities. In order to streamline the continuity of high quality care, an outpatient burn clinic was established on our inpatient burn center in 1991. Management of the outpatient clinic required alternate staffing patterns and supply allocation plus training in managed care and third party payors. Budget decisions and health care trends affected the number of full time equivalents (FTEs). Between 1990 and 1998, a 33% RN FTE reduction occurred with an overall 22% decrease in total inpatient care providers. Clinic positions were allocated as patient volume and workload data could justify additional staff. Enhanced flexibility in assignment and use of personnel with varying skill levels led to efficient integration of inpatient and outpatient care with an overall reduction in RN FTEs. The purpose of this study is to review the changes in nursing management strategies required by this consolidation.

Burn Units↗
PubMed1984

MMPI characteristics of borderline personality inpatients.

MMPI (Form R) profiles of psychiatric inpatients (N = 45) meeting DSM-III criteria for borderline personality disorder were compared with chronic schizophrenic inpatients (N = 48) and with inpatients with acute psychotic illness (N = 20). Profile shape was similar among the three groups, although the borderline sample showed significantly higher elevations on four of the 10 clinical scales--Depression, Hysteria, Psychopathic Deviate, and Psychasthenia--when compared to the chronic schizophrenic cohorts. The borderline sample showed only one significant deviation on the clinical scales when compared to the acute psychotic sample as evidenced by a higher elevation on the Psychopathic Deviate scale. Clinically, the borderline MMPI responses suggest features of irritability, hostility, and resentfulness. On the validity scales, the borderline sample showed a significantly lower score on the L scale when compared to both comparison groups, although all of the groups' L scale scores were within conventional limits. While significant differences between groups did not emerge on the F scale, the borderline sample attained a clinically elevated score suggestive of weakened ego defenses and unconventional thinking. Analysis was also performed of a composite measure of psychoticism probability (the Goldberg Index) between groups. While the borderline and acute psychotic samples showed Goldberg indices suggestive of increasing likelihood for psychotic illness, the chronic schizophrenic group yielded a Goldberg Index significantly greater than both of the other groups, thus confirming the validity of the hypothesis. Finally, the MMPI borderline profiles were also compared to previously published norms of borderline outpatients and veteran borderline inpatients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2001

Prevalence of dissociative disorders among psychiatric inpatients in a German university clinic.

The aim of the study was to determine the frequency of dissociative disorders among psychiatric inpatients in Germany and to investigate the relationship between childhood trauma and dissociation. The German version of the Dissociative Experiences Scale (DES), the Fragebogen für Dissoziative Symptome (FDS), was used to screen 115 consecutive inpatients admitted to the psychiatric clinic of a university hospital. Patients with FDS scores higher than 20 were interviewed by a trained clinician, using the German translation of the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R). The German version of the Childhood Trauma Questionnaire (CTQ) was administered to investigate prevalence of childhood trauma and relations between childhood trauma and dissociation in adult life. Twenty-five of the 115 patients (21.7%) had a score higher than 20 on the FDS. Of these, 15 patients were interviewed with the SCID-D-R. One patient was diagnosed with a dissociative identity disorder, three with dissociative disorders not otherwise specified, and one patient with depersonalization disorder. All diagnoses were confirmed clinically. A significant positive relationship was found between the severity of childhood trauma and dissociation. Dissociative disorders are common among German psychiatric inpatients. Clinicians who work in psychiatric inpatient units should be mindful of these disorders.

Adolescent↗
PubMed1998

Emergency Department Observation Unit versus hospital inpatient care for a chronic asthmatic population: a randomized trial of health status outcome and cost.

OBJECTIVES: This study was designed to determine if an accelerated treatment protocol administered to acute asthmatics presenting to a Hospital Emergency Department Observation Unit (EDOU) can offset the need for inpatient admissions and reduce total cost per episode of care without sacrificing patient quality of life. METHODS: The authors used a prospective randomized controlled trial comparing postintervention patient quality of life for EDOU care versus standard inpatient care as measured by the standardized Medical Outcomes Study (MOS) SF-36 instrument. Other measures reported include: clinical status as measured by peak flow rates, total cost per treatment arm using microcosting techniques, and relapse-free survival 8 weeks after treatment. Eligible patients (n = 113) were assigned randomly to an EDOU or inpatient care from a consecutive sample of 250 acute asthmatic patients presenting to an urban hospital emergency department who could not resolve their acute asthma exacerbation after 3 hours of emergency department therapy. RESULTS: Patients assigned to the EDOU had lower mean costs of treatment (EDOU = $1,202 versus Hospital Inpatient = $2,247) and higher quality of life outcomes after intervention in five of eight domains measured by the MOS SF-36: Physical Functioning, Role Functioning-Emotional, Social Functioning, Mental Health, and Vitality. No differences were found in clinical outcomes as measured by peak flow rates or postintervention relapse-free survival. Univariate comparative findings were re-examined and confirmed through multivariable analysis when baseline SF-36 scores and postintervention peak expiratory flow rates clinical status were used as covariates. CONCLUSIONS: The study showed that the EDOU was a lower cost and more effective treatment alternative for a refractory asthmatic population presenting to the Emergency Department. Several baseline MOS SF-36 domains proved useful in predicting or validating posttreatment clinical status, relapse, and total costs of care. Outcome SF-36 domain scores were also useful in identifying patients with the most favorable clinical, cost, and relapse rate outcomes at the study endpoint.

Adolescent↗
PubMed1999

Variation in inpatient resource use in the treatment of HIV: do the privately insured receive more care?

OBJECTIVE: To estimate the impact of insurance status on inpatient resource use after adjusting for health upon admission and site of care. DESIGN: Detailed patient information linked to billing records from the AIDS Cost and Service Utilization Survey (ACSUS), a longitudinal analysis of inpatient and outpatient care between March 1991 and August 1992. SETTING: Hospitalizations of human immunodeficiency virus (HIV) patients from 10 US cities with high incidence of AIDS. PATIENTS: One thousand, nine hundred and forty nine adolescents and adults at various stages of HIV. MAIN OUTCOME MEASURES: We estimate inpatient charges, payments and length of stay as a function of patient, and provider and reimbursement characteristics for more than 1,500 hospitalizations to HIV patients. We control for patient characteristics and underlying risk factors including disease stage, CD4 percentage, mode of transmission, discharge status, type of admission, and region. We use hospital-fixed effects to control for unmeasured differences across facilities. RESULTS: Unadjusted means indicate that uninsured patients or patients covered by public insurance have significantly lower charges and payments than privately insured patients with similar medical conditions. We find that those differences are substantially reduced after controlling for the hospital in which care is received. Further, we find little evidence that "underinsured" patients are discharged sooner on average. CONCLUSIONS: Inpatient resource use is affected by both the hospital in which care is received and the type of patient admitted. Failure to control for unmeasured differences across hospitals is likely to overstate the impact of insurance substantially.

Adolescent↗
PubMed2000

Hoptel equalizes length of stay for homeless and domiciled inpatients.

BACKGROUND: There is growing evidence that homeless individuals have longer inpatient lengths of stay with significantly higher medical costs than domiciled individuals. We compared adjusted mean lengths of stay among domiciled patients and homeless patients discharged to a hospital hotel (hoptel). Because the hoptel allowed homeless patients to be discharged when medically indicated, we hypothesized no significant differences in lengths of stay between the 2 groups after adjustment for severity of illness. METHODS: Demographic, diagnosis, and length of stay data were obtained for all patients discharged from all inpatient wards at a large, urban Veterans Affairs Medical Center during the first 32 months of hoptel operation (1996 through 1998). Adjusted mean lengths of stay for domiciled patients and homeless patients discharged to the hoptel were compared. ANCOVA was used to adjust for demographic characteristics (age, income, race/ethnicity), diagnosis-related group (DRG), principal diagnosis, and substance abuse comorbidity. Three types of hospitalizations were analyzed on the basis of major DRG categories: general medical, psychiatric, and all hospitalizations. RESULTS: No significant differences were found in adjusted mean lengths of stay between domiciled patients and homeless patients discharged to the hoptel. Homeless hoptel patients stayed an average 0.7, 0.3, and 0.4 days longer than domiciled patients for all, general medical, and psychiatric hospitalizations (P = 0.504, 0.627, and 0.839), respectively. CONCLUSIONS: These data suggest that hoptels may help equalize inpatient lengths of stay among domiciled and homeless patients discharged to a hoptel. Public health care systems seeking innovative ways of reducing inpatient lengths of stay among homeless patients ought to consider establishing hoptels.

Aftercare↗
PubMedDate not supplied

Impact on patients and partners of inpatient and extended cardiac counseling and rehabilitation: a controlled trial.

OBJECTIVES: This study evaluated the effectiveness of cardiac counseling and rehabilitation programs led by a nurse counselor, compared with normal care on outcomes for myocardial infarction (MI) patients and their partners. METHODS: A randomized controlled trial with follow-up to 1 year was conducted with 100 patients recruited within 72 hours of a first MI and their partners: a Control group received normal care; an Inpatient group received cardiac rehabilitation from a nurse counselor while in hospital; and an Extended group received the same cardiac rehabilitation as the Inpatient group, but with additional sessions continuing up to 6 weeks after discharge from hospital. The scales for main outcome measures were 1) knowledge of heart disease and treatment (correct, misconceptions, and uncertainty); 2) mood (Hospital Anxiety and Depression Scale); 3) satisfaction; 4) disability (Functional Limitations Profile). RESULTS: Inpatient cardiac counseling and rehabilitation resulted in more knowledge, less anxiety, less depression, and greater satisfaction with care in both patients and partners and in less disability in patients, with effects enduring to 1 year. There was some evidence of additional benefit from the Extended program. Both nurse counselors achieved benefits on all outcome variables. CONCLUSIONS: This Inpatient cardiac counseling and rehabilitation program resulted in significant and enduring benefits of clinical value. It is likely that it would be acceptable to most post-MI patients, many of whom are not offered or are unable to accept outpatient cardiac rehabilitation.

Aged↗