General Inpatient Unit Research Articles

Reducing Inappropriate Hospital Use on a General Pediatric Inpatient Unit

Studies have documented high rates of inappropriate hospital use in children. We assessed the effectiveness of an audit-and-feedback intervention at reducing inappropriate hospital days on a general pediatric inpatient unit. A prospective observational study, using a before-and-after design, was conducted at a tertiary care pediatric hospital in Canada between March 2005 and August 2006. The appropriateness of all hospital days for all admissions was evaluated by a nurse trained in using a utilization review tool. This tool classifies hospital days as "qualified" or "nonqualified" on the basis of the nature of the inpatient services that are used. Reasons for nonqualified days were classified. The intervention consisted of (1) weekly feedback to attending physicians of which patients were nonqualified and (2) dissemination of summary reports to attending physicians. Comparisons were made between the preintervention (March 2005 to August 2005) and intervention (March 2006 to August 2006) phases. The intervention was associated with a significantly lower risk of inappropriate hospital days. Of the 7246 hospital days in the 6-month intervention phase, 2413 (33%) were nonqualified versus 3859 (47%) of 8228 hospital days in the 6-month preintervention phase. A total of 7.35 hospital days would have to be reviewed, combined with weekly feedback, to prevent 1 nonqualified hospital day. The 48-hour readmission rate in the intervention phase and preintervention phase was 1.0% and 1.6%, respectively. The proportion of nonqualified days to total hospital days that were attributable to "finishing intravenous antibiotics," "awaiting tests," "providing nutrition," "observation only," "tapering treatment," and "teaching" decreased significantly, whereas the "lack of an alternate level of care" increased significantly. An audit-and-feedback intervention directed at attending physicians was associated with a lower risk of inappropriate hospital days without an increase in the readmission rate. The utilization review tool also identified processes that impact on inappropriate hospital days.

Dengue and Relative Bradycardia

To the Editor: We have found that relative bradycardia is a notable clinical feature of dengue fever in Singapore. To our knowledge, this sign has not been previously associated with dengue. Awareness of this possible clinical finding could help in the early recognition of dengue and potentially reduce illness and death associated with dengue virus infection. Clinical features that can be used in the initial assessment of febrile patients are essential tools for clinicians, especially in limited resource settings.

Preliminary Statistical Assessment of Intervention by a Palliative Care Team Working in a Japanese General Inpatient Unit

The effectiveness of intervention by the palliative care team at the University of Tokyo Hospital was assessed using the Support Team Assessment Schedule. During the study, 316 consecutive patients with malignant tumor disease were referred to the palliative care team, which assessed 11 physical symptoms. Results were tested by paired t test to calculate 95% confidence intervals comparing the mean Support Team Assessment Schedule scores for each symptom from the first time to the last time after palliative care intervention. The study concluded that (1) intervention by a palliative care team in general inpatient units can effectively control pain, nausea, and vomiting in patients up until the terminal stage; (2) it is likely that cough is controllable in the terminal stage with intervention by a palliative care team; (3) mouth dryness, anorexia, constipation, diarrhea, fatigue, and ascites are difficult to alleviate in the long term even with palliative intervention.

High Prevalence of Developmental Disabilities in Children Admitted to a General Pediatric Inpatient Unit

Objective: Evaluate a) the prevalence of developmental disabilities (DD) in children admitted to a general pediatrics inpatient unit, and b) the number of children admitted to the unit with previously undiagnosed developmental disability. Methods: Prevalence was evaluated through retrospective record review. Subjects: One hundred ninety children older than five months of age admitted to a general pediatric unit. Results: Of 190 children admitted, 155 (81.6%) had adequate developmental screening documented in the record. Forty-nine (25.7% of total, 31.6% of screened) had a developmental disability, 22 (12.1% of total, 14.8% of screened) had a previously unrecognized disability. Sample prevalence of DD was: cerebral palsy (6.8%), developmental delay or mental retardation (8.4%), language delay (4.6%), learning disability (8.2%), and hearing loss (1.5%). New diagnoses included: three children with probable mental retardation (MR), nine with learning disability (may include mild MR), seven with language delay, three with abnormal motor skills (fine and/or gross motor), one each of: neurofibromatosis type I, hearing loss, cerebral palsy, dysphagia. Some children had more than one new diagnosis. Conclusion: The prevalence of disabilities in a general pediatrics inpatient unit is much higher than the prevalence in the community. Because almost half of the disabilities were previously unrecognized, acute hospitalization is an excellent opportunity to conduct developmental screening.

Are Patient Preferences for Life‐Sustaining Treatment Really a Barrier to Hospice Enrollment for Older Adults with Serious Illness?

To determine whether patient preferences are a barrier to hospice enrollment. Prospective cohort study. Fifteen ambulatory primary care and specialty clinics and three general medicine inpatient units. Two hundred three seriously ill patients with cancer (n=65, 32%), congestive heart failure (n=77, 38%), and chronic obstructive pulmonary disease (n=61, 30%) completed multiple interviews over a period of up to 24 months. Preferences for high- and low-burden life-sustaining treatment and site of death and concern about being kept alive by machines. Patients were more likely to enroll in hospice after interviews at which they said that they did not want low-burden treatment (3 patients enrolled/16 interviews at which patients did not want low-burden treatment vs 47 patients enrolled/841 interviews at which patients wanted low-burden treatment; relative risk (RR)=3.36, 95% confidence interval (CI)=1.17-9.66), as were interviews at which patients said they would not want high-burden treatment (5/28 vs 45/826; RR=3.28, 95% CI=1.14-7.62), although most patients whose preferences were consistent with hospice did not enroll before the next interview. In multivariable Cox regression models, patients with noncancer diagnoses who desired low-burden treatment (hazard ratio (HR)=0.46, 95% CI=0.33-0.68) were less likely to enroll in hospice, and those who were concerned that they would be kept alive by machines were more likely to enroll (HR=5.46, 95% CI=1.86-15.88), although in patients with cancer, neither preferences nor concerns about receiving excessive treatment were associated with hospice enrollment. Preference for site of death was not associated with hospice enrollment. Overall, few patients had treatment preferences that would make them eligible for hospice, although even in patients whose preferences were consistent with hospice, few enrolled. Efforts to improve end-of-life care should offer alternatives to hospice that do not require patients to give up life-sustaining treatment, as well as interventions to improve communication about patients' preferences.

Poster 136: Rehabilitation of Patients With End-Stage Renal Disease Requiring Dialysis: Clinical Characteristics, Medical Complications, and Functional Outcomes

Objectives: To describe the clinical characteristics, length of stay (LOS), and functional outcomes of end-stage renal disease (ESRD) patients undergoing inpatient rehabilitation and to compare these results with non-ESRD patients in a similar program. Design: Database review. Setting: Acute general inpatient rehabilitation unit. Participants: Of a total of 835 patients, 24 ESRD patients were admitted to the unit over a 42-month period. Intervention: Comprehensive inpatient rehabilitation program.

Describing Use of Nursing Interventions for Three Groups of Patients

To describe the nursing interventions used most frequently during an acute hospital stay for three patient groups. Analysis of nursing interventions documented by use of the Nursing Interventions Classification (NIC) contained in an electronic clinical database obtained from 33 general inpatient units in one large health care facility from July 1, 1998, to June 30, 2002. The numbers of hospitalizations for each sample in the analyses were: 1,435 in the heart failure group, 567 in the hip fracture procedures group, and 11,756 in the fall prevention group. The mean number of interventions done at least once during a single hospitalization ranged from 18 to 22 for the three samples. For the total number of patient hospitalizations for each group, the number of interventions ranged from 94 for the hip fracture procedures sample to 182 for the fall prevention sample. Seven interventions were done twice or more a day in at least 20% of the sample in all three groups. Patterns of interventions during the first 6 days of care differed by intervention and sample, indicating that nursing care was individualized. The results indicate the types of information that can result from analysis of actual clinical nursing data documented with standardized language (Nursing Interventions Classification) in a nursing information system. The knowledge of nursing interventions used in clinical practice has major implications for staff development and nursing education. The information is also useful in making staffing decisions for different types of patient populations.

Treatment for Adolescents Following a Suicide Attempt: Results of a Pilot Trial

To compare the efficacy of a skills-based treatment protocol to a supportive relationship therapy for adolescents after a suicide attempt. Thirty-nine adolescents (12-17 years old) and parents who presented to a general pediatric emergency department or inpatient unit of a child psychiatric hospital after a suicide attempt were randomized to either a skills-based or a supportive relationship treatment condition. Follow-up assessments were conducted at intake and 3 and 6 months post-attempt. In contrast to the low rates of treatment received by adolescent suicide attempters in the community, approximately 60% of this sample completed the entire treatment protocol. Significant decreases in suicidal ideation and depressed mood at 3- and 6-month follow-ups were obtained, but there were no differences between treatment groups. There were six reattempts in the follow-up period. When adolescents who attempt suicide are maintained in treatment, significant improvements in functioning can be realized for the majority of patients.

Evaluation of a Staff-Only Hospitalist System in a Tertiary Care, Academic Children's Hospital

The staff/housestaff hospitalist system has been evaluated in 2 pediatric centers in the United States. In Canada, fewer residents and duty hour restrictions led to the development of a staff-only hospitalist system. The objective of this study was to compare the staff-only pediatric hospitalist system and the staff/housestaff hospitalist system with respect to traditional outcome measures. This cohort study (staff-only hospitalist system versus staff/housestaff system) used electronic health records data (July 1, 1996, to June 30, 1997) for all admissions (n = 3807) to the general pediatric inpatient unit of an urban, tertiary care, pediatric, teaching hospital in Toronto, Canada. Outcome measures included length of hospital stay, subspecialty consultations, readmission to the hospital, and death during the hospital stay. The median length of hospital stay was reduced by 14% for patients admitted to the staff-only hospitalist system, compared with the staff/housestaff hospitalist system (2.5 and 2.9 days, respectively). This difference remained statistically significant after adjustment for age, gender, and comorbidity. There were no significant differences between the 2 models of care with respect to subspecialty consultation, hospital readmission, or mortality rates. A stratified analysis showed similar findings for the 10 most frequent diagnostic groups. The staff-only hospitalist system was associated with a significant reduction in the hospital length of stay, without evidence of adverse effects on mortality or readmission rates, compared with the staff/hospitalist system. In the context of recent restrictions on resident duty hours in the United States, these findings may be of interest to pediatric teaching hospitals considering the development of a similar staff-only hospitalist model.

Geriatric patients improve as much as younger patients from hospitalization on general psychiatric units.

To determine whether geriatric patients aged 65 and older on general adult psychiatric units improve as much as younger patients, over what duration their improvement occurs, and their risk of readmission. Cohort study. Inpatient psychiatric unit of an urban, university-affiliated, county hospital from January 1993 through August 1999. A total of 5,929 inpatients. Standardized, routine assessments by attending psychiatrists included the Psychiatric Symptom Assessment Scale (PSAS) on admission and discharge. Discharge scores, length of stay (LOS), and risk of readmission within 1 year were modeled for the groups using multiple regression analyses. Geriatric patients constituted 5% (n=299) of the 5,929 admissions. In multivariate analysis, geriatric status was not associated with discharge PSAS scores. Median LOS was longer for geriatric patients (16 days) than younger patients (10 days, P<.001), especially in older women (14 days) and geriatric patients with mild medical illness severity (13 days vs 11 days in those with moderate-to-severe medical illness). Geriatric patients were as likely to be readmitted within 1 year of discharge as younger patients. Geriatric patients on general inpatient psychiatry units improved as much as younger patients. Their longer LOS was associated with milder medical illness severity. There may be a role for more specialized care of elderly women or geriatric patients with mild to moderate medical illness to improve the efficiency of their care.

Can a "good death" be made better?: A preliminary evaluation of a patient-centred quality improvement strategy for severely ill in-patients.

BackgroundPrior studies attempting to improve end-of-life care have focused on specific outcomes deemed important to healthcare providers, with disappointing results. Improvement may be best achieved by identifying concerns important to individual patients, communicating the patients' concerns to the treating medical team, and repeating the process frequently until all concerns are addressed. Our objective was to conduct a preliminary evaluation of this innovative patient-centred quality improvement strategy.MethodsInitial interviews elicited participants' ideas for improvement, which were then fed back to health care providers by the study investigator. A rapid-cycle change model ensured frequent reassessment and continued feedback. The study involved 36 seriously ill, hospitalized patients on teaching general medical inpatient units of a tertiary care hospital. The main outcome measure was participants' ratings of satisfaction within different domains of care on follow-up interviews.ResultsThe proportion of participants who rated various aspects of their care as "excellent" or "very good" on initial interview was 72% for overall care, 64% for symptom control, 66% for level of support, and 75% for discussions about life sustaining treatments. Patients and families identified many actionable steps for improvement such as; better control of pain and shortness of breath, better access to physicians and medical information, more help with activities of daily living, improving the patient's environment, and shorter waits for nursing care, diagnosis, and treatment. Following feedback to the clinical team, participants reported improvement in overall care (32%), symptom control (44%), and support (40%). Only a minority had further discussions about life sustaining treatments.ConclusionA patient-centred approach using rapid-cycle change was feasible and shows promise for improving the quality of end-of-life care. It should be evaluated on a larger sample in a controlled trial.

Comparison of inpatients with major mental illness who do and do not consent to low-risk research

The generalizability of research data depends on the degree to which the studied sample represents the larger population of interest. By influencing the likelihood of research participation, socio-demographic and clinical factors could bias a sample. To evaluate this, we retrospectively identified 155 consecutive admissions over an 18-month period to a general acute male psychiatry inpatient unit in a Veterans Affairs Hospital on which all competent patients were offered the opportunity to participate in low-risk clinical research. Male inpatients who did ( N=70) and did not consent ( N=85) were compared on 17 variables. Patients who consented to research were somewhat younger ( M difference=4.6 year) and were significantly more likely to carry a diagnosis of schizophrenia. The groups did not differ in financial resources, living situation or alcohol/drug abuse. We conclude that at least in this setting, general socio-demographic and clinical variables were not major influences on sample selection.

Dementia in elderly persons in a general hospital.

This study investigated the prevalence of dementia in a general hospital, reasons for which patients with dementia were admitted, and the relationship between dementia and length of stay, cost, and in-hospital mortality rate. The study focused on data from the hospital database on 21,251 patients aged 60 and older who were discharged in 1996 and 1997. Patients were grouped as with or without a discharge diagnosis of dementia by ICD-9-CM criteria. The groups were compared on sociodemographic characteristics, principal discharge diagnoses, lengths of stay, costs, and in-hospital mortality rates. The prevalence of dementia among discharged patients was 3.9% (N=823); it was dependent on age (age 60-64, prevalence=2.6%; age 85 and older, prevalence=8.9%). The primary discharge diagnoses of the groups were different. The mean length of stay was 10.4 days for patients with dementia and 6.5 days for patients without dementia. Per capita hospital costs were $4,000 higher for patients with dementia. Differences in lengths of stay and per capita costs were statistically significant after adjusting for age, race, and sex. Lengths of stay and hospital costs for patients with dementia were significantly higher for eight primary discharge diagnoses after adjusting for age, race, and sex. Dementia is present in a significant proportion of patients admitted to general inpatient units. Patients with dementia are admitted for different reasons than patients without dementia and appear to have longer stays, which are associated with higher costs. Efforts to identify dementia early during hospitalization could improve patient care and reduce costs.

Predicting deterioration in previously healthy infants hospitalized with respiratory syncytial virus infection.

To estimate the incidence of clinical deterioration leading to intensive care unit transfer in previously healthy infants with respiratory syncytial virus (RSV) infection hospitalized on a general pediatric unit and, to assess the hypothesis that history, physical examination, oximetry, and chest radiographic findings at time of presentation can accurately identify these infants. A virology database was used to identify and determine the disposition of all children </=1 year of age admitted to the Children's Hospital at Strong (CHaS) with RSV infection during the 1985 to 1994 respiratory seasons. Index patients were all previously healthy, full-term infants admitted initially to the general inpatient services at CHaS or Rochester General Hospital, a second University of Rochester teaching hospital, whose clinical deterioration led to transfer to the pediatric intensive care unit (PICU). These infants were matched retrospectively (for year and date of infection, sex, chronologic age, and race) with two hospitalized controls who did not require PICU transfer. Chest radiographic findings, respiratory rate (RR), O(2) saturation, and presence of wheezing at time of presentation to the emergency department (ED) were compared. During the study years, 542 previously healthy, full-term infants were admitted to the general pediatric unit at CHaS with proven RSV infection. Ten (1.8%; 95% confidence interval, 0.9%, 3.4%) were transferred subsequently to the PICU, primarily for close monitoring of progressive respiratory distress. Data for these patients and 7 patients transferred from Rochester General Hospital to the PICU at the CHaS were compared with those for control patients. The mean RR in the ED (63 vs 50), and O(2) saturation in the ED (88% vs 93%) were modestly abnormal in cases compared with controls. Wheezing on examination at time of presentation and chest radiographic findings did not differ between the two groups. A RR >80 and an O(2) saturation <85% at time of presentation each had a specificity >97% for predicting subsequent deterioration. Each parameter, however, had a sensitivity </=30%. Clinical deterioration requiring PICU admission is an uncommon occurrence in previously healthy infants admitted to a general pediatric inpatient unit with RSV infection. Extreme tachypnea and hypoxemia were both associated with subsequent deterioration; however, only a small proportion of patients who clinically deteriorated presented in this way. The clinical usefulness of these parameters, therefore, is limited. respiratory syncytial virus, deterioration, healthy infants, prediction.

Acute physiological and behavioral effects of oral cocaine in humans: a dose-response analysis

The present study was designed to assess the acute physiological and behavioral effects of a wide range of doses of oral cocaine HCL (placebo, 50, 100, 200, and 300 mg). Nine volunteers (eight males and one female) with recent histories of cocaine use resided on a general inpatient psychiatry unit while they participated. Drug doses were administered in a double-blind fashion under medical supervision, but for safety purposes, they were administered in ascending order. The physiological, subject-rated, and performance effects of oral cocaine HCL were assessed before drug administration and periodically afterwards for 5 h. Oral cocaine HCL increased heart rate and blood pressure as a graded function of dose, but the magnitude of these effects were not clinically significant. Oral cocaine HCL produced positive subject-rated drug effects (e.g. increased ratings of good effects, like drug, and willing to take again), but did not affect performance. Consistent with the pharmacokinetics of oral cocaine HCL, drug effects were generally discernible from placebo 0.5–1 h after administration, peaked approximately 1 h after administration, and progressively abated during the remainder of the experimental session. The results of this experiment demonstrate that across a six-fold range of doses oral cocaine HCL is well tolerated by individuals with recent histories of cocaine use and can be safely administered under controlled laboratory and medical conditions.

Frequency of dissociative disorders among psychiatric inpatients in a Turkish University Clinic.

The aim of this study was to determine the rate of dissociative disorders among psychiatric inpatients in a university clinic in Turkey. The Dissociative Experiences Scale was used to screen 166 consecutive inpatients admitted to the psychiatry clinic of a university hospital. The patients who had scores higher than 30 were matched for age and gender with 19 of the patients who scored below 10 on the scale. The patients in both groups were then interviewed with the Dissociative Disorders Interview Schedule by interviewers who were blind to their diagnoses and scores on the Dissociative Experiences Scale. Patients who were diagnosed as having a dissociative disorder according to the Dissociative Disorders Interview Schedule were then interviewed by a clinician. Twenty-four (14.5%) of the 166 patients had a score higher than 30 on the Dissociative Experiences Scale; 17 patients (10.2%) were diagnosed as having a dissociative disorder according to the Dissociative Disorders Interview Schedule. Nine patients (5.4%) had clinically confirmed dissociative identity disorder. A considerable proportion of the psychiatric inpatients in a Turkish university psychiatry clinic had dissociative disorder. Clinicians who work in general psychiatric inpatient units should be alert for chronic complex dissociative disorders.

Postoperative myocardial ischemia: Etiology of cardiac morbidity or manifestation of underlying disease?

Study Objective: To determine the relationship between postoperative ST segment changes and clinically apparent cardiac morbidity in noncardiac surgery patients. Design: Prospective, cohort study. Setting: General inpatient and intensive care units at a tertiary care hospital. Patients: 145 high-risk noncardiac surgery patients. Measurements and Main Results: Patients were monitored for ST segment changes using ambulatory electrocardiographs (ECG) recorders from the end of the surgical period for up to the third postoperative day. Patients were evaluated for a clinically apparent cardiac event (cardiac death or myocardial infarction) by daily 12-lead ECGs, and CK-MB isoenzymes, as clinically indicated. Nine patients sustained a clinically apparent cardiac event, 7 of whom had a cardiac event during the period in which they were monitored by ambulatory ECG. All 7 patients who sustained a cardiac event during the monitoring period had at least one episode of myocardial ischemia, which persisted for a minimum of 30 minutes either prior to or at the same time of the event, with no morbidity occurring in the group of patients who had only short durations of myocardial ischemia. Three of the patients with events had continuous ST segment changes, while the other patients had transient ST segment changes. Conclusions: These observations suggest that clinically apparent cardiac events are associated with prolonged ST segment changes detected on ambulatory ECG recorders. The cardiac ischemia leading to prolonged postoperative ST segment changes may itself result in cardiac morbidity, or it may be a reflection of underlying pathophysiology.

Seasons and bipolar disorder.

The records of 377 bipolar disorder patients who were consecutively admitted to a general inpatient psychiatric unit in mid-Michigan over a 6-year period were examined. The seasonal variation of hospitalization, total sleep time, thyroid stimulating hormone, creatinine levels, lithium dosage and serum levels, aggressive behavior, and treatment outcome were analyzed. Among men, the admission rate peaked in the springtime. Women demonstrated a bimodal season distribution, with peak admission rates in spring and fall. Aggressive behavior in both men and women peaked in the spring (z = 2.50, p < 0.05). Men maintained on lithium achieved higher serum lithium levels during the summer months. These findings parallel previous reports regarding the influence of seasons upon bipolar disorder. The therapeutic implications related to seasonality and mania are discussed.

Focused Time-Limited Inpatient Treatment of Borderline Personality Disorder

This paper describes a model for the short-term, time-limited inpatient treatment of patients with borderline personality disorder on a general psychiatry inpatient unit. The model includes many structural elements believed necessary for the successful short-term inpatient treatment of borderline patients such as preadmission contracts, a goal-oriented inpatient behavioral treatment contract, a focus on reducing symptoms related to the current crisis, the setting early in hospitalization of a discharge date, and the delineation of specific goal-oriented criteria for readmission. The model combines these “structures” with an adaptation to the short-term of a specific cognitive-behavioral approach, Dialectical Behavioral Therapy as developed by Marsha Linehan. This 7- to 14-day treatment model appears to (1) prevent regression in the patient and (2) help the patient to become a partner in and take responsibility for progress during the inpatient stay.

A computer workstation for clinical medicine

New computer tools for physicians, nurses, and the medical care team will become common in the 1990s. This paper describes a clinical workstation (CWS) development project that uses new technology that moves the technical support for medical decision making from the computer room to the nursing station. Collection, processing, and display of clinical information including patient identification, laboratory, and radiology results and current medications are carried out in the environment of a multi-windowed computer workstation. Easy access to automated medical literature databases from the workstation is also provided. This pilot project has successfully demonstrated a CWS operating on an acute general neurology and neurosurgical inpatient nursing unit and a critical care unit at The Johns Hopkins Hospital.