Department Acute Care Research Articles

Immigration and neurological diseases: a longitudinal study in an acute neurological care

Very few data exist on causes and outcomes of hospitalization of immigrants in Italy. Even though immigration is a real challenge for the western countries, we are still unaware of how it reflects on the costs and the management of an acute care department. This study was aimed to compare the patterns of hospital use by immigrants incoming to the Acute Care Department of Neurology in Brescia, Italy, with those of the resident Italian people. The study was based on the hospital discharge data. Discharges of immigrants were compared to those of a random selection of Italian patients matched by age and sex. The length of the study period was of 2.5 years. A similar pattern of hospital use by age was observed between foreigners and Italian patients; however, average length of hospitalization was significantly longer in immigrant population.

Epidemiology of nosocomial bloodstream infections in Estonia

A prospective multicentre hospital-wide surveillance study was performed to investigate nosocomial bloodstream infections (BSIs) and to promote BSI surveillance in Estonia in 2004-2005. All patients from the acute care departments of two referral centres and one central hospital were included. A total of 549 episodes of BSI occurred in 507 patients (0.6 cases per 1000 patient-days). Of those, 55% occurred in intensive care units and 47% were catheter-associated infections. Of BSI cases, 24% occurred in patients with haematological malignancy. The in-hospital case-fatality rate was 31%. Of causative micro-organisms, 315 (53%) were Gram-positive aerobes, 232 (39%) were Gram-negative aerobes and 35 (6%) were fungi. Anaerobic bacteria accounted for 2%. The most common pathogens were coagulase-negative staphylococci (26%), Enterobacteriaceae (24%), enterococci (13%) and pseudomonas (10%). Eight percent of BSI were polymicrobial. Seven percent of Staphylococcus aureus isolates were meticillin resistant. Of pseudomonas isolates, 19%, 25%, 30% and 44% were resistant to ceftazidime, meropenem, piperacillin/tazobactam and imipenem, respectively. The incidence of BSI did not differ significantly from other reported studies. With the exception of relatively high antimicrobial resistance among pseudomonas, the overall resistance patterns of Estonian nosocomial bloodstream pathogens were similar to those seen in Nordic countries and lower than in Central and Southern Europe. This study contributes to the development and implementation of surveillance in Estonian hospitals.

Role of Early Symptoms in Assessment of Syncope in Elderly People: Results from the Italian Group for the Study of Syncope in the Elderly

To assess the ability of specific early symptoms to predict cardiac and noncardiac syncope in elderly people. Multicenter cross-sectional observational study. Inpatient geriatric acute care departments and outpatient clinics. Two hundred forty-two patients with syncope (mean age 79+/-8) consecutively referred for evaluation of transient loss of consciousness to any of six clinical centers participating in the Italian Group for the Study of Syncope in the Elderly (GIS Study). All patients were assessed according to European Society of Cardiology Syncope guidelines and interviewed about symptoms and signs present before syncope. One hundred seventy-four of 242 patients (75.4%) had noncardiac syncope, and 34 (14.7%) had cardiac syncope; 165 patients (71.1%) related symptoms before the loss of consciousness. When elderly patients with syncope were stratified for the presence and absence of symptoms, noncardiac syncope showed the highest prevalence of symptoms (75.3%, P<.01). Awareness of being about to faint, sweating, blurred vision, and nausea are more prevalent in noncardiac syncope. Dyspnea is more prevalent in cardiac syncope. All symptoms except awareness of being about to faint and weakness had good specificity, but sensitivity was low for all symptoms considered. Multivariate regression analysis adjusted for sex and age indicated that nausea (relative risk (RR)=3.7, 95% confidence interval (CI)=1.26-11.2), blurred vision (RR=3.5, 95% CI=1.34-9.59), and sweating (RR=2.8, 95% CI=.21-6.89) were predictive of noncardiac syncope. Dyspnea (RR=5.5, 95% CI=1.0-30.2) was the only symptom predictive of cardiac syncope. The data show that symptoms such as nausea, blurred vision, and sweating are predictive of noncardiac syncope, whereas only dyspnea is predictive of cardiac syncope in elderly people.

Stress assessment in acute care department nurses by measuring interleukin‐8

Cytokines, such as interleukin (IL)-8, have been shown to be related to depressive symptoms or inflammatory diseases and may be useful as stress biomarkers. This study was to assess whether urinary IL-8 levels were reliable indicators of stress among acute care department (AD) nurses. A total of 118 nurses participated in the study. Urinary IL-8 levels of 49 AD nurses were compared with levels of a control group of 69 chronic care department (CD) nurses. The urinary IL-8 levels of AD nurses, who reported a higher level of professional stress, were higher than the levels of CD nurses (P < 0.01). Measurement of urinary IL-8 may be an appropriate biomarker for stress assessment in nurses.

Pediatric interhospital transport: Diagnostic discordance and hospital mortality*

Determine the rate of discordance between the reason for transport (determined by referring institution) and the final diagnosis (determined by accepting institution), identify factors associated with diagnostic discordance, and determine whether diagnostic discordance is associated with mortality and morbidity. Cross-sectional analysis of prospectively collected transport data using an existing multicenter database. Interfacility transport of neonatal and pediatric patients referred to five tertiary centers during years 1998-2000. Patients were 4,905 neonatal and pediatric patients undergoing interhospital transport ultimately assigned to a general or intensive level of care based on initial triage information. None. Discordant events were categorized by diagnosis, referring hospital location, and physician type. Discordance between primary reason for transport and discharge diagnosis category occurred in 474 (11.5%) transport events (95% confidence interval 10.5-12.5). Significant predictors of diagnostic discordance included diagnoses of gastrointestinal, metabolic, multi-trauma with head injury, multi-trauma without head injury, renal, and toxicology. Acute care, referring physician, and emergency department subpopulations demonstrated similar discordance rates. One hundred ten (2.7%) patients experienced at least one unplanned event (unintended extubation, intubation requiring more than attempts, loss of intravenous access, malpositioned endotracheal tube, medication error, pneumothorax). Of the 474 patients given discordant diagnoses, 16 (3.4%) experienced at least one unplanned event compared with 94 of 3,645 (2.6%) of patients given concordant diagnoses. Hospital mortality for all transport events was 6% (95% confidence interval 5.3-6.7). Of the total discordant population, 37 of 474 died compared with 207 of 3,645 of those with concordant diagnoses (7.8% vs. 5.7%, p = .065). When adjusted for severity, age, and diagnosis, the increased mortality was not statistically significant. Discordance between primary reason for transport and diagnosis category is common in the pediatric interhospital transport population. Although discordance does not appear to lead to increased mortality, further study is needed to determine the impact of diagnostic discordance on other patient outcomes.

Improving Asthma-Related Health Outcomes Among Low-Income, Multiethnic, School-aged Children: Results of a Demonstration Project That Combined Continuous Quality Improvement and Community Health Worker Strategies

The purpose of this work was to improve asthma-related health outcomes in an ethnically and geographically disparate population of economically disadvantaged school-aged children by using a team-based approach using continuous quality improvement and community health workers. A demonstration project was conducted with 7 community clinics treating approximately 3000 children with asthma 5 to 18 years of age. The overall clinic population with asthma was assessed for care-process changes through random cross-sectional chart reviews at baseline and 24 months (N = 560). A subset of patients with either moderate or severe persistent asthma or poorly controlled asthma (N = 405) was followed longitudinally for specific asthma-related clinical outcomes, satisfaction with care, and confidence managing asthma by family interview at baseline and at 12 or 24 months. Patient-centered and care-process outcomes included patient/parent assessment of quality of care and confidence in self-management, asthma action plan review, and documentation of guideline-based indicators of quality of care. Direct clinical outcomes included daytime and nighttime symptoms, use of rescue medications, acute care and emergency department visits, hospitalizations, and missed school days. Each clinic site's degree of adherence to the intervention model was evaluated and ranked to examine the correlation between model adherence and outcomes. Cross-sectional data showed clinic-wide improvements in the documentation of asthma severity, review of action plans, health services use, and asthma symptoms. At follow-up in the longitudinal sample, fewer patients reported acute visits, emergency department visits, hospitalizations, frequent daytime and nighttime symptoms, and missed school days compared with baseline. More patients reported excellent or very good quality of care and confidence in asthma self-management. Linear regression analysis of the clinical sites' model adherence ranks against site-level combined scores estimating overall outcomes, clinical outcomes, and improvements in clinical care processes showed significant linear correlations with R2 > or = 0.60. The demonstration produced major improvements in asthma-related care processes and clinical outcomes. Closer adherence to the demonstration model was directly associated with better outcomes.

Screening for suicide risk in the pediatric emergency and acute care setting

This paper reviews epidemiology, psychiatric comorbidities, risk factors, warning signs, screening measures, and issues related to screening for suicide risk in the pediatric emergency department and acute care settings. For the first time in over a decade, rates of adolescent suicide are increasing. A recent review found physician gatekeeper training to be one of only two effective prevention strategies. Limited methods exist to assess for suicide risk in pediatric acute care settings that are able to meet the demands and challenges presented in time-limited medical settings. Suicide is the third leading cause of death in adolescents. Although a prior suicide attempt is the single most important risk factor, affective, cognitive, family and peer factors also affect risk of completed suicide. Practitioners in the acute care and emergency department setting are well positioned to identify, assess, and appropriately refer these adolescents and their families. Screening instruments in this setting need to be accurate, brief, and relevant to patients, families, and providers. We propose a two-question algorithm that targets imminent risk for a suicide attempt. This type of screening also needs to be accompanied by hospital or community-based support systems for further assessment, intervention and follow-up.

Rehabilitation Outcomes of Terror Victims With Multiple Traumas

Schwartz I, Tsenter J, Shochina M, Shiri S, Kedary M, Katz-Leurer M, Meiner Z. Rehabilitation outcomes of terror victims with multiple traumas. Objectives To describe the rehabilitation outcomes of terror victims with multiple traumas, and to compare those outcomes with those of patients with nonterror-related multiple traumas treated in the same rehabilitation facility over the same time period. Design Retrospective chart reviews. Setting Rehabilitation department in a university hospital in Jerusalem, Israel. Participants Between September 2000 and September 2004, we treated 72 victims of terrorist attacks who had multiple traumas. Among them, 47 (65%) had multiple traumas without central nervous system involvement (MT subgroup), 19 (26%) had multiple traumas with traumatic brain injury (TBI subgroup), and 6 (8%) had multiple traumas with spinal cord injury (SCI subgroup). We matched, according to their types of injury and demographic data, each terror victim with a control patient treated in the same period in our rehabilitation department. Intervention Interdisciplinary inpatient and outpatient rehabilitation. Main Outcome Measures Hospital length of stay (LOS) in acute care departments, inpatient and outpatient rehabilitation departments, functional outcome (FIM instrument score), occupational outcome (returning to previous occupation), and psychologic outcome (Solomon PTSD [post-traumatic stress disorder] Inventory). Results The mean LOS of terror victims was 218±131 days; for the nonterror group it was 152±114 days ( P<.01). In comparison with the control subgroups, the MT subgroup of terrorist victims had significantly longer LOS in the acute care and outpatient rehabilitation departments ( P=.06) and the terror TBI subgroup had a longer LOS in outpatient department only ( P<.05). The LOS of the SCI patients, both terror victims and control patients, was significantly longer than that of the other 2 subgroups. The difference between FIM value at entry and discharge (ΔFIM) was significantly higher for terror victims than for the controls (41.1±21.6 vs 30.8±21.8, P=.002). This difference was mainly the result of the significantly higher ΔFIM achieved by the terror MT subgroup than by the MT controls. The rate of PTSD was higher among terror victims than among controls (40.9% vs 24.2%, P=.04). The rate of return to previous occupations was similar between terror victims and nonterror patients (53% vs 46.9%, respectively). Conclusions Victims of terror spent longer periods in rehabilitation than the nonterror group; however, they regained most activity of daily living functions similar to the nonterror group. Despite the higher rate of PTSD, terror victims succeeded in returning to their previous occupations at a similar rate to that of the nonterror group.

Diagnosis and Characteristics of Syncope in Older Patients Referred to Geriatric Departments

To test the applicability and safety of a standardized diagnostic algorithm in geriatric departments and to define the prevalence of different causes of syncope in older patients. Multicenter cross-sectional observational study. In-hospital geriatric acute care departments and outpatient clinics. Two hundred forty-two patients (aged>or=65, mean+/-standard deviation=79+/-7, range 65-98) consecutively referred for evaluation of transient loss of consciousness to any of six clinical centers participating in the study. Of these, 11 had a syncope-like condition (5 transient ischemic attack; 6 seizures), and 231 had syncope (aged 65-74, n=71; aged>or=75, n=160). Protocol designed to define etiology and clinical characteristics of syncope derived from European Society of Cardiology Guidelines on syncope. No major complication occurred with use of the protocol. Neurally mediated was the more prevalent form of syncope in this population (66.6%). Cardiac causes accounted for 14.7% of all cases. The neuroreflex form of syncope (vasovagal, situational, and carotid sinus syndrome) was more common in younger than in older patients (62.3% vs 36.2%; P=.001), whereas orthostatic syncope was more frequent in the older than in the younger group (30.5% vs 4.2%; P<.001). In only 10.4% of cases, syncope remained of unexplained origin. After initial evaluation, a definite diagnosis was possible in 40.1% of the cases, and a suspected diagnosis was obtained in 57.9%. Syncope of suspected cardiac origin after initial evaluation was confirmed in 43.7% of cases, and neuromediated causes were confirmed in 83.5% of the cases. The protocol is applicable even beyond the age of 90 in geriatric departments. The standardized protocol is associated with a reduction in the frequency of unexplained syncope to about 10%.

The anergy panel: An ineffective tool to validate tuberculin skin testing

During a 2-year period, the infection control practitioners at an acute care Department of Veterans Affairs health care system administered 440 tuberculin purified protein derivative (PPD) and 335 anergy panels. Each patient’s computerized medical record was reviewed retrospectively. Of patients, 79% (265/ 335) who received both PPD and anergy testing and 62% (23/37) who were PPD positive had no response to anergy. We conclude that using the anergy panel to validate PPD skin tests was not useful in our patient population. The tuberculin skin test with tuberculin purified protein derivative (PPD) is themost widely used screening test for latent tuberculosis. Anergy skin testing is used to assess cell-mediated, delayed-type hypersensitivity response to antigens and, thus, verify the validity of a negative PPD. The Food and Drug Administration has approved mumps and Candida antigen for intradermal delayed-type hypersensitivity testing. However, anergy testing has not been standardized, resulting in an assortment of antigens with varied interpretation of the results. In October 1995, 2 infection control practitioners (ICPs) assumed the responsibility for administering, reading, and documenting PPDs and anergy panels as ordered for all inpatients in an 140-bed acute care Department of Veterans Affairs (VA) health care system to assure consistent reading and documentation of the skin tests. After several months, the ICPs noted that many patients including some patients who were PPD positive did not respond to anergy testing. Because anergy testing was a common practice, the validity of anergy testing was questioned.

Operations, total hospital stay and costs of critical leg ischemia: A population-based longitudinal outcome study of 321 patients

In a longitudinal analysis of all 321 patients in a defined population having surgery for critical leg ischemia during 1 year in Malmöhus county (0.53 million inhabitants), Sweden, we investigated all vascular procedures and amputations on both legs, total hospital stay and hospital costs from the first procedure in each patient until death or at follow-up at least 6 years postoperatively. The first (key) operation during the inclusion year was a reconstructive vascular procedure in 96 patients, a restorative vascular procedure in 111 and a major amputation in 114 patients. One third of those with a reconstructive and half of those with a restorative key procedure had an ipsilateral major amputation. The mean number of surgical procedures and length of hospital stay among all patients were 3 (1-19) procedures and 117 (1-1097) days, respectively. Of the total number of days in hospital, less than half were in surgical departments, 10% in other acute-care departments and almost half in rehabilitation clinics and nursing homes. The total hospital and surgical costs among all patients were USD 15.1 million (mean USD 47,000/patient), with no significant differences in relation to the key operation. We conclude that patients who have undergone surgery for critical leg ischemia accumulate very high total long-term hospital costs due to the need for repetitive surgery and long hospital stays. Our findings also show that a longitudinal study, including hospital stay in departments other than surgical, is necessary for a correct cost-and-outcome analysis.

The neurosurgical nurse in the courtroom.

Questions or comments regarding this article may be directed to the author at: Rutgers University, College of Nursing, Newark, New Jersey 07102. Dr. Wille is an Associate Professor and Chairperson of the Acute Care Department.