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Discharged Patients (discharged + patient)
Selected AbstractsThe Effect of Emergency Department Crowding on Length of Stay and Medication Treatment Times in Discharged Patients With Acute AsthmaACADEMIC EMERGENCY MEDICINE, Issue 8 2010Jesse M. Pines MD ACADEMIC EMERGENCY MEDICINE 2010; 17:834,839 © 2010 by the Society for Academic Emergency Medicine Abstract Objectives:, This study sought to determine if emergency department (ED) crowding was associated with longer ED length of stay (LOS) and time to ordering medications (nebulizers and steroids) in patients treated and discharged with acute asthma and to study how delays in ordering may affect the relationship between ED crowding and ED LOS. Methods:, A retrospective cohort study was performed in adult ED patients aged 18 years and older with a primary International Classification of Diseases, 9th Revision (ICD-9), diagnosis of asthma who were treated and discharged from two EDs from January 1, 2007, to January 1, 2009. Four validated measures of ED crowding (ED occupancy, waiting patients, admitted patients, and patient-hours) were assigned at the time of triage. The associations between the level of ED crowding and overall LOS and time to treatment orders were tested by analyzing trends across crowding quartiles, testing differences between the highest and lowest quartiles using Hodges-Lehmann distances, and using relative risk (RR) regression for multivariable analysis. Results:, A total of 1,716 patients were discharged with asthma over the study period (932 at the academic site and 734 at the community site). LOS was longer at the academic site than the community site for asthma patients by 90 minutes (95% confidence interval [CI] = 79 to 101 minutes). All four measures of ED crowding were associated with longer LOS and time to treatment order at both sites (p < 0.001). At the highest level of ED occupancy, patients spent 75 minutes (95% CI = 58 to 93 minutes) longer in the ED compared to the lowest quartile of ED occupancy. In addition, comparing the highest and lowest quartiles of ED occupancy, time to nebulizer order was 6 minutes longer (95% CI = 1 to 13 minutes), and time to steroid order was 16 minutes longer (95% CI = 0 to 38 minutes). In the multivariable analysis, the association between ED crowding and LOS remained significant. Delays in nebulizer and steroid orders explained some, but not all, of the relationship between ED crowding and ED LOS. Conclusions:, Emergency department crowding is associated with longer ED LOS (by more than 1 hour) in patients who ultimately get discharged with asthma flares. Some but not all of longer LOS during crowded times is explained by delays in ordering asthma medications. [source] Emergency Department Treatment of Viral Gastritis Using Intravenous Ondansetron or Dexamethasone in ChildrenACADEMIC EMERGENCY MEDICINE, Issue 10 2006Christine M. Stork PharmD Abstract Objectives To compare the efficacy of intravenous ondansetron or dexamethasone compared with intravenous fluid therapy alone in children presenting to the emergency department with refractory vomiting from viral gastritis who had failed attempts at oral hydration. Methods This double-blind, randomized, controlled trial was performed in a tertiary care pediatric emergency department. Children aged 6 months to 12 years presenting with more than three episodes of vomiting in the past 24 hours, mild/moderate dehydration, and failed oral hydration were included. Patients with other medical causes were excluded. Subjects were randomized to dexamethasone 1 mg/kg (15 mg maximum), ondansetron 0.15 mg/kg, or placebo (normal saline [NS], 10 mL). All subjects also received intravenous NS at 10,20 mL/kg/hr. Oral fluid tolerance was evaluated at two and four hours. Those not tolerating oral fluids at four hours were admitted. Discharged patients were evaluated at 24 and 72 hours for vomiting and repeat health care visits. The primary study outcome was hospitalization rates between the groups. Data were analyzed using chi-square test, Kruskal,Wallis test, Mantel,Haenszel test, and analysis of variance, with p < 0.05 considered significant. Results A total of 166 subjects were enrolled; data for analysis were available for 44 NS-treated patients, 46 ondansetron-treated patients, and 47 dexamethasone-treated patients. Hospital admission occurred in nine patients (20.5%) receiving placebo (NS alone), two patients (4.4%) receiving ondansetron, and seven patients (14.9%) receiving dexamethasone, with ondansetron significantly different from placebo (p = 0.02). Similarly, at two hours, more ondansetron-treated patients (39 [86.6%]) tolerated oral hydration than NS-treated patients (29 [67.4%]; relative risk, 1.28; 95% confidence interval = 1.02 to 1.68). There were no differences in number of mean episodes of vomiting or repeat visits to health care at 24 and 72 hours in the ondansetron, dexamethasone, or NS groups. Conclusions In children with dehydration secondary to vomiting from acute viral gastritis, ondansetron with intravenous rehydration improves tolerance of oral fluids after two hours and reduces the hospital admission rate when compared with intravenous rehydration with or without dexamethasone. [source] Exhaled Nitric Oxide Levels during Acute Asthma ExacerbationACADEMIC EMERGENCY MEDICINE, Issue 7 2005Michelle Gill MD Abstract Objectives: Fractional exhaled nitric oxide (FENO) has been shown in laboratory settings and trials of patients with stable asthma to correlate with the degree of airway inflammation. The authors hypothesized that the technique of measuring FENO would be reproducible in the setting of acute asthma in the emergency department (ED) and that the FENO results during ED visits would potentially predict disposition, predict relapse following discharge, and correlate with the National Institutes of Health (NIH) asthma severity scale and peak expiratory flow measurements. Methods: The authors prospectively measured FENO in a convenience sample of ED patients with acute exacerbations of asthma, both at the earliest possible opportunity and then one hour later. Each assessment point included triplicate measurements to assess reproducibility. The authors also performed spirometry and classified asthma severity using the NIH asthma severity scale. Discharged patients were contacted in 72 hours to determine whether their asthma had relapsed. Results: The authors discontinued the trial (n= 53) after a planned interim analysis demonstrated reproducibility (coefficient of variation, 15%) substantially worse than our a priori threshold for precision (4%). There was no association between FENO response and corresponding changes in spirometry or clinical scores. Areas under the receiver operating characteristic curves for the prediction of hospitalization and relapse were poor (0.579 and 0.713, respectively). Conclusions: FENO measurements in ED patients with acute asthma exacerbations were poorly reproducible and did not correlate with standard measures of asthma severity. These results suggest that using existing technology, FENO is not a useful marker for assessing severity, response to treatment, or disposition of acute asthmatic patients in the ED. [source] The effects of a transitional discharge model for psychiatric patientsJOURNAL OF PSYCHIATRIC & MENTAL HEALTH NURSING, Issue 1 2004W. REYNOLDS phd mphil rn This pilot randomized control trial was motivated by the discovery that many individuals with mental health problems are re-hospitalized within a year, with many being unable to fully adjust to community living. A solution was proposed in the form of an intervention called transitional discharge. The transitional discharge model included: (1) peer support, which is assistance from former patients who provide friendship, understanding and encouragement; and (2) overlap of inpatient and community staff in which the inpatient staff continue to work with the discharged patient until a working relationship is established with a community care provider. The overall aim of this study was to test the discharge model designed to assist patients discharged from acute admission wards to adjust to community living. This aim was tested through a number of related hypotheses, which suggest that, 5 months following discharge from an acute admission ward of a psychiatric hospital, individuals participating in a transitional discharge model: (1) report fewer symptoms; (2) report better levels of functioning; (3) have better quality of life; (4) are less likely to have been re-admitted to hospital. The study used a randomized experimental design with two conditions: experimental and usual treatment. In general, both the control and the experimental group demonstrated significant improvements in symptom severity and functional ability after 5 months. Usual treatment subjects in the control group were more than twice as likely to be re-admitted to hospital. This study needs to be replicated in Scotland with a larger sample and with a modified variation of the intervention called the Transitional Care Intervention. [source] Prediction of five-year survival for patients admitted to a department of internal medicineJOURNAL OF INTERNAL MEDICINE, Issue 5 2001B. O. Eriksen Abstract.,Eriksen BO, Kristiansen IS, Pape JFr (University Hospital of Tromsø and University of Tromsø, Tromsø, Norway). Prediction of five-year survival for patients admitted to a department of internal medicine. J Intern Med 2001; 250: 435,440. Objective.,The effect of many common forms of therapy, as medication for mild hypertension or hypercholesterolaemia, only reaches clinical significance after years of treatment. The meaningful application of such therapy presupposes that physicians can, at least to some extent, predict the remaining lifetime of patients. We investigated whether clinicians from different disciplines were able to predict the 5-year survival of patients admitted to a department of internal medicine. Design.,The members of two groups, each consisting of an internist, a surgeon and a general practitioner, made individual predictions of the expected remaining lifetime of discharged patients from written summaries of clinical information. Each patient was randomized to be assessed by the members of either of the two groups. The predictions were compared with actual 5-year survival. Setting.,Department of internal medicine at a university hospital. Subjects.,Patients admitted consecutively during a 6-week period. Main outcome measures.,Sensitivity, specificity, positive and negative predictive values and areas under the receiver operating characteristic (ROC) curves for predictions of 5-y ear survival for each of the six experts. Results.,A total of 402 patients were included. Five-year survival was 0.63. The sensitivity of the predictions ranged from 0.81 to 0.95, the specificity from 0.61 to 0.77, the positive predictive value from 0.78 to 0.87 and the negative predictive value from 0.68 to 0.87. The areas under the ROC curves ranged from 0.84 to 0.91. Conclusion.,The quality of predictions of 5-year survival made by experienced clinicians should permit the rational use of treatments with long-term effects. [source] Thromboprophylaxis rates in US medical centers: success or failure?JOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 8 2007A. AMIN Summary.,Background:,As hospitalized medical patients may be at risk of venous thromboembolism (VTE), evidence-based guidelines are available to help physicians assess patients' risk for VTE, and to recommend prophylaxis options. The rate of appropriate thromboprophylaxis use in at-risk medical inpatients was assessed in accordance with the 6th American College of Chest Physicians (ACCP) guidelines.Methods:,Hospital discharge information from the Premier PerspectiveÔ inpatient data base from January 2002 to September 2005 was used. Included patients were 40 years old or more, with a length of hospital stay of 6 days or more, and had no contraindications for anticoagulation. The appropriateness of VTE thromboprophylaxis was determined in seven groups with acute medical conditions by comparing the daily thromboprophylaxis usage, including type of thromboprophylaxis, dosage of anticoagulant and duration of thromboprophylaxis, with the ACCP recommendations.Results:,A total of 196 104 discharges from 227 hospitals met the inclusion criteria. The overall VTE thromboprophylaxis rate was 61.8%, although the appropriate thromboprophylaxis rate was only 33.9%. Of the 66.1% discharged patients who did not receive appropriate thromboprophylaxis, 38.4% received no prophylaxis, 4.7% received mechanical prophylaxis only, 6.3% received an inappropriate dosage, and 16.7% received an inappropriate prophylaxis duration based on ACCP recommendations.Conclusions:,This study highlights the low rates of appropriate thromboprophylaxis in US acute-care hospitals, with two-thirds of discharged patients not receiving prophylaxis in accordance with the 6th ACCP guidelines. More effort is required to improve the use of appropriate thromboprophylaxis in accordance with the ACCP recommendations. [source] Predictors of Hospital Admission for Chronic Obstructive Pulmonary Disease Exacerbations in Canadian Emergency DepartmentsACADEMIC EMERGENCY MEDICINE, Issue 4 2009Brian H. Rowe MD, CCFP(EM) Abstract Objectives:, The objective was to examine predictors of hospital admission among adults presenting to Canadian emergency departments (EDs) for acute exacerbations of chronic obstructive pulmonary disease (COPD). Current acute treatment approaches and outcomes 2 weeks after the ED visit are also described. Methods:, Subjects, aged ,35 years presenting with COPD exacerbations to 16 EDs across Canada, underwent a structured in-ED interview and a telephone interview 2 weeks later. Results:, Of 501 study patients, 247 (49.3%; 95% confidence interval [CI] = 44.9% to 53.6%) were admitted. Admitted patients were older, were more often former smokers, and had more admissions for COPD during the past 2 years. They also reported more days of activity limitation and use of inhaled beta2 -agonists in the previous 24 hours. Canadian Triage and Acuity Scale (CTAS), respiratory rate (RR), and airflow obstruction were more severe in the hospitalized group. Most of the patients received inhaled beta2 -agonists, anticholinergics, oral corticosteroids (CS), and antibiotics; hospitalized patients received more aggressive treatments. The median ED length of stay (LOS) of admitted patients was 13.1 hours (interquartile range [IQR] = 7.4-23.0) compared to 5.6 hours (IQR = 4.2-8.4) in discharged patients. Admission was associated with at least two COPD admissions in the past 2 years (odds ratio [OR] = 2.10; 95% CI = 1.24 to 3.56), receiving oral CS for COPD (OR = 1.72; 95% CI = 1.08 to 2.74), having a CTAS score of 1,2 (OR = 2.04; 95% CI = 1.33 to 3.12), and receiving adjunct ED treatments (OR = 3.95; 95% CI = 2.45 to 6.35). Use of EDs for usual COPD care was associated with a reduced risk of admission (OR = 0.43; 95% CI = 0.28 to 0.66). Conclusions:, Exacerbations of COPD in Canadian EDs result in prolonged ED stays and approximately 50% hospitalization despite aggressive acute treatment approaches. Historical, severity, and treatment-related factors were strongly associated with hospital admission. Validation of these results should be completed prior to widespread use. [source] Clinical Experience with Molecular Adsorbent Recirculating System (MARS) in Patients with Drug-induced Liver FailureARTIFICIAL ORGANS, Issue 5 2004Xin-min Zhou Abstract:, The molecular adsorbent recirculating system (MARS) is a novel extracorporeal technique for liver support. We report the clinical results in a group of fourteen patients with drug-induced liver failure. Fourteen patients, aged 22,83 years, with acute or subacute liver failure [mean Child,Turcotte,Pugh (CTP) score 11 (range 8,15)] due to the intake of various drugs (diet pill overdose,2; Chinese traditional medicine (CTM),4; antibiotic, paracetamol, tuberculostatic, or vasodilator abuse,8) were treated with one to seven sessions of MARS. Beneficial effects such as the improvement of encephalopathy and prothrombin activity, as well as a reduction of bilirubin and ammonia were recorded during MARS treatments. Thirteen out of fourteen patients survived the hospitalization (93%), and two of the discharged patients died during the follow-up of 6,12 months. The overall survival rate was about 79%. MARS therapy can contribute to the improved treatment of drug-induced liver failure patients. [source] The Effects of an Institutional Care Map on the Admission Rates and Medical Costs in Women with Acute PyelonephritisACADEMIC EMERGENCY MEDICINE, Issue 4 2008Kyuseok Kim MD Abstract Objectives:, There are no disposition guidelines for the management of acute pyelonephritis (APN) in women. Recent studies have demonstrated considerable variation in admission rates for women with APN. The authors evaluated the effect of a predetermined, written protocol for the management of APN on the admission rates and medical costs in adult women with APN. Methods:, From January 2006 to December 2006, women presenting to an emergency department (ED) with APN (the after group) were prospectively enrolled. Patients were managed using a predetermined, written protocol that included intravenous ciprofloxacin, antipyretics, antiemetics, and hydration. After a 6-hour observation, patients were reevaluated and discharged on oral medications if they met predefined discharge criteria. Data from all APN patients who presented from May 2003 to December 2005 (before the written protocol was adopted) were also collected for comparative analysis (the before group). These two groups were compared in terms of admission rates, rates of revisits to the ED within 7 days, ultimate admission rate, and medical costs incurred. Mean costs of admission and outpatient-based APN management were determined by analyzing the hospital cost database of the before group. Results:, There were 388 and 139 patients in the before and after groups, respectively. The initial admission rate of the after group was significantly lower than that of the before group (15.1% vs. 47.7%, p < 0.01). However, no significant difference was observed between the two groups with respect to ED revisit rates after initial discharge (11.9% vs. 15.1%, p = 0.38). For initially discharged patients, 8.5% of the before group and 5.8% of the after group were later admitted, which was not significantly different (p = 0.42). Mean direct medical costs (in U.S. dollars) for initially hospitalized and discharged patients in the before group were $1,520 and $263 (p < 0.001). With the price rise during the study period, it was not reasonable to sum and calculate the mean cost with all before and after protocol costs. Conclusions:, Use of a standardized written protocol reduced the admission rates and medical costs in women presenting to the ED with APN. [source] Introduction of a Stat Laboratory Reduces Emergency Department Length of StayACADEMIC EMERGENCY MEDICINE, Issue 4 2008Adam J. Singer MD Abstract Objectives:, Emergency department (ED) length of stay (LOS) impacts patient satisfaction and overcrowding. Laboratory turnaround time (TAT) is a major determinant of ED LOS. The authors determined the impact of a Stat laboratory (Stat lab) on ED LOS. The authors hypothesized that a Stat lab would reduce ED LOS for admitted patients by 1 hour. Methods:, This was a before-and-after study conducted at an academic suburban ED with 75,000 annual patient visits. All patients presenting to the ED during the months of August and October 2006 were considered. A Stat lab located within the central laboratory was introduced in September 2006 to reduce laboratory TAT. The test TATs and ED LOS before (August 2006) and after (October 2006) implementing the Stat lab for all ED patients were the data of interest. ED LOS before and after the Stat lab was introduced was compared with the Mann-Whitney U-test. A sample size of 5,000 patients in each group had 99% power to detect a 1-hour difference in ED LOS. Results:, There were 5,631 ED visits before and 5,635 visits after implementing the Stat lab. Groups were similar in age (34 years vs. 36 years) and gender (51% males in both). The percentages of patients with laboratory tests before and after Stat lab implementation were 68.7 and 71.3%, respectively. Test TATs for admitted patients were significantly improved after the Stat lab introduction. Implementation of the Stat lab was associated with a significant reduction in the median ED LOS from 466 (interquartile range [IQR] = minutes before to 402 (IQR = 296,553) minutes after implementing the Stat lab. The effects of the Stat lab on ED LOS were less marked for discharged patients. Conclusions:, Introduction of a Stat lab dedicated to the ED within the central laboratory was associated with shorter laboratory TATs and shorter ED LOS for admitted patients, by approximately 1 hour. [source] Methicillin-resistant Staphylococcus aureus: risk assessment and infection control policiesCLINICAL MICROBIOLOGY AND INFECTION, Issue 5 2008E. Tacconelli Abstract The endemic state of methicillin-resistant Staphylococcus aureus (MRSA) occurs through a constant influx of MRSA into the healthcare setting from newly admitted MRSA-positive patients, followed by cross-transmission among inpatients and an efflux of MRSA from the hospital with discharged patients. To date, most MRSA prevention strategies have targeted cross-transmission among hospitalised patients. Intensive concerted interventions that include isolation can reduce the MRSA incidence substantially. However, debate continues about the cost-effectiveness of infection control policies, including screening protocols, to control the influx of MRSA into hospitals. The rationale and cost-effectiveness of wide screening, as compared to targeted screening, should be further studied using appropriate statistical approaches and economic modelling. [source] | ||||||||||