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PubMed2006

Controlled trial of multidisciplinary care teams for acutely ill medical inpatients: enhanced multidisciplinary care.

BACKGROUND: Acute hospital general medicine services care for ageing complex patients, using the skills of a range of health-care providers. Evidence suggests that comprehensive early assessment and discharge planning may improve efficiency and outcomes of care in older medical patients. AIM: To enhance assessment, communication, care and discharge planning by restructuring consistent, patient-centred multidisciplinary teams in a general medicine service. METHODS: Prospective controlled trial enrolling 1538 consecutive medical inpatients. Intervention units with additional allied health staff formed consistent multidisciplinary teams aligned with inpatient admitting units rather than wards; implemented improved communication processes for early information collection and sharing between disciplines; and specified shared explicit discharge goals. Control units continued traditional, referral-based multidisciplinary models with existing staffing levels. RESULTS: Access to allied health services was significantly enhanced. There was a trend to reduced index length of stay in the intervention units (7.3 days vs 7.8 days in control units, P = 0.18), with no change in 6-month readmissions. In-hospital mortality was reduced from 6.4 to 3.9% (P = 0.03); less patients experienced functional decline in hospital (P = 0.04) and patients' ratings of health status improved (P = 0.02). Additional staffing costs were balanced by potential bed-day savings. CONCLUSION: This model of enhanced multidisciplinary inpatient care has provided sustainable efficiency gains for the hospital and improved patient outcomes.

Acute Disease↗
PubMed2004

Identifying and accommodating statistical outliers when setting prospective payment rates for inpatient rehabilitation facilities.

OBJECTIVE: To demonstrate how a Bayesian outlier accommodation model identifies and accommodates statistical outlier hospitals when developing facility payment adjustments for Medicare's prospective payment system for inpatient rehabilitation care. DATA SOURCES/STUDY SETTING: Administrative data on costs and facility characteristics of inpatient rehabilitation facilities (IRFs) for calendar years 1998 and 1999. STUDY DESIGN: Compare standard linear regression and the Bayesian outlier accommodation model for developing facility payment adjustors for a prospective payment system. DATA COLLECTION: Variables describing facility average cost per case and facility characteristics were derived from several administrative data sources. PRINCIPAL FINDINGS: Evidence was found of non-normality of regression errors in the data used to develop facility payment adjustments for the inpatient rehabilitation facilities prospective payment system (IRF PPS). The Bayesian outlier accommodation model is shown to be appropriate for these data, but the model is largely consistent with the standard linear regression used in the development of the IRF PPS payment adjustors. CONCLUSIONS: The Bayesian outlier accommodation model is more robust to statistical outlier IRFs than standard linear regression for developing facility payment adjustments. It also allows for easy interpretation of model parameters, making it a viable policy alternative to standard regression in setting payment rates.

Bayes Theorem↗
PubMed2001

Prevention in the inpatient setting.

PURPOSE: To review the literature on and describe approaches to implementing health promotion and disease prevention practices in the inpatient setting. DATA SOURCES: Comprehensive review of nursing and medical literature, clinical practice guidelines, and U.S. government documents. CONCLUSIONS: Preventive screening has been shown to reduce morbidity and mortality from many diseases. Health promotion and disease prevention activities form the foundation of practice for many nurse practitioners (NPs). As increasing numbers of NPs begin to practice in the acute care setting, it is important they incorporate prevention into the inpatient setting. IMPLICATIONS FOR PRACTICE: Because there are many barriers that impact appropriate preventive screening, health care providers must take advantage of every patient encounter including those in the inpatient setting. Although it may not be feasible to actually perform certain screening exams while a patient is hospitalized, it is feasible in many cases to take a few minutes to review recommended preventive screening.

Health Promotion↗
PubMed1992

[Isolation of MRSA from inpatients, staff and environment in the hospital].

The state of MRSA contamination of inpatients, hospital staff, and the hospital environment was evaluated. Nasal, pharyngeal, and digital samples from 182 patients admitted in September and October, 1990, and 288 hospital staff members and sputum, urine, and feces of the inpatients were cultured. Environmental contamination was examined in samples collected from the air by air sampling and from the floor by the wiping method. The MIC and the coagulase type of the MRSA obtained were determined, and their relationships were evaluated. MRSA was detected in 9.5% of nasal samples, 7% of pharyngeal samples, 10% of sputum samples, 0% of urine samples, and 2.6% of fecal samples from the 182 inpatients. It was detected in 4% of nasal samples, 0.7% of pharyngeal samples, and 1% of digital samples from the 288 hospital staff members. From the environment, MRSA was detected from hospital rooms of the surgery and neurosurgery wards, the nursing room and corridors of the obstetrics and gynecology ward, and the recovery room of the urology ward. The coagulase type of the MRSA obtained was the primarily type II regardless or whether the samples were obtained from the subjects or the environment. Concerning the drug sensitivity, many MRSA strains were highly resistant to DMPPC and FOM, but the sensitivity to RFP was 0.1 microgram/ml or less in all strains except for one highly resistant strain (200 micrograms/ml or above).(ABSTRACT TRUNCATED AT 250 WORDS)

Air Microbiology↗
PubMed2004

Performance assessment of the fecal leukocyte test for inpatients.

Traditionally, fecal leukocyte testing detects large bowel inflammation or disruption, conditions that allow leukocytes into the stool. However, test usefulness with inpatients is unclear. Two hundred five inpatients who had undergone one to three tests were identified, and their FLT results were compared to their gastrointestinal disease diagnoses at time of discharge. A specificity of 92% for detecting intact colonic mucosae in inpatients was found.

Clostridioides difficile↗
PubMed1986

Demands on surgical inpatient services after mass mammographic screening.

The changes in the demand for surgical inpatient care created by mammographic screening for breast cancer were analysed by comparing two counties, one with and one without a mass screening campaign. A comprehensive computerised register of inpatient care in the region was used. The results indicate that population based screening offered to women above 40 years and repeated every two to three years will increase the number of operations required for breast cancer and inpatient days by at least 150% during the initial screening round. During the second round the figures tend to return to previous levels. Of decisive importance for the demands on health service resources are the specificity of screening, the duration of the first screening round, and the age groups included.

Adolescent↗
PubMed1997

Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies.

OBJECTIVES: To identify clinical characteristics of elderly inpatients that predict their chance of falling (phase 1) and to use these characteristics to derive a risk assessment tool and to evaluate its power in predicting falls (phases 2 and 3). DESIGN: Phase 1: a prospective case-control study. Phases 2 and 3: prospective evaluations of the derived risk assessment tool in predicting falls in two cohorts. SETTING: Elderly care units of St Thomas's Hospital (phase 1 and 2) and Kent and Canterbury Hospital (phase 3). SUBJECTS: Elderly hospital inpatients (aged > or = 65 years): 116 cases and 116 controls in phase 1,217 patients in phase 2, and 331 in phase 3. MAIN OUTCOME MEASURES: 21 separate clinical characteristics were assessed in phase 1, including the abbreviated mental test score, modified Barthel index, a transfer and mobility score obtained by combining the transfer and mobility sections of the Barthel index, and several nursing judgements. RESULTS: In phase 1 five factors were independently associated with a higher risk of falls: fall as a presenting complaint (odds ratio 4.64 (95% confidence interval 2.59 to 8.33); a transfer and mobility score of 3 or 4 (2.10 (1.22 to 3.61)); and primary nurses' judgment that a patient was agitated (20.9 (9.62 to 45.62)), needed frequent toileting (2.48 (1.08 to 5.70)), and was visually impaired (3.56 (1.26 to 10.05)). A risk assessment score (range 0-5) was derived by scoring one point for each of these five factors. In phases 2 and 3 a risk assessment score > 2 was used to define high risk: the sensitivity and specificity of the score to predict falls during the following week was 93% and 88% respectively in phase 2 and 92% and 68% respectively in phase 3. CONCLUSION: This simple risk assessment tool predicted with clinically useful sensitivity and specificity a high percentage of falls among elderly hospital inpatients.

Accidental Falls↗
PubMed2006

Psychiatric disorders in inpatients on a neurology ward: estimate of prevalence and usefulness of screening questionnaires.

BACKGROUND: Patients on neurology wards have been shown to have high rates of psychiatric illness. Prevalence figures of 39-64% have been reported previously. However a low rate of recognition of psychiatric illness is also observed in this population. OBJECTIVES: To estimate the prevalence of psychiatric illness in neurology inpatients in a regional neuroscience centre and to assess the sensitivity and specificity of a batch of screening questionnaires. METHOD: Patients were assessed using the following screening questionnaires: Primary Care Evaluation of Mental Disorders, Mini Mental State Examination, Frontal Assessment Battery, Alcohol Use Disorders Identification Test and a neurologist-rating scale of organicity. All patients also had a full psychiatric assessment using the Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV). The screening questionnaires were then compared with our "gold standard", the psychiatric assessment. RESULTS: The prevalence of psychiatric illness (as determined by the psychiatric interview) in neurology inpatients in a tertiary referral centre was found to be 51.3% (95% confidence interval 44 to 58%). The sensitivity of this batch of screening questionnaires is 81.2% and the specificity is 77.1%. CONCLUSION: A high prevalence of psychiatric disorder was observed in inpatients on a dedicated neurology ward. The screening questionnaires used had a high sensitivity and specificity and could therefore be used as a simple way of identifying those with psychiatric illness.

Adolescent↗
PubMed2002

One-year follow-up of dual diagnosis patients attending a 4-month integrated inpatient treatment.

The purpose of this study was to assess a 4-month inpatient treatment program based on integrated models for patients with substance use and psychiatric disorders (dual diagnosis patients). On admission and at the 1-year follow-up, a consecutive sample of 118 dual diagnosis patients who entered the program were assessed by interview. Eighty-four patients (70.6%) completed the 1-year follow-up interview, reporting less frequent substance use, less severe psychiatric symptoms, a lower rehospitalization rate, and better housing conditions than on admission. Patients diagnosed with a comorbid personality disorder had a better improvement in the frequency of drinking and were less likely to be rehospitalized than patients with schizophrenia or depression. The results suggest that the integrated inpatient program may be a promising treatment approach for dual diagnosis patients. The results await replication in controlled studies that need to include an assessment of outpatient treatment following inpatient programs.

Adult↗
PubMedDate not supplied

Ceftriaxone for the treatment of febrile episodes in nonneutropenic patients with hematooncological disease or HIV infection: comparison of outpatient and inpatient care.

BACKGROUND: Patients with hematooncological disease or HIV infection and febrile episodes are usually treated in hospital with broad-spectrum antibiotics. The aim of this observational study was to assess the feasibility of ambulatory parenteral antibiotic therapy in hematooncological or HIV-infected patients with confirmed or suspected infection. METHODS: The results in an outpatient treatment group were compared with those obtained in a group initially treated in hospital. Data were gathered on 90 outpatients and 72 inpatients. The inclusion criteria were fever > or =37.5 degrees C with an identified focus of infection, fever > or =38.0 degrees C of suspected bacterial origin with no identified focus of infection, leukocytosis > or =9,000/microl or C-reactive protein elevation > or =10 mg/l. RESULTS: Eighty outpatients and 69 inpatients were evaluable. Treatment in the outpatient group was begun with ceftriaxone. This led to defervescence in 87.5% of cases. The mean treatment duration was 7.1 days. Comparison of results in the outpatients with those initially hospitalized for treatment showed similar success rates. The mean hospital stay in the latter group was 12.9 days. CONCLUSIONS: Ceftriaxone represents an effective treatment for outpatient management of febrile episodes in patients with hematooncological disease or HIV infection. Outpatient treatment is more cost-effective than inpatient care.

Adolescent↗
PubMed2005

Comparison of changes in physical self-concept, global self-esteem, depression and anxiety following two different psychomotor therapy programs in nonpsychotic psychiatric inpatients.

BACKGROUND: The first objective of this study was to compare the changes in physical self-concept, global self-esteem, depression and anxiety after participation in one of two 16-week psychomotor therapy programs for nonpsychotic psychiatric inpatients. The second objective was to study the relationship between changes in these variables. METHODS: One hundred and ninety-nine inpatients were randomly assigned to either a personalized psychomotor fitness program, consisting of aerobic exercise and weight training, or a general program of psychomotor therapy, consisting of different forms of physical exercises and relaxation training. Physical self-concept was evaluated using the Dutch version of the Physical Self-Perception Profile at baseline, after 8 weeks, and after completion of the 16-week interventions. At the same time points, additional variables of global self-esteem, depression and anxiety were assessed by means of the Rosenberg Self-Esteem Inventory, the Beck Depression Inventory and the Trait Anxiety Inventory, respectively. RESULTS: After 16 weeks, both groups showed significant improvements in all outcome measures (p values ranged from 0.01 to < 0.0001), with no between-group differences. In both groups, the improvement in physical self-concept was correlated with increased global self-esteem and decreased depression and anxiety levels (p < 0.01). CONCLUSIONS: The results suggest that both psychomotor therapy programs are equally effective in enhancing physical self-concept. The relationship between improvements in physical self-concept and enhancements in global self-esteem, depression and anxiety supports the potential role of the physical self-concept in the recovery process of depressed and anxious psychiatric inpatients.

Adult↗
PubMed2007

Inpatient and community ischemic strokes in a university hospital.

BACKGROUND: Previous studies have shown that inpatient strokes are common and severe. We sought to characterize the risk factors, stroke subtypes, timing of acute stroke evaluation and frequency of thrombolytic therapy in inpatient ischemic strokes compared with community ischemic strokes. DESIGN/METHODS: The hospital records of patients admitted for acute ischemic stroke between 1996 and 2002 were reviewed. Acute stroke was defined as occurrence of stroke symptoms within 72 h, and in-hospital status was assigned if the patient was currently admitted for another illness at the time of the stroke. Patient demographics such as medical versus surgical service, admission diagnoses, clinical features including stroke risk factors, access to thrombolytic therapy and immediate outcome were analyzed. RESULTS: Of 947 patients with acute ischemic stroke, 161 (17.0%) had strokes occurring while already in the hospital (IHIS), compared to 786 (83%) that occurred in the outpatient community (CIS). Approximately two thirds of IHIS occurred on medical services (102, 63.4%) and one third on surgical services (59, 36.7%). Mean age, male gender, atherothrombotic etiology and risk factors including hypertension, diabetes and smoking history were of similar frequencies in IHIS and CIS, but penetrating artery disease was the cause of only 5.6% of IHIS compared to 21.8% of CIS (p<0.0001). The mean modified Rankin scale for IHIS at presentation was 4.33 +/- 0.74, compared to 3.67 +/- 1.03 for CIS (p<0.0001). Of 161 IHIS patients, 21 (13.0%) had neurological assessment within 3 h of symptom onset, compared to 16.0% of CIS patients (p=0.403, n.s.), and the rate of thrombolytic therapy was not significant between IHIS (3.7%) and CIS (5.6%) patients. CONCLUSIONS: IHIS are common and severer than CIS. The use of thrombolytic therapy in IHIS patients was limited because of time of recognition and inpatient-associated conditions. Increased vigilance for timely neurological assessment of these patients is warranted.

Aged↗
PubMed2001

Treatment with tissue plasminogen activator and inpatient mortality rates for patients with ischemic stroke treated in community hospitals.

BACKGROUND AND PURPOSE: Most analyses of intravenous tissue plasminogen activator (IV tPA) use for acute stroke in routine practice have been limited by sample size and generally restricted to patients treated in large academic medical facilities. In the present study, we sought to estimate among community hospitals the use of IV tPA and to identify factors associated with the use of IV tPA and inpatient mortality. METHODS: We evaluated a retrospective cohort of 23 058 patients with ischemic stroke from 137 community hospitals. RESULTS: Three hundred sixty-two (1.6%) patients were treated with IV tPA, and 9.9% of those patients died during the hospitalization period. In 35.0% of the hospitals, no patients were treated with IV tPA, whereas 14.6% of hospitals treated approximately 3.0% with IV tPA. After control for multiple factors, younger patients, more severely ill patients (OR 2.02, 95% CI 1.36 to 3.01), and patients treated in rural hospitals (OR 1.80, 95% CI 0.99 to 3.26) were more likely to receive IV tPA, whereas black patients were less likely (OR 0.54, 95% CI 0.31 to 0.95). There also was a trend showing that women were less likely to receive IV tPA (OR 0.84, 95% CI 0.69 to 1.03). Factors associated with an increased odds of inpatient mortality included receipt of IV tPA among men (OR 2.81, 95% CI 1.72 to 4.58) and increased age. Black patients were 27% less likely to die during hospitalization (95% CI 0.60 to 0.90). CONCLUSIONS: In this large, retrospective evaluation of community hospital practice, the use IV tPA and inpatient mortality rates among IV tPA-treated patients were consistent with those of other studies. The likelihood of receiving IV tPA varies by race, age, disease severity, and possibly gender. These factors may influence mortality rates.

Aged↗
PubMed2000

A content analysis of state hospital policies on sex between inpatients.

Eighty-one state psychiatric hospitals in 16 states were surveyed about whether they had policies on sex between inpatients. Thirty-one hospitals responded by sending a copy of their policies, which were analyzed for explicit definitions and distinctions between various sexual behaviors; for the presence and content of statements about patients' rights and personal autonomy, duty to protect, competency to consent, and staff guidance and education; and for instructions on the management of sexual incidents. Fourteen of the 31 policies explicitly forbade inpatient sex; 12 stressed patient autonomy. Only five specified that staff should receive special training. The results indicate that hospitals vary widely in their attention and management approach to inpatients' sexual behavior.

Health Care Surveys↗
PubMed2003

Managing sexual behavior on adult acute care inpatient psychiatric units.

OBJECTIVE: Protecting and safeguarding persons with impaired decisional capacity are among the critical functions of a psychiatric hospital. The objective of this study was to investigate the elements of these functions as they relate to sexual behavior on an adult acute care inpatient psychiatric unit and to develop a policy to prevent or at least manage such behavior. METHODS: The authors undertook an extensive literature review of articles and legal cases. The review was presented at numerous meetings of staff and interdisciplinary teams on the adult teaching unit at Bellevue Hospital in New York City. The findings from the review and the results of staff discussions were used in creating the policy. RESULTS AND CONCLUSIONS: In the acute care setting, it may be both reasonable and prudent to prevent all sexual interactions between patients, especially given the potential risks of such behavior. Concerns include the transmission of sexually transmitted disease, reproductive issues, and the legal implications of nonconsensual activity. Despite these concerns, adult psychiatric inpatients should be granted as many rights as are possible without having an adverse effect on their treatment or recovery. There is currently no standard for a sexual behavior policy for psychiatric inpatients. Thus ward staff are left with minimal guidance and potential confusion in the event that sexual incidents do occur, and there is a greater likelihood of arbitrary responses. The policy developed through this study is an example of how individual institutions can enforce a structured protocol when dealing with an ambiguous and difficult issue.

Adult↗
PubMed2004

Treatment of tobacco use in an inpatient psychiatric setting.

OBJECTIVE: Despite high rates of tobacco use among psychiatric patients, such patients are one of the least studied groups of smokers, and little is known about their access to cessation treatment. This study examined delivery of tobacco cessation services in a smoke-free inpatient psychiatric setting. METHODS: Medical records of 250 psychiatric inpatients who were admitted from 1998 to 2001 were randomly selected and systematically reviewed. RESULTS: A total of 105 patients (42 percent) were identified as current smokers; the mean+/-SD number of cigarettes that they smoked per day was 21+/-15. Smokers evidenced statistically greater agitation and irritability compared with nonsmokers. None of the smokers received a diagnosis of nicotine dependence or withdrawal, and smoking status was not included in treatment planning for any patient. Nicotine replacement therapy was prescribed for 59 smokers (56 percent); of these patients, 54 (92 percent) used it. Smokers who were not given a prescription for nicotine replacement therapy were more than twice as likely as nonsmokers and smokers who were given a prescription for this therapy to be discharged from the hospital against medical advice. Only one smoker was encouraged to quit smoking, referred for cessation treatment, or provided with nicotine replacement therapy on discharge. CONCLUSIONS: Psychiatric inpatients smoke at high rates, yet interventions to treat this deadly addiction are rare. Furthermore, nicotine withdrawal left unaddressed may compromise psychiatric care.

Adult↗
PubMed2006

Personality disorders and unmet needs among psychiatric inpatients.

OBJECTIVE: This study sought to examine the association between unmet need and personality disorders in a sample of psychiatric inpatients. The authors tested the hypothesis that the presence of a personality disorder would be independently associated with a significantly greater number of unmet needs. METHODS: A total of 153 psychiatric inpatients from four acute hospital wards serving an inner-city borough in London, United Kingdom, received standardized assessments of need and personality disorder by use of the Camberwell Assessment of Need Short Assessment Schedule and Structured Clinical Interview for DSM-IV Personality Disorders. RESULTS: Fifty-four percent of the sample had a personality disorder. The presence of a personality disorder was associated with greater unmet need. In multiple regression analyses, after adjustment was made for the effects of all covariates, severity of personality disorder was significantly associated with unmet need. Personality disorder was significantly associated with greater need in eight of 22 domains of need: self-care, psychotic symptoms, psychological distress, risk to self, risk to others, alcohol use, sexual expression, and budgeting. CONCLUSIONS: Personality disorder was found to be independently associated with a greater level of unmet need among psychiatric inpatients. The study highlights for the first time the importance of a comprehensive assessment of need for patients with personality disorders.

Adult↗
PubMed1998

Customer satisfaction and self-reported treatment outcomes among psychiatric inpatients.

OBJECTIVE: Relationships among different dimensions of patient satisfaction and selected demographic, clinical, and outcome variables were explored in a sample of severely ill people receiving inpatient psychiatric services. METHOD: The sample consisted of 81 patients admitted to and discharged from an inpatient psychiatric unit at a midwestern Veterans Affairs medical center. Stepwise multiple regression was used to examine the relationship between patient satisfaction and self-reported changes in quality of life, symptomatology, and level of functioning as measured by the Treatment Outcome Profile. Other variables such as diagnosis, length of stay, employment, living situation, and prior psychiatric and substance abuse treatment were also considered. A subsample of the most satisfied and dissatisfied patients was chosen to further explore variables contributing to satisfaction with services. RESULTS: Patient satisfaction was related to initial level of functioning, certain diagnoses, and treatment gains. Clinicians were highly accurate in identifying patients who were satisfied, based on blind chart reviews. CONCLUSIONS: This study underscores the significant relationships between patient satisfaction, psychiatric diagnosis, and other outcome measures, and argues for the validity and utility of patient satisfaction measures in assessing the efficacy of inpatient care.

Attitude to Health↗