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PubMed2004

The psychological impact of September 11 terrorism on Australian inpatients.

OBJECTIVE: To investigate the psychological impact on Australian hospital patients of the media coverage of the September 11 (9/11) terrorist attack. METHODS: Thirty psychiatry and 26 matched medical and surgical inpatients were assessed. RESULTS: Both reported and observed distress was common. Women reported significantly more distress than men. Individuals with psychiatric illness were significantly more varied in their attribution of cause for 9/11. Seven patients (29%) with pre-existing psychosis became delusional surrounding the events, but there were no significant differences between the psychiatry and the medical and surgical inpatients. CONCLUSIONS: Clinical impressions were confirmed, namely, that a large proportion of hospital inpatients were adversely affected by TV footage of the 9/11 terrorist attack. Most vulnerable were those already with a mental disorder, particularly those with a pre-existing psychotic illness.

Adaptation, Psychological↗
PubMed2005

A methodology for timing reviews of inpatient hospital stay.

OBJECTIVE: This paper aims to describe a methodology to inform decisions about the optimal time to schedule reviews of a patient's hospital stay and to provide an example of its implementation. METHOD: Length of hospital stay was assessed in 1227 consecutive inpatient admissions. Data were transformed to reflect the probability of discharge from hospital in the following 7 days. RESULTS: The resulting data reflected the points at which the conditional probability of being discharged were declining, revealing the potentially efficient times to conduct reviews of inpatient admissions. CONCLUSIONS: The methodology outlined appears useful in assisting psychiatrists responsible for inpatient care to decide upon optimal times to review a patient's stay in hospital.

Adult↗
PubMed2004

Improving the rates of inpatient pneumococcal vaccination: impact of standing orders versus computerized reminders to physicians.

OBJECTIVE: To determine the impact of interventions using standing orders and computerized reminders to physicians on inpatient pneumococcal vaccination rates relative to a control group. DESIGN: Open trial of the following approaches, each on a different ward: (1) standing orders for vaccination of eligible consenting patients, (2) computerized reminders to physicians, and (3) usual practice. SETTING AND PATIENTS: Four hundred twenty-four patients were admitted to three 30-bed inpatient medical wards during a 4-month period in 1999 at one hospital. Unvaccinated patients 65 years or older and competent to give oral consent were included. INTERVENTION: A pharmacist activated a standing orders protocol for vaccination of all eligible consenting patients on one ward and computerized reminders to physicians on a second ward. A third ward served as a control group. RESULTS: Forty-two patients met inclusion criteria and accepted vaccination in the standing orders arm versus 35 patients in the computerized reminder arm. Vaccination rates on the standing orders ward included 98% of those eligible and accepting vaccination, 73% of eligible patients, and 28% of all patients admitted. Rates on the computerized reminder ward were 23%, 15%, and 7%, respectively. All of the rates from the standing orders ward were significantly greater than those from the computerized reminder ward (P < .0001). Only 0.6% of all patients on the control arm were vaccinated. CONCLUSION: Although both interventions were effective in increasing inpatient pneumococcal vaccination rates relative to baseline practice, physician independent initiation of standing orders was clearly more effective.

Female↗
PubMed1998

Pyogenic bacterial pneumonia in human immunodeficiency virus-infected inpatients: a clinical, radiological, microbiological, and epidemiological study.

We prospectively studied features of pyogenic bacterial pneumonia in 263 consecutive human immunodeficiency virus-infected inpatients over a 6-month study period. Risk factors for bacterial pneumonia were examined by a case-control study that included 33 cases who presented with at least one episode of bacterial pneumonia and 80 controls without bacterial pneumonia. The estimated cumulative incidence of bacterial pneumonia per year was 12.5 cases per 100 inpatients (95% confidence interval [CI], 8.8-17.2). The 38 episodes of bacterial pneumonia that occurred in the 33 inpatients were mainly unilateral, but 32 episodes were patchy lobar or diffuse infiltrates. Microbiological etiologies were obtained in 33 of the 38 episodes of bacterial pneumonia. Thirty-seven pathogens were identified, including Streptococcus pneumoniae (16, of which 12 had a decreased susceptibility to penicillin), Haemophilus influenzae (6), and Pseudomonas aeruginosa (6). The risk factors for bacterial pneumonia that were identified after logistic regression included prior sinusitis within 1 month before admission (odds ratio [OR], 3.2; 95% CI, 1.1-9.1) and prior bacterial infection of the lower respiratory tract within 6 months before admission (OR, 3.1; 95% CI, 1.1-8.3).

AIDS-Related Opportunistic Infections↗
PubMed2004

Atypical antipsychotic use in a state hospital inpatient adolescent population.

Atypical antipsychotics are now the most commonly prescribed antipsychotics in young patients. These drugs are increasingly being used because of better tolerance and safety as seen in the adult populations. Youth with more severe psychopathology who are treated in the inpatient setting have been overlooked in much of the published research, and the extent of use and rationale in this population is unknown. This naturalistic retrospective study examined a population of adolescents in an inpatient state hospital setting with regard to their use of atypical antipsychotics. All patients who received an inpatient prescription for atypical antipsychotics between January 1, 1997 and June 1, 2000 and were ages 18 or younger at the time of medication initiation were included in the study. Twenty-three percent (88/380) of patients received an atypical antipsychotic: 68% (60/88) risperidone, 27% (24/88) olanzapine, and 5% (4/88) quetiapine. Psychotic disorders were considered as the primary diagnosis in only 17% of patients treated with atypical antipsychotics, and no particular diagnosis was predictive of monotherapy with an atypical antipsychotic. In the adolescent populations, atypical antipsychotics are being used for a wide variety of diagnoses and are commonly used adjunctively (more than 80%) with many concomitant psychotropic medications. More research is needed to develop useful and specific practice guidelines in children and adolescents for these commonly used medications.

Adolescent↗
PubMed2002

Development and implementation of an inpatient acute palliative care service.

CONTEXT: Although hospice programs are a well-established feature of the American medical system, inpatient palliative care services are a recent development. Therefore limited data about inpatient palliative care services has been published, and no large series has yet been reported. OBJECTIVE: To describe the development and implementation, as well as the characteristics and effectiveness, of a large inpatient acute palliative care service (APCS). DESIGN, SETTING, AND PARTICIPANTS: Data on patient demographics, diagnoses, key symptoms, and outcome were collected on each of the 3,712 patients seen from March 1997 to December 2000 by the APCS in a midwestern urban-suburban three-hospital system. Summary statistics were calculated and analyzed. MAIN OUTCOME MEASURES: APCS intervention, most common symptoms, and diagnoses, survival, and discharge destination. RESULTS: Of the 3,712 patients seen by the APCS, 56.9% were transferred to the acute palliative care units (APCU) from elsewhere in the hospital, 16.3% were directly admitted to the APCU, and 26.9% were seen in consultation by the APCS without transfer to the APCU. The most common symptoms were dyspnea (53.9%), weakness (42.5%), and pain (40.8%); 88.7% of patients had one to three symptoms. The most frequent diagnoses were cancer (41.3%), cardiac disease (17.4%), pulmonary disease (14.0%), and stroke (9.4%). Of all patients seen by the APCS, 49.5% survived to discharge, although patients whose primary diagnosis was cancer or dementia had significantly higher discharge rates (64.7% and 59.6% respectively, p < 0.001). Of those discharged, 72.0% went home or to an extended care (ECF) with hospice, 13.8% went to an facility ECF without hospice, and 14.2% went home with other home care services. CONCLUSION: Mount Carmel Health has developed an APCS and APCU integrated into the mainstream of each of its hospitals, providing an opportunity for a more appropriate focus on end-of-life issues for patients with poor prognoses, intense medical needs, and complex family issues.

Adult↗
PubMed1997

Screening for depression among acutely ill geriatric inpatients with a short Geriatric Depression Scale.

BACKGROUND: Depression is not uncommon among acutely ill geriatric inpatients. METHOD: The performances of shorter versions of the Geriatric Depression Scale (GDS) in screening for depression among acutely ill geriatric inpatients were examined. RESULTS: A cut-off of 2/3 gives the best sensitivity (88%) and specificity (75%) for the 10-item version (GDS10). A cut-off of 0/1 gives the best sensitivity (72%) and specificity (90%) for the 4-item version (GDS4). A positive response to item 6 ("Do you often feel helpless?") on the GDS10 gave a sensitivity of 76% and specificity of 75%. Patients found the GDS10 tolerable and acceptable. CONCLUSION: Both shorter versions of the GDS may be utilized in screening for depression among acutely ill geriatric inpatients.

Aged↗
PubMed2000

A comparison of a low-dose warfarin induction regimen with the modified Fennerty regimen in elderly inpatients.

OBJECTIVES: To compare a new low-dose warfarin induction regimen with the Fennerty regimen in elderly inpatients. DESIGN: Age-stratified, randomized prospective study. SUBJECTS: 120 age-stratified elderly inpatients. INTERVENTIONS: Each patient was randomized to either the new induction regimen or to a modified Fennerty regimen. MAIN OUTCOMES MEASURES: Days to therapeutic International Normalized Ratio (INR >2); days in the therapeutic range (INR 2-3) during induction; number of patients with INR >4.5; ability of day 4 INR to predict day 8 warfarin dose. RESULTS: The mean time to therapeutic INR was longer for the new induction regimen than modified Fennerty regimen in patients aged 65-75 years [4.6 (mean) +/- 1.6 (SD) days vs 3.8 +/- 0.8 days; P = 0.03] and in patients aged >75 years (4.5 +/- 1.4 days vs 3.5 +/- 0.7 days; P = 0.003). Patients spent more time in the therapeutic INR range with the new induction regimen [3.0 +/- 1.3 days vs 2.7 +/- 1.3 days (P = 0.03) for those aged 65-75 years and 2.9 +/- 1.1 days vs 2.4 +/- 1.3 days (P = 0.04 for those aged >75 years]. Fewer patients using the new regimen had INRs >4.5 in the first 8 days [1 (3%) vs 6 (20%) for 65-75 years (P < 0.05) and 1 (3%) vs 11 (37%) for >75 years (P < 0.01)]. The ability to predict the maintenance dose to within 1 mg was 55% for both regimens. CONCLUSION: The low-dose regimen has important clinical advantages over the Fennerty regimen for anticoagulating elderly inpatients.

Aged↗
PubMed2000

Improving the quality of the order-writing process for inpatient orders and outpatient prescriptions.

Because many preventable medication errors occur at the ordering stage, a program for improving the quality of writing inpatient orders and outpatient prescriptions at one institution was developed. To determine whether potential problems existed in the order-writing process for inpatients, all physician orders for a seven-day period in 1997 were reviewed (n = 3740). More than 10% of all orders had illegible handwriting or were written with a felt-tip pen, which makes NCR copies difficult to read. Other potential errors were also identified. Following educational programs for physicians and residents focusing on the importance of writing orders clearly, physician orders were reviewed for a 24-hour period (n = 654). The use of felt-tip pens decreased to 1.37% of all orders, and no orders had illegible handwriting. A similar quality improvement approach was used to evaluate the outpatient prescription-writing process. A review of all new prescriptions for a consecutive seven-day period at a local hospital-owned community pharmacy (n = 1425) revealed that about 15% of the prescriptions had illegible handwriting and roughly 10% were incomplete. Additional data were gathered through a survey sent to 71 outside provider pharmacies requesting information on problems related to prescriptions written by physicians from the institution; 66% responded. Failure to print prescriber name (96%), illegible signature (94%), failure to include DEA number (89%), and illegible handwriting other than signature (69%) were reported as the main problems. Each physician was given a self-inking name stamp to use when writing prescriptions. In addition, educational programs covering examples of poorly written prescriptions and the legal requirements of a prescription were held for physicians and residents. A follow-up survey showed that 72% of pharmacies saw stamps being used; when stamps were not used, however, illegible signatures continued to be a problem. Follow-up reviews of outpatient prescriptions indicate improvements in handwriting and completeness, but continuing educational efforts are needed. The quality of order writing for inpatients and outpatients continues to be monitored on a regular basis. Ongoing educational programs, follow-up reminders, and feedback to physicians have greatly improved the prescription-writing habits of physicians.

Ambulatory Care↗
PubMed1982

Preoperative starvation and blood glucose concentrations in children undergoing inpatient and outpatient anaesthesia.

Blood glucose concentrations were measured in 82 children undergoing inpatient anaesthesia and in 46 children undergoing anaesthesia as outpatients. The children were aged between 6 months and 9 yr. Outpatients were fasted from bedtime, while inpatients were randomly allocated to two groups. In group A the children were fasted from bedtime, whereas in group B the children were fed 6 h before anaesthesia. There was no difference in mean blood glucose concentration between the fasted inpatients and outpatients nor between children younger than, or older than, 4 years of age. A blood glucose concentration of less than 40 mg dl-1 was found in only one of the fasted children (1%). The mean blood glucose concentration was greater in group B than A, but only significantly so for children older than 4 yr. It is concluded that to minimize the risks of hypoglycaemia and inhalation of vomit on induction of anaesthesia children older than 6 months should be fasted overnight and operated on in the morning.

Ambulatory Surgical Procedures↗
PubMed2004

Physiological abnormalities in early warning scores are related to mortality in adult inpatients.

BACKGROUND: Early warning scores using physiological measurements may help identify ward patients who are, or who may become, critically ill. We studied the value of abnormal physiology scores to identify high-risk hospital patients. METHODS: On a single day we recorded the following data from 433 adult non-obstetric inpatients: respiratory rate, heart rate, systolic pressure, temperature, oxygen saturation, level of consciousness, urine output for catheterized patients, age and inspired oxygen. We also noted the care required and given. RESULTS: Twenty-six patients (6%) died within 30 days. They were significantly older than survivors (P<0.001). Their median hospital stay was 26 days (interquartile range 16-39). Mortality increased with the number of physiological abnormalities (P<0.001), being 0.7% with no abnormalities, 4.4% with one, 9.2% with two and 21.3% with three or more. Patients receiving a lower level of care than desirable also had an increased mortality (P<0.01). Logistic regression modelling identified level of consciousness, heart rate, age, systolic pressure and respiratory rate as important variables in predicting outcome. CONCLUSIONS: Simple physiological observations identify high-risk hospital inpatients. Those who die are often inpatients for days or weeks before death, allowing time for clinicians to intervene and potentially change outcome. Access to critical care beds could decrease mortality.

Adult↗
PubMed1997

Antimicrobial resistance in isolates from inpatients and outpatients in the United States: increasing importance of the intensive care unit.

To compare the occurrence of antimicrobial resistance in hospitals with that in the community, we analyzed data for isolates collected from inpatients and outpatients in eight U.S. hospitals. The percentage of resistant isolates from inpatients was higher than that from outpatients for the following combinations of antimicrobials and organisms: methicillin/coagulase-negative Staphylococcus (49.0% vs. 36.0%, respectively; P < .01); methicillin/Staphylococcus aureus (33.0% vs. 14.5%, respectively; P < .01); ceftazidime/Enterobacter cloacae (26.0% vs. 12.0%, respectively; P < .01); imipenem/Pseudomonas aeruginosa (12.0% vs. 6.5%, respectively; P < .01); ceftazidime/P. aeruginosa (7.8% vs. 4.0%, respectively; P < .01); and vancomycin/Enterococcus species (6.3% vs. 1.4%, respectively; P < .01). There was a significant stepwise decrease in the percentage of resistant organisms isolated from patients in the intensive care unit (ICU), non-ICU inpatients, and outpatients. These results suggest that resources allocated to control antimicrobial resistance should continue to be focused in the hospital, particularly in the ICU.

Ciprofloxacin↗
PubMed1995

Benzodiazepine use as a cause of cognitive impairment in elderly hospital inpatients.

BACKGROUND: Benzodiazepine drugs are used very frequently by the elderly and have been associated with a number of untoward events in them. In an earlier publication, we showed that there was an association between benzodiazepine use and episodes of confusion in hospital. The purpose of this study was to examine that association in more detail by studying only patients with intact cognitive function on admission and by taking into consideration a range of demographic, drug use, and clinical confounders. METHODS: A prospective cohort study was carried out of inpatients who had normal cognitive function on admission to hospital. The subjects were 418 hospital inpatients who had a normal result of a Mini-Mental State Examination (MMSE) performed within 24 hours of admission. They were aged 59-88 years. A clinical history and detailed drug use history were taken on admission and then the patients were followed prospectively for 10 days or until discharge, whichever was sooner. The MMSE was repeated every 2 days and all significant clinical events and episodes of delirium noted. RESULTS: 10.8% (95% Confidence Interval [CI]: 7.8-13.8%) of patients developed cognitive impairment (as indicated by a decrease in the MMSE). Factors that were statistically significantly related to the development of cognitive impairment included admission diagnoses of cancer or central nervous system (CNS) disease, alcohol consumption > 40 gms/day, hypoxia, and presence of benzodiazepines in the urine on admission. After adjusting for age, alcohol consumption, and admission diagnoses, those who reported taking benzodiazepines in daily doses equivalent to 5 mg or more of diazepam were at significantly higher risk of cognitive impairment than those who had not taken benzodiazepines (adjusted odds ratio = 3.5; 95% CI: 1.4-8.8). Twenty-one (5.0%, 95% CI: 2.9-7.1%) patients developed delirium as defined by the DSM-IIIR criteria. Age and hypoxia were statistically significantly related to the development of delirium. Due to the small number of cases of delirium, the power of the study to detect significant associations was low. CONCLUSIONS: Elderly hospital inpatients who have intact cognitive function on admission to hospital have a low risk of developing cognitive impairment and delirium during their hospital stay. In this population, however, benzodiazepine use accounted for 29% of cases of cognitive impairment which did occur. The data also suggest that dehydration, urinary retention, and an admission diagnosis of CNS disease may be important risk factors for delirium.

Aged↗
PubMed1994

Facilitating problem drinking clients' transition from inpatient to outpatient care.

Engaging and retaining problem drinkers in the helping process are among the most difficult tasks encountered by professionals working with alcoholic clients. The engagement process is particularly difficult for individuals who are referred for outpatient treatment following inpatient care. This article reports on the use of transition groups to improve the linkages between inpatient and outpatient alcoholism treatment. Findings revealed that clients who had access to a transition group had more favorable outcomes than did individuals who had no access to the group. The group was especially useful for inpatients who had encounters with the outpatient clinic before their hospitalizations. This investigation illustrates the positive impact of simple service adjustments on the delivery of care.

Adult↗
PubMed1993

What is important in psychiatric inpatient care? Quality of care from the patient's perspective.

The development of quality assurance programs for psychiatric care has increased the interest in quality of care and accountability from the patient's perspective. However, most investigations of patient satisfaction use instruments which rate aspects of care defined and held to be important by professionals and care givers. The aims of this study were 2-fold. To map descriptive characteristics of ideal inpatient psychiatric care through open patient interviews, using a sample of 78 hospitalized patients and, secondly, based on a content analysis of these interviews, to have another sample of 77 hospitalized patients rank the importance of 48 treatment characteristics extracted from the qualitative analysis. Results of the content analysis showed that characteristics of ideal inpatient treatment could be classified in six categories: staff-patient relationship, patient co-influence, treatment content, activities, ward atmosphere and staff competence. Results from the patients' rating of the importance of treatment characteristics showed that patients put the highest emphasis on staff empathic qualities: being caring, interested and understanding, respecting patients, devoting time to patients, and creating a safe treatment environment. The least importance was ascribed to characteristics of the physical environment and daily routines on the ward. It is concluded that in order to secure content validity of investigations of the quality of psychiatric inpatient care from the patient's perspective, effort should be put into including the areas of staff-patient relationships and patient information and co-influence.

Adult↗
PubMed1991

Home detoxification from alcohol: its safety and efficacy in comparison with inpatient care.

The safety and short-term effectiveness of home detoxification (HD) was investigated by contrasting rates of treatment completion and of complications of 41 service users with those of a retrospectively matched inpatient comparison group. The latter comprised patients of a detoxification unit matched for age, sex and degree of alcohol dependence with HD subjects. HD subjects had severe problems with alcohol--they averaged 28.7 on the SADQ, 4.6 serious alcohol-related problems in the previous 2 months, a GGT of 123.8 and 174.6 reported units of alcohol consumed in the week before treatment. A high follow-up rate was achieved for both HD subjects and their relatives; there was close agreement between clients' reports, carers' reports and breathalyser readings with regard to further alcohol consumption. The HD subjects were visited at home an average of 6.9 times over 6.15 days. Chlormethiazole was prescribed in 36 cases at an average maximum daily dose of 6.3 capsules--significantly fewer than for the inpatient group. Both rates of completion and complication were virtually identical in the 2 groups. It is concluded that these data suggest HD is equivalent in both its safety and immediate efficacy to more expensive inpatient care.

Adult↗
PubMed2002

"Real world" atypical antipsychotic prescribing practices in public child and adolescent inpatient settings.

This article examines the factors that influence antipsychotic use among youth treated in public inpatient facilities. By combining data from 11 focus groups, a survey of 43 researchers and clinicians, and a chart review of 100 closed patient charts, we investigated the interplay between physicians' and staff members' perceptions of problems related to antipsychotic prescribing, their beliefs concerning optimal approaches, their actual recorded prescribing behaviors, and the discrepancies between their beliefs and their recorded practices. We discovered that antipsychotics are prescribed broadly to treat a variety of conditions, including nonpsychotic disorders among children in public inpatient facilities. Despite overall expert consensus regarding "best practices," physicians described systemic obstacles that prevent the application of these practices, and our data confirmed that best practices are not always followed. Future research should be done with this patient population and should investigate the factors that influence antipsychotic use among inpatient youth.

Adolescent↗
PubMed1999

Violence in inpatients with schizophrenia: a prospective study.

Accurate evaluations of the dangers posed by psychiatric inpatients are necessary, although a number of studies have questioned the accuracy of violence prediction. In this prospective study, we evaluated several variables in the prediction of violence in 63 inpatients with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder. Nurses rated violent incidents with the Overt Aggression Scale. During hospitalization, sociodemographic variables, clinical history, neurological soft signs, community alcohol or drug abuse, and electroencephalographic abnormalities did not differ between violent and nonviolent groups. Violent patients had significantly more positive symptoms as measured by the Positive and Negative Syndrome Scale (PANSS), higher scores on the PANSS general psychopathology scale, and less insight in the different constructs assessed. A logistic regression was performed to discriminate between violent and nonviolent patients. Three variables entered the model: insight into symptoms, PANSS general psychopathology score, and violence in the previous week. The actuarial model correctly classified 84.13 percent of the sample; this result is significantly better than chance for the base rate of violence in this study. At hospital admission, clinical rather than sociodemographic variables were more predictive of violence. This finding has practical importance because clinical symptoms are amenable to therapeutic approaches. This study is the first to demonstrate that insight into psychotic symptoms is a predictor of violence in inpatients with schizophrenia.

Adult↗