Delayed Hospital Presentation Research Articles

Clinical Duration as a Predictor for Bowel Resection in Intussusception

Introduction . Delayed hospital presentation is a characteristic we found in management of intussusception in our institution. However, with this delayed, surgical intervention is the only option in treatment. Thus, duration of onset is an answered problem. We run a study aimed to find out whether duration is a predictor of bowel resection in management of intussusception. Method . We run retrospective study on idiopathic intussusception managed in period of January 2008 to December 2015 in Cipto Mangunkusumo Hospital, Jakarta. Those other than idiopathic and insufficient data were excluded. Period of onset, signs and symptoms, ultrasound and surgical treatment as well as intraoperative findings were set as the variables and subjected to statistical analysis using χ 2 or Fisher’s exact test and t–test; significance is met if p value of <0.05. Analysis to find out cut–off point using receiver operating characteristic curve were carried out. Results . There were seventy–three subjects diagnosed as intussusception enrolled in the study. Median age was 7 months (3-48 month). Median period of onset to definitive treatment was 81 hours (15-256 hours). Bloody stools found in 90.4% instead of classic triad (28.7%). All subjects underwent surgical procedure, and out of 73 subjects, 61.6% underwent resection. We found clinical duration was associated to bowel resection (p 0.004) and area under curve 73.7% (p 0.001). The cut–off point as prediction of bowel resection was 78.5 hours with sensitivity of 67.9% and specificity of 71.1%. Conclusion. Surgical intervention is recommended for management of intussusception in those with clinical duration of more than 78.5 hours, instead of non–surgical reduction Keywords : intussusception, clinical duration, bowel resection

Delayed Hospital Presentation and Neuroimaging in Non-surgical Spinal Cord Infarction.

Lack of timely recognition and neuroimaging may be a barrier to reperfusion efforts in acute spinal cord infarction. We performed a retrospective study of patients diagnosed with acute non-surgical spinal cord infarction at our tertiary academic center from 2001 to 2015. We studied parameters associated with time from symptom onset to initial hospital presentation and magnetic resonance imaging (MRI) of the spinal cord. We identified 39 patients among whom anterior spinal artery syndrome was the most frequent presentation (87.2%) and atherosclerosis the most common etiology (56.4%). Nearly, half of the patients presented to the emergency department on the same day of symptom onset (48.7%) but only nine (23.1%) within the first 6 h. Average time from symptom onset to spinal cord MRI was 3.2 days. We could not identify clinical, radiological, or outcome patterns associated with early vs. delayed presentation and imaging. Our study found a time lag from symptom onset to hospital presentation and spinal cord MRI in patients with acute spinal cord infarction. These findings point at low clinical suspicion of spinal cord syndromes and limited recognition as a potentially treatable medical emergency.

Characterization of Readmission by Day of Rehospitalization After Colorectal Surgery.

Factors associated with readmission stratified by the day of postdischarge rehospitalization after colorectal surgery have not been characterized previously. The purpose of this study was to identify factors leading to readmission on a day-to-day basis after discharge from colorectal surgery. This was a retrospective analysis of patients readmitted within 30-days after colorectal surgery. Reasons and factors associated with readmission each day after discharge were evaluated. Early readmitted patients (day 0-5 postdischarge) were compared with those readmitted later (day 6-29 postdischarge). The study was conducted at a tertiary center. Patients included those who had undergone primary colorectal resection from the American College of Surgeons National Surgical Quality Improvement Program (2012-2013). The study intended to identify factors associated with any early versus late hospital readmission and to evaluate diagnoses for unplanned readmissions on a day-to-day basis after discharge. For 69,222 elective colorectal procedures, 7476 patients (10.8%) were readmitted to the hospital within 30 days. Early (median, 3 days) and late (median, 11 days) readmissions were 3278 (43.8%) and 4198 (56.2%). Except for sex, patient demographics were similar between groups. Neurologic comorbidity; wound disruption; sepsis or septic shock; unplanned reintubation and reoperation; anastomotic leak and ileus; and neurological, cardiovascular, and pulmonary complications were significantly higher in the early readmission, whereas disseminated malignancy, stoma creation, and renal/urological complications were significantly higher in the late readmission group. On multivariable analysis, early readmission was significantly associated with male patients, wound disruption, sepsis or septic shock, reoperation, reintubation, and postoperative neurological complications. Disseminated malignancy, ostomy creation, and postoperative renal dysfunction/urological infection were associated with delayed readmission. Thirty-day readmissions and reasons for unplanned rehospitalizations were evaluated. Differing factors are associated with early versus late readmission after colorectal resection. These data suggest that early readmission is intricately related to patient and operative complexity and hence may be inevitable, whereas delayed hospital presentation is associated with identifiable perioperative predictors at the time of discharge and hence more likely to be targetable.

Factors Influencing Delayed Hospital Presentation in Patients with Appendicitis

Factors Influencing Delayed Hospital Presentation in Patients with Appendicitis

Factors influencing delayed hospital presentation in patients with appendicitis: the APPE survey

BackgroundAmong patients with acute appendicitis (AA), perforation is thought to be associated with symptom duration before treatment. Perforation rates vary between hospitals raising the possibility that some perforations are preventable. The factors that compel patients to present earlier or later are unknown but are critical in developing quality improvement interventions aimed at reducing perforation rates. Materials and methodsThe Appendicitis Patient Pre-Hospital Experience (APPE) Survey is a prospective study of adults and parents of children with AA in six hospitals participating in Washington State's Comparative Effectiveness Research Translation Network (CERTAIN). The APPE survey includes questions about symptom duration before presentation (late defined as >24 h), predisposing characteristics, enabling factors, and need. ResultsAmong 80 patients, perforation occurred more frequently in late presenters (44% versus 11%, P < 0.01). Late presenters more frequently drove themselves to the hospital (64% versus 52%, P = 0.05) as opposed to relying on friends/family members and described their health behavior as “waiting it out” when something is wrong (71% versus 46%, P = 0.03). We found similar sociodemographics, clinical characteristics, health care utilization, optimism, health care trust, and risk taking between the two cohorts. ConclusionsLate presenters described reduced social support and a tendency to “wait it out” and had higher rates of perforation than early presenters. These characteristics have not been well-studied conditions but are important to understand to identify patients at high risk for delayed presentation. Future interventions might target those with low social support or those who are reluctant to seek care early to decrease rates of perforation.

A prospective study of risk stratification in patients undergoing emergency laparotomy with POSSUM and P-POSSUM

Background: Physiological and operative severity score for enumeration of mortality and morbidity (POSSUM) and its Portsmouth modification (P-POSSUM) have been developed and validated in many studies to assess the risk of mortality and morbidity associated with the various surgical procedures. Prediction of risk of mortality and morbidity involved in a surgical procedure not only helps clinicians in adequate preparation but also patient counselling.Methods: One hundred and seven consecutive patients who underwent emergency laparotomy in the year 2009 at our center were studied. Mortality and Morbidity risk were calculated in each using POSSUM and P-POSSUM. The ratio of observed to predicted death and morbidity (0: E) were calculated and compared using chi square test. Serum creatinine level and delay in presentation to hospital were also noted in each as adjuncts variables.Results: POSSUM was found to over predict both mortality and morbidity (O: E = 0.44 and 0.66 respectively). P-POSSUM accurately predicted mortality (O: E =0.98). Both POSSUM and P-POSSUM over predicted mortality in low risk groups (predicted risk of mortality &lt;20%, O: E= 0.00 and 0.34 respectively). Average serum creatinine levels and delay in presentation to hospital among patients who survived and those who expired were 1.67 &amp; 2.42 mg/dl and 2.04 &amp; 2.89 days respectively.Conclusions: Although both equations are useful tools for risk-adjusted surgical audit of patients undergoing emergency laparotomy, P-POSSUM is a better predictor of mortality than POSSUM. Overall, morbidity and mortality risk were found to be significantly higher with delayed hospital presentation and deranged creatinine levels.

Wake-up Stroke and Onset-to-door Duration Delays: Potential Future Indications for Reperfusion Therapy

There is limited utilisation of acute stroke reperfusion treatments which have narrow therapeutic windows, with delayed hospital presentation being a major limiting factor in Singapore. Most patients who wake up with symptoms are ineligible for reperfusion treatments as duration from onset time is not known. We studied the profile of wake-up strokes, onset-to-door duration and their associated factors among ischaemic stroke patients in the context of potential new treatments. This is an observational study of consecutive ischaemic stroke patients presenting within 2 weeks of symptom onset to the Singapore General Hospital in 2012. Of the 642 ischaemic stroke patients studied, 33% of the cases were wake-up strokes [median age 64 years, 88%<80 years; median NIHSS score 4, 98%<20]. The median onset-to-door duration was 14.3 hours (Interquartile range, 4.8 to 38.2 hours), 20% of them arrived <3.5 hours (considering eligibility for intravenous alteplase in the proven 4.5 hours window accounting for a one hour door-to-needle duration), 14%: ≥3.5 to <8 hours, 11%: ≥8 to <12 hours, and 56%: ≥12 hours. Most patients with known stroke risk factors including atrial fibrillation (66%), hypertension (78%) and prior stroke (81%) presented beyond 3.5 hours. The one- third proportion of wake-up stroke in this cohort and low prevalence of relative contraindications suggest this is a promising group for emerging thrombolysis indications. With the majority of patients presenting after 8 hours, widening of the therapeutic window with new potential reperfusion treatments would not appreciably increase treatment utilisation. This study reaffirms the urgent need for public education to improve stroke awareness in Singapore.

How can stroke patients have better accessibility to stroke fast track system in Thailand?

In Thailand, 2005, the mortality rate of stroke was 24.3 per 100,000 populations and since then it has continuously increased. The prevalence of stroke increased from 216.6 to 307.9 in 2008 to 2010. Diabetes, hypertension and hyperlipidaemia are the root cause of stroke and myocardial infarction. To prevent stroke is to prevent complication, and in order to do so, it needs the implementation of effective stroke fast track policy. In 2009, the National Health Security Office (NHSO) launched stroke fast track policy by supporting the costs of thrombolytic agent (rt-PA), computed tomography scan, physical therapy and home visit. The policy aimed to reduce mortality rate and disability for patients covered by universal coverage scheme (UCS). However, this special management for stroke fast track are not covered by the civil servant medical benefit scheme (CSMBS) and social security office (SSO). Up till now, the utilization rate of thrombolytic agent is still low. One factor is delayed hospital presentation in patients with such condition. This is because of lack of knowledge and understanding of early signs and symptoms of stroke. However, stroke fast track is the best practice to increase the accessibility and reduce the severity and disability of patients. The question remains whether stroke fast track policy is successful, and whether it can improve the accessibility to care. Which factors influence policy implementation? It is therefore important to study the process of this policy in order to develop policy implementation.

Sex Differences in Interpersonal Violence in Malawi: Analysis of a Hospital‐Based Trauma Registry

Although interpersonal violence ("assault") exists in every society, the World Health Organization (WHO) estimated that 90 % of the exposure burden occurs in low- and middle-income countries. The objectives of this study were to define the incidence of assault-related injuries among subjects presenting for emergency room care secondary to sustained trauma in Lilongwe, Malawi; to measure the impact of sex on incidence, injury type, and care received; and to measure the effect of both sex and geographic location of the injury on time to presentation for medical care. This is a retrospective cohort analysis of data prospectively collected in the Kamuzu Central Hospital Trauma Surveillance Registry from July 2008 to December 2010 (n = 23,625). We used univariate, bivariate, and logistic regression analyses to measure association of sex with variables of interest, and geospatial mapping to evaluate the association of location of assault on time to presentation for care. The mean age of our trauma cohort was 27.7 years. Assaults accounted for 26.8 % of all injuries. Of those assaulted, 21.0 % (1299) were female, who were younger (26.2 vs. 28.1 years, p < 0.001), more likely to arrive to the hospital by minibus (p < 0.001), and less likely to arrive by police (p < 0.001). Altogether 62 % of the females were assaulted in their homes-much more often than their male counterparts (p < 0.001). Females were more likely to sustain contusions (p < 0.001) and males more likely to have lacerations and penetrating stab wounds (p < 0.001) or head injury (p < 0.001). Females had delayed hospital presentation following assault (p = 0.001) and were more likely to be treated as outpatients after adjusting for age, injury type, and injury location (adjusted odds ratio 1.74, 95 % CI 1.3-2.3, p < 0.001). Assaults clustered geographically in the Lilongwe district. Delayed presentation of females occurred irrespective of proximity to the hospital. This study brings attention to sex differences in assault victims. A prevention strategy focusing on sex roles and domestic abuse of women is paramount. Efforts are needed to stop dischargin female assault victims back into a potentially unsafe, abusive environment.

Delayed hospital presentation in acute decompensated heart failure: Clinical and patient reported factors

BackgroundPatients with acute decompensated heart failure (ADHF) often wait a considerable amount of time before going to the hospital. Prior studies have examined the reasons why such delays may occur, but additional studies are needed to identify modifiable factors contributing to these delays. PurposeTo describe care-seeking delay times, factors associated with prolonged delay, and patient's thoughts and actions in adult men and women hospitalized with ADHF. MethodsWe surveyed 1271 patients hospitalized with ADHF at 8 urban medical centers between 2007 and 2010. ResultsThe average age of our study population was 73 years, 47% were female, and 72% had prior heart failure. The median duration of pre-hospital delay prior to hospital presentation was 5.3 h. Patients who delayed longer than the median were older, more likely to have diabetes, peripheral edema, to have symptoms that began in the afternoon, and to have contacted their medical provider(s) about their symptoms. Prolonged care seekers were less likely to have attributed their symptoms to ADHF, less likely to want to have bothered their doctor or family, and were more likely to be concerned about missing work due to their illness (all p values < 0.05). ConclusionsCare-seeking delays are common among patients with ADHF. A variety of factors contribute to these delays, which in some cases may represent efforts to manage ADHF symptoms at home. More research is needed to better understand the detrimental effects of these delays and how best to encourage timely care-seeking behavior in the setting of ADHF.

Authors' response to Dr Reiter

Authors' response to Dr Reiter

Cognitive factors that influence delayed decision to seek treatment among older patients with acute myocardial infarction in Korea

The incidence of acute myocardial infarction (AMI) is rapidly increasing among older adults in Korea. However, the factors associated with a delayed decision to visit a hospital and the reasons for this delay have not been explored adequately among older patients. To determine factors predicting a prehospital delay time of > 6 h and to identify the cognitive barriers in the delayed decision of AMI patients aged ≥ 65 years. This study adopted a mixed methodological approach using quantitative and qualitative analyses. The sample included 94 male and 71 female patients hospitalized for first-time AMI at a university hospital in Korea. Thematic content analysis was used to identify the themes from the qualitative interview data, and multiple logistic regression analysis was used to predict delayed hospital presentation by > 6 h. The median prehospital delay time was 12 h. Low education level, presence of preinfarction angina pain, and attribution of symptoms to a non-cardiac origin were found to be the predicting factors. From the qualitative data, four meaningful themes including 10 subthemes that influenced the delayed decision were identified. Some culturally peculiar themes were found in this Korean sample. Educational strategies that focus on these cognitive decision-making barriers should be planned for elderly Korean at high risk for AMI.

A clinico-pathological study of orbito-ocular tumors at Ahmadu Bello University Teaching Hospital, Shika-Zaria, Nigeria: A 5-year review

Background: Orbito-ocular tumors are a common cause of morbidity and mortality in our environment. Patients often present late with unsightly fungating tumors resulting in difficult management and poor outcome. The aim of the study was to determine the clinical profile, diagnostic work-up, treatment and histo-pathological types of orbito-ocular tumors seen at Ahmadu Bello University Teaching Hospital, Shika-Zaria from June 2006 to June 2011. Materials and Methods: A retrospective analysis of all patients who presented to the eye clinic with orbito-ocular tumors during the study period was made. Information extracted incwudes patient demographics, clinical diagnoses, radiological and sonological reports, surgery performed, and histology reports as well as adjuvant chemotherapy and radiotherapy where indicated. Results: A total of 54 patients were managed during the study period. Those without histology reports were excluded from the study. Forty-nine patients were included for analysis. There were 29 male and 20 female patients giving a male to female ratio of 1.8:1. Their age range was 1.5-74 years with a mean of 22 years. Eighteen of the patients had retinoblastoma, eleven had squamous cell carcinoma, two had Kaposi' sarcoma, and one case of nasopharyngeal carcinoma. There were 2 patients with pre-malignant conditions and 10 patients with benign lesions. Thirty-two of the patients had exenterations, sixteen had excisional biopsies, and one had enucleation. Seventy eight percent of the tumors were malignant. Conclusion: Most of the orbito-ocular tumors seen in this study were malignant. Delayed hospital presentation is a characteristic feature. Retinoblastoma and squamous cell carcinoma are the most common orbito-ocular tumors.

Preoperative pillow placement under the injured extremity had better analgesic effects than skin traction for hip fracture

Rosen JE, Chen FS, Hiebert R, et al. Efficacy of preoperative skin traction in hip fracture patients: a prospective, randomized study. J Orthop Trauma2001 Feb; 15 : 81 –5 [OpenUrl][1][CrossRef][2][PubMed][3][Web...

Time to presentation with acute myocardial infarction in the elderly: associations with race, sex, and socioeconomic characteristics.

Although prompt treatment is a cornerstone of the management of acute myocardial infarction (AMI), prior studies have shown that one fourth of AMI patients arrive at the hospital >6 hours after symptom onset. It would be valuable to identify individuals at highest risk for late arrival, but predisposing factors have yet to be fully characterized. Data from the Cooperative Cardiovascular Project, involving Medicare beneficiaries aged >65 years hospitalized between January 1994 and February 1996 with confirmed AMI, were used to identify patients who presented "late" (>/=6 hours after symptom onset). Patient characteristics were tested for associations with late presentation by use of backward stepwise logistic regression. Among 102 339 subjects, 29.4% arrived late. Significant predictors of late arrival (odds ratio, 95% CI) included diabetes (1.11, 1.07 to 1.14) and a history of angina (1.32, 1.28 to 1.35), whereas prior MI (0.82, 0.79 to 0.85), prior angioplasty (0.80, 0.75 to 0.85), prior bypass surgery (0.93, 0.89 to 0.98), and cardiac arrest (0.52, 0.46 to 0. 58) predicted early presentation. Additionally, initial evaluation at an outpatient clinic (2.63, 2.51 to 2.75) and daytime presentation (1.67, 1.59 to 1.72) predicted late arrival. Finally, female sex, black race, and poverty, which were evaluated with an 8-level race-sex-socioeconomic status interaction term, were also risk factors for delay. Delayed hospital presentation is a common problem among Medicare beneficiaries with AMI. Factors associated with delay include not only clinical and logistical issues but also race, sex, and socioeconomic characteristics. Education efforts designed to hasten AMI treatment should be directed at individuals with risk factors for late arrival.

Delayed hospital presentation in patients who have had acute myocardial infarction.

In patients who have had acute myocardial infarction, the delay between the onset of symptoms and hospital presentation is a critical factor in determining the initial management strategy and outcomes of treatment. To examine the determinants of delayed hospital presentation in patients who have had acute myocardial infarction. Retrospective chart review. 37 hospitals in Minnesota. 2409 persons hospitalized with acute myocardial infarction between October 1992 and July 1993. Hospital presentation delayed more than 6 hours after the onset of symptoms of acute myocardial infarction. Information on length of delay was available for 2404 patients. Of these patients, 969 (40%) delayed presentation to the hospital for more than 6 hours after the onset of symptoms. Factors associated with prolonged delay included advanced age and female sex. The presence of chest discomfort and a history of mechanical revascularization significantly reduced the risk for prolonged delay. Risk for delay was greatest during the evening and early morning hours (6:00 p.m. to 6:00 a.m.) Patients with a history of hypertension were more likely to delay presentation. Only 42% of all patients hospitalized with acute myocardial infarction had used emergency medical transport services. Patients who have had acute myocardial infarction often delay hospital presentation. Educational interventions that encourage the prompt use of emergency medical transport services and target specific patient populations, such as elderly persons, women, and persons with cardiac risk factors, may be most successful in reducing the length of delay and improving the outcomes of patients with acute myocardial infarction.