General Medical Department Research Articles

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In order to meet two-week referral targets for patients with colorectal symptoms, trusts must provide an efficient and effective patient pathway. On the face of it, the paper by Beggs et al suggests an attractive model for streamlining the process and potentially lowering costs. However, when one considers factors other than efficiency and cost effectiveness, the pathway may appear less than ideal. In the straight-to-colonoscopy pathway described, patients are sent full bowel preparation with instructions. In response to a number of adverse incidents, the National Patient Safety Agency has published clear guidelines for the use of bowel cleansing solutions.1 These include the need for clinical assessment to be undertaken by the clinician responsible for the procedure to ensure no contraindication or risks from their use. By the time a patient on a straight-to-colonoscopy pathway first sees the clinician responsible he or she will have already taken his or her bowel preparation. This is too late for an assessment of risk and an explanation on the safe use of the product. A second but related concern pertains to consent. Guidelines for obtaining informed consent are widely circulated by the General Medical Council2 and Department of Health.3 For elective procedures it is generally considered good practice to seek the patient's consent well in advance, with the clinician checking before the procedure starts that the person still consents. If a person is not asked to signify his or her consent until just before the procedure is due to start, at a time when he or she may be feeling particularly vulnerable, there may be real doubts as to its validity. While it remains important to meet targets and continue to improve the efficiency of our service, we would caution colleagues in the potential for compromise in the quality of that service.

Hospital hand hygiene opportunities: Where and when (HOW2)? The HOW2 Benchmark Study

Measurement and monitoring of health care workers' hand hygiene compliance (i.e., actions/opportunities) is a key component of strategies to eliminate hospital-acquired infections. Little data exist on the expected number of hand hygiene opportunities (HHOs) in various hospital settings, however. The purpose of this study was to estimate HHOs in 2 types of hospitals--large teaching and small community--and 3 different clinical areas-medical-surgical intensive care units, general medical wards, and emergency departments. HHO data were collected through direct observations using the World Health Organization's monitoring methodology. Estimates of HHOs were developed for 12-hour AM/PM shifts and 24-hour time frames. During 436.7 hours of observation, 6,640 HHOs were identified. Estimates of HHOs ranged from 30 to 179 per patient-day on inpatient wards and from 1.84 to 5.03 per bed-hour in emergency departments. Significant differences in HHOs were found between the 2 hospital types and among the 3 clinical areas. This study is the first to use the World Health Organization's data collection methodology to estimate HHOs in general medical wards and emergency departments. These data can be used as denominator estimates to calculate hand hygiene compliance rates when product utilization data are available.

Trends and costs of overtime among nurses in Canada

To examine the regular and overtime working hours of Registered Nurses in acute care and their associated costs by employment status (full time, part time, casual) and department over a 4-year period. Data were extracted for 2005-2008 from one health region's payroll database for Registered Nurses in acute care in British Columbia, Canada. Regular and overtime hours by employment status and department were plotted over time and tested using simple linear regression. Regular and overtime wage costs were calculated at the individual level using the employee's wage rate and stratified by year, gender, age, employment status and department. Full time Registered Nurses are working an increasing amount of overtime hours each year. Full time nurses in Emergency, Intensive Care and General Medical departments are working the highest proportion of overtime hours per total hours and consequently, contributing the highest proportion of overtime costs. Efforts to lighten the burden of overtime should be focused at the department level. Creating more full time positions out of overtime hours may be one solution to alleviate this burden of overtime and to assuage the nursing shortage in Canada.

Research on the effect of technology operation training with communication skills on the quality of nursing

Objective To study the influence of technology operation training with communication skills on the quality of nursing.Methods 830 nurses were randomly divided into general surgery department group which were given technology operation training with communication skills and general medical department group which were given traditional technology operation training.Then,the operating results was measured by obscure mathematics evaluation and the degree of satisfaction was investigated before and after training.Results The scores of all items and the degree of satisfaction in general surgery department group were higher than those of genenal medical department group after training (P＜0.01) .The scores of aim,check,preparation,practice,the qualities of operators,record and relevant system,principles in general medical department group were significantly improved after training than before training (P＜0.01) .But the scores of evaluation,infoming,humane care in general medical department group were no significantly different between before and after traing (P＞0.05) .Conclusions Technology operation training with communication skills could show a better effect than traditional technology operation training,therefore,it could enhance the connotation of nursing and the professional values and the degree of recognition of patients. Key words: Technology operation; Communication skills; Quality of nursing

TRENDS IN UTILIZATION OF PLEURAL FLUID CYTOLOGY IN AN ENGLISH DISTRICT HOSPITAL

PURPOSE: Pleural effusions are a common presentation to general medical departments of district general hospitals in England. In such a setting, we know that the quality of diagnostic work-up as well as the treatment rates of lung cancer patients improve with trained respiratory physician leadership (Gupta P, Bhattacharya M, Mukherjee R. The role of a trained respiratory physician in lung cancer management. European Respiratory Journal 2008; 32: 52. 237s). Whether this improves the diagnosis of unilateral pleural effusions is not well understood.

Revue de pertinence des journées d’hospitalisation en médecine et chirurgie : un tiers de journées inappropriées au CHU de Nantes

To assess the rate of inappropriate hospital days at Nantes University Hospital, to compare Internal Medicine and General Medicine departments to other hospital departments and to describe the main reasons for inappropriateness. A cross-sectional study was conducted during spring 2006, on a given day that differed in the 11 participating medical and surgical departments. All inpatients in the departments were included, except those admitted or discharged that day. The French version of the Appropriateness Evaluation Protocol was used to assess each day. Overall 32.4% of hospital days (71/219) (95% confidence interval: 26.1-38.7) were inappropriate. This rate did not vary significantly between internal and general medical, specialty, and surgical departments, although their inpatients had different characteristics. The risk factors for inappropriateness included long stays, unplanned admissions, behavioral disorders, and older age. Only a long stay was identified as a risk factor in all departments. Most of these inappropriate days (77.5%) were due to external causes (patients awaiting transfer). The decision of the patient (or family) was involved in 12.7%, and internal organizational reasons in 9.8%. This study showed a variety of risk factors for inappropriate days, differing according to department (except long stays, which were a risk factor in all departments). This confirms that patient characteristics play a major role, more significant than the department itself. Our analysis of the causes of these inappropriate hospital days, like those of most other studies, finds that only a few of these causes are susceptible to internal improvements. To optimize patient transfers, however, several units have begun training to make hospital staff aware of the importance of early planning. The impact of these measures on the number of inappropriate days should be assessed in the future.

Patients' perception and actual practice of informed consent, privacy and confidentiality in general medical outpatient departments of two tertiary care hospitals of Lahore.

BackgroundThe principles of informed consent, confidentiality and privacy are often neglected during patient care in developing countries. We assessed the degree to which doctors in Lahore adhere to these principles during outpatient consultations.Material & MethodThe study was conducted at medical out-patient departments (OPDs) of two tertiary care hospitals (one public and one private hospital) of Lahore, selected using multi-stage sampling. 93 patients were selected from each hospital. Doctors' adherence to the principles of informed consent, privacy and confidentiality was observed through client flow analysis performed by trained personnel. Overall patient perception was also assessed regarding these practices and was compared with the assessment made by our data collectors.ResultsSome degree of informed consent was obtained from only 9.7% patients in the public hospital and 47.8% in the private hospital. 81.4% of patients in the public hospital and 88.4% in the private hospital were accorded at least some degree of privacy. Complete informational confidentiality was maintained only in 10.8% and 35.5% of cases in public & private hospitals respectively. Informed consent and confidentiality were better practiced in the private compared to the public hospital (two-sample t-test > 2, p value < 0.05). There was marked disparity between the patients' perspective of these ethical practices and the assessment of our trained data collectors.ConclusionObservance of medical ethics is inadequate in hospitals of Lahore. Doctors should be imparted formal training in medical ethics and national legislation on medical ethics is needed. Patients should be made aware of their rights to medical ethics.

Rural Organisation of Acute Stroke Teams project

Improving the care of stroke patients is a national priority for the health system in Australia. In rural areas the challenges may be greater. Although best-practice guidelines for acute and subacute stroke care are well established, their general uptake appears to be limited and implementation strategies are required to promote the use of this evidence-based care. The Rural Organisation of Australian Stroke Teams (ROAST) project sought to promote the evidence-based stroke practice in rural hospitals. This was a prospective observational project designed to improve the services provided to rural stroke patients, primarily through better organisation of care on general medical wards and emergency departments. Using recognized support strategies, we encouraged the use of nationally recognized key performance indicators and provided audit and feedback of adherence to these indicators to participating hospitals. Six Victorian hospitals participated in this initial phase of the ROAST project. Information was collected on 348 patients. Ten of the 11 indicators showed greater than 10% improvement in adherence levels and by the end of the project period compared favourably to levels of adherence described in metropolitan hospitals. The ROAST projected supported a network of clinicians to implement evidence-based guidelines in acute stroke care in the setting of general medical wards. In doing so, this project has shown that it is quite feasible to deliver best-practice care to stroke patients in rural Australia.

Management of older patients presenting after a fall--an accident and emergency department audit.

It is common for older patients to present to accident and emergency (AE) departments after a fall. Management should include assessment and treatment of the injuries and assessment and correction of underlying risk factors in order to prevent recurrent falls. To determine management of older patients presenting after a fall to the AE department of Groote Schuur Hospital in Cape Town, South Africa. Hospital records were reviewed for a random sample of 100 patients aged 65 years and older presenting to the AE department after a fall, between December 2001 and May 2002. The mean age of the sample was 78.6 years (range 65-98 years); 72% of subjects were female. History of a previous fall, and history of drug or alcohol intake, were recorded in less than 20% of cases. Blood pressure and pulse rate were recorded in approximately 90% of cases, and pulse rhythm and postural blood pressure in 2%. Examination of the musculoskeletal system was done in 86% of cases and that of other systems in less than 50%; cognitive assessment was conducted in less than 30%. Radiological investigations were performed in 89% of cases, glucose and haemoglobin in 32%, renal profile and electrocardiogram in 5%, and urinalysis in 4%. Three-quarters of the patients were referred for further management: 52% to orthopaedic surgery, 12% to other surgical subspecialties, 6% to the general medical department, and 6% to other hospitals and clinics. No referrals were made to geriatric medicine, physiotherapy or occupational therapy. In managing elderly patients after a fall, the AE department focused on injuries sustained. Little effort was made to establish and manage risk factors, hence to prevent recurrent falls. Guidelines are needed for the management of such patients in AE departments.

Gender Differences in Factors Associated with Nutritional Status of Older Medical Patients

Objectives: To evaluate gender differences in nutritional risk of older people admitted to an acute-care general medical department, and identify gender-specific risk factors.Design: Cross-sectional study. Setting: Internal Medicine Department in an acute care, university-affiliated hospital in southern Israel.Subjects: 204 cognitively intact patients aged 65 and over, admitted during a 12-month period to a general medical department. Measures of outcome: Evaluation included demographic and clinical data consisting of the sum of medical conditions and of prescribed medications, evaluation of nutritional status, cognitive status, depression assessment and functional ability. Statistical analyses were conducted to evaluate the gender specific risk factors for under-nutrition.Results: 32.5% of the men and 48.1% of the women admitted to an internal medicine department were at risk for under-nutrition. Those at nutritional risk had a higher rate of depression, lower cognitive and physical ability, poorer reported health status and more diagnosed diseases. Nutritional risk for men was associated with higher depression score, longer hospitalization, and poor appetite. For women, nutritional risk was associated with lower functional status and more diagnosed diseases. In a multivariate analysis, being a female increased the risk of under-nutrition by 3.3 fold.Conclusion: Risk of under-nutrition is prevalent among older in-patients and is gender-related. Female inpatients are at markedly increased risk for under-nutrition. The mechanism of the gender discrepancy in factors related to nutritional deterioration is complex and poorly understood.

Goldratt's Thinking Process Applied to the Budget Constraints of a Texas MHMR Facility

Managers for years have known that the best way to run a business is to constantly be looking for ways to improve the way to do business. The barrier has been the ability to identify and solve the right problems. Eliyahu Goldratt (1992c), in his book The Goal, uses a love story format to illustrate his “Theory of Constraints.” In Goldratt's (1994) next book, It's Not Luck, he further illustrates this powerful technique called “The Thinking Process” which is based on the Socratic method, using the “if … then” reasoning process, The first step is to identify UDEs or undesirable effects within the organization and then use these UDEs to create a Current Reality Tree (CRT) which helps to identify the core problem. Next, use an Evaporating Cloud to come up with ideas and a way to break the constraint. Finally, use the injections in the Evaporating Cloud to create a Future Reality Tree, further validating the idea and making sure it does not create any negative effects. In this article, the “Thinking Process” will be used to identify and solve problems related to the General Medical Department of an MHMR State Hospital.

Stroke management on general medical departments. A multicenter study in Austria

Despite the claimed superiority of Stroke Units a majority of patients with acute stroke is still treated on general medical departments in many countries. In Austria 90 % of 121 medical departments state that they take care of stroke patients routinely or at least sometimes. Therefore, our aim was to evaluate whether stroke management on medical wards meets up-to-date standards. 55 medical departments all over Austria participated in a prospective multicenter registry documenting diagnostics, treatment and the in-hospital course of unselected patients admitted with an acute stroke according to a standardised protocol. 1100 patients, 56 % female, with a median age of 75 years were assessed. Median hospital stay was 14 days. In 96 % a cranial computer tomogram was performed. 81 % of cerebral lesions were ischemic, 10 % haemorrhagic. Only 10 % had no risk factor or accompanying medical disease. 31 % suffered at least one medical and 18 % one neurological complication (p = 0.00000003). In-hospital mortality was 17 %, functional outcome was poor in 27 % (Rankin scale [RS] 4 or 5) and good in 56 % (RS 0-3). 74 % of discharged patients could leave to their home, 13 % were transferred to a nursing home and 13 % to a rehabilitation center. 95 % of surviving patients left on either an antiplatelet or an anticoagulant medication and 73 % received antihypertensives. Outcome of stroke patients treated on general medical departments seems to be fairly comparable to that commonly reported by neurological Stroke Units. Further improvements may be obtained by implementation of integrated "mixed assessment" units into medical departments.

Nutritional Status of Cancer Patients upon Admission

【The purpose of this study was to assess the nutritional status of cancer patients and non-cancer patients who were admitted to an internal medical department and to determine the degree of malnutrition among these patients. The study was performed from May to July l996 with 151 subjects recruited from the general medical department at D University Hospital. For nutritional assessment the anthropometric and biochemical assessment were performed. Biochemical measurements included serum hemoglobin, albumin, and lymphocytes. For anthropometric assessment, patient's body weight, skinfold thickness in four areas, body mass index, and percent of body fat were measured. The results were as follows : 1) Of the 151 patients who were studied, 47 patients had cancer while 104 patients had non cancer related disease. The mean age of the cancer patients was 57 and 52 for non cancer patients. The percentage of patients who had lost body weight during the last 6 months was 29.8% in cancer patients and 15.4% in non cancer patients. This percentage difference between the 2 groups was statistically significant. However, there was no statistical significance between the 2 groups in gastrointestinal symptoms which lasted more than 2 weeks. 2) There was a statistically significant difference in nutritional status(lympocyte : P＝.002 ; skinfold thickness in four areas : p＜0.05) between the cancer and the non-cancer patients. The percentage of the patients who had the possibility of malnutrition was 65.5% in cancer patients and 6% in non-cancer patients. 3) There was a correlation between the weight loss during the last 6 months before admission and body mass index and skinfold thickness.】

How do general practitioners compare with the outpatient department when requesting upper abdominal ultrasound examinations?

The recent re-organization of the National Health Service has placed a new emphasis on reexamining the services that hospitals provide to General Practitioners (GPs). To assess the positive findings from an existing open access ultrasound service for GPs in a metropolitan District General Hospital, a retrospective study was performed of 300 consecutive patients referred by GPs compared with 300 consecutive patients referred from the general medical, surgical and geriatric Outpatient Departments--specifically with regard to upper abdominal ultrasound. The frequency with which the clinical indication for referral was associated with an ultrasound finding which could explain the patient's symptoms was measured and the similarities and differences in the two groups are discussed. The study did not attempt to assess the complete value of this service since that would have necessitated assessment of the importance of negative findings. In the two groups the total number of ultrasound abnormalities was similar. A total of 25.3% of GP referrals had an abnormality which could account for their symptoms. The corresponding figure for hospital outpatients was 33.6%. On this criterion, the provision of open access for abdominal ultrasound to GPs is justified.

Cost-Effectiveness in the Hospital Use of Antibiotics: Introductory Considerations

A cost-effectiveness analysis was performed for three antibiotic drug therapies in pneumonia and bronchopneumonia: broad spectrum penicillins, III generation cephalosporins and ceftriaxone. The study was based on records from 117 patients in 9 general medical departments in North and Central Italy during 1989. Costs included direct cost of drugs, staff, accommodation, and other hospital costs. Effectiveness was measured radiographically as clinical cure, interruption of therapy or death. The effectiveness and shorter duration of therapy with ceftriaxone in respect to the other treatments, produced a 15.18% savings of hospital resources compared with other III generation cephalosporins, and a 14.76% savings compared with broad spectrum penicillins. This is a provisional conclusion requiring confirmation with a larger number of patients and randomized trials.

Patient dumping, COBRA, and the public psychiatric hospital.

Serious clinical and risk management problems arise when indigent patients with acute medical conditions are transferred from general medical hospitals or emergency departments to public psychiatric hospitals that are ill equipped to provide medical care. To combat such practices, referred to as dumping, Congress included measures in the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) prohibiting such transfers. Because physicians and administrators in public psychiatric hospitals are generally not aware of the potential usefulness of COBRA in reducing dumping, this paper describes its important provisions. The key to preventing dumping is to educate referral sources to limitations on the medical care available at the receiving hospital and to discourage negligent patient transfers by enforcing COBRA. Public hospital staff and legal counsel who become familiar with COBRA's provisions can develop an antidumping strategy.

Transmission of infectious diseases in outpatient health care settings

Increased provision of health care in outpatient settings and concerns about occupational transmission of infections have focused attention on the risk of transmission of infectious diseases in ambulatory health care settings. In contrast to inpatient nosocomial infections, infections transmitted in outpatient settings are neither systematically monitored nor likely to be detected by routine qi surveillance. To better define the spectrum of such events, we reviewed the literature to identify cases and clusters of infections associated with outpatient health care. In this review, we identified and epidemiologically characterized 53 such reports that occurred from 1961 through 1990. Transmission occurred in general medical offices, clinics, and emergency departments (23); ophthalmologists' offices and clinics (11); dental offices (13); and alternative-care settings (six). Our findings suggest that inpatient infection-control practices should be extended to outpatient health care settings by assigning specific responsibility for infection control and by adapting surveillance methods and prevention measures. (<i>JAMA</i>. 1991;265:2377-2381)

Transmission of Infectious Diseases in Outpatient Health Care Settings

Increased provision of health care in outpatient settings and concerns about occupational transmission of infections have focused attention on the risk of transmission of infectious diseases in ambulatory health care settings. In contrast to inpatient nosocomial infections, infections transmitted in outpatient settings are neither systematically monitored nor likely to be detected by routine qi surveillance. To better define the spectrum of such events, we reviewed the literature to identify cases and clusters of infections associated with outpatient health care. In this review, we identified and epidemiologically characterized 53 such reports that occurred from 1961 through 1990. Transmission occurred in general medical offices, clinics, and emergency departments (23); ophthalmologists' offices and clinics (11); dental offices (13); and alternative-care settings (six). Our findings suggest that inpatient infection-control practices should be extended to outpatient health care settings by assigning specific responsibility for infection control and by adapting surveillance methods and prevention measures.

Effect of Isoflurane on the Canine Hepatic Circulation and Hepatic Oxygen Balance

Departments of Anesthesia, Glasgow Royal Infirmary and Stobhill General Hospital, Glasgow, and Medical Department, Lilly Industries, Basingstoke, U.K.

The Distribution of Mental Illness Found by DIS (Diagnostic Interview Schedule) among Internal and Orthopedic Patients

In order to understand how psychiatric problems are distributed in general medical departments, we used DIS (Diagnostic Interview Schedule). The subjects are 307 inpatients and outpatients in the Departments in Internal Medicine and Orthopedics of Fukuoka University Hospital, M Hospital and N Hospital. As a result, 53.4% of all the subjects showed some psychiatric problems. These are, in a descending order, tobacco dependence (30.0%), psychosexual dysfunction (14.3%), alcohol abuse/dependence (14.0%), major depressive episode (6.5%), organic brain syndrome (4.9%), obsessive-compulsive disorder (3.9%), dysthymic disorder (2.3%), panic disorder (2.0%) and others. Also, we discussed comparison between internal patients and neurotic patients who visited psychiatrists complaining of physical symptoms, and the incidence of DIS diagnoses in individual physical diseases.