General Medical Inpatients Research Articles

Implementation of proven interventions in general medical inpatients: development and evaluation of a new quality indicator for drug therapy

Background:Among adult general medical inpatients, there are numerous interventions whose benefits outweigh their risks. However, there are no published reports describing the overall use of such proven interventions in this...

Anti-rheumatic and analgesic drug usage and acute gastro-intestinal bleeding in elderly patients.

The records of 1878 general medical in-patients (aged 75 years and over) at Hereford have been examined for associations between the commonly used antirheumatic and analgesic drugs and acute gastro-intestinal bleeding. One third of 93 in-patients admitted because of acute bleeding had been taking ibuprofen, indomethacin or aspirin. The usage of these drugs was significantly greater than in the control population who comprised the remaining 1785 elderly medical in-patients. It is suggested that very elderly patients taking any of these three drugs form a vulnerable high risk group who are liable to develop acute gastro-intestinal bleeding.

Poor Care, Not Poor Protocols, for Alcohol Withdrawal–Reply–I

Poor Care, Not Poor Protocols, for Alcohol Withdrawal–Reply–I

Audits of nutrition screening tool completion rates on general medical and elderly care inpatients (2000 to 2007)

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Audits of nutrition screening tool completion rates on general medical and elderly care inpatients (2000 to 2007)

Audits of nutrition screening tool completion rates on general medical and elderly care inpatients (2000 to 2007)

Outcomes for general medical inpatients with diabetes mellitus and new hyperglycaemia

To investigate the relationship between admission glycaemic status and inpatient mortality in patients with and without pre-existing diabetes. Prospective observational cohort study. A general medical ward in an Australian tertiary referral hospital. 903 patients admitted to the general medical ward between February 2003 and July 2004. Inpatient death. The overall inpatient mortality was 5.4% (n = 49). In the total cohort, age > 75 years and admission fasting plasma glucose (FPG) levels > or = 5.6 mmol/L were independent predictors of mortality. For patients without a known history of diabetes, each 1 mmol/L rise in admission FPG was associated with a 33% increase in mortality. In these patients, elevated (> 6.0%) and normal glycated haemoglobin (HbA(1c)) levels were associated with mortalities of 11.3% and 4.4%, respectively (odds ratio, 2.47; 95% CI, 1.16-5.26). In contrast, in patients with known diabetes, there was no association between admission FPG levels, HbA(1c) and mortality. Length of stay was not independently associated with FPG, HbA(1c), or diabetes status. In patients without known diabetes, the risk of death was increased for admission FPG levels > or = 5.6 mmol/L. However, pre-existing abnormal glucose metabolism, reflected by elevated HbA(1c) levels, appeared a more important predictor of inpatient mortality than glucose levels in patients without known diabetes.

Delirium in elderly general medical inpatients: a prospective study

More than 49% of all US hospital days are spent caring for patients with delirium. There are few Australian data on this important condition. The aim of the study was to determine the prevalence and incidence of delirium in older medical inpatients in a metropolitan teaching hospital, the incidence of known risk factors and current practice in identifying and managing patients at risk of this condition. Patients aged 65 years or more, and admitted to a general medical unit, were eligible for study inclusion. Participants were screened with an Abbreviated Mental Test Score (AMTS) and chart review. Confusion Assessment Method was used to diagnose delirium if confusion was documented or AMTS < 8. Barthel Index (BI), demographics, delirium risk factors and management were recorded. Prevalent delirium was diagnosed in 19 of 104 (18%) and incident delirium in 2 of 85 (2%) participants. Pre-existing cognitive impairment and admission AMTS < 8 were strongly associated with prevalent delirium (P-values < 0.01). Age > 80 years, Barthel Index < or = 50, use of high-risk medications and electrolyte disturbance were also associated with prevalent delirium. Prevalent delirium was not recognized by the treating unit in 4 of 19 cases (21%). Five of 104 (4.8%) of participants had a formal cognitive assessment on admission. One of 19 patients (5.3%) with prevalent delirium had an orientation device in their room. Pre-existing cognitive impairment and admission AMTS are strong predictors of delirium. Despite this, formal cognitive assessment is not routinely carried out in elderly medical patients. Recognition of delirium may be improved by routine cognitive assessment in elderly medical patients.

Vitamin D deficiency in general medical inpatients in summer and winter

Vitamin D deficiency is common in various populations worldwide. Adverse effects of vitamin D deficiency are the development of bone disorders; however, other diseases such as multiple sclerosis, type 1 diabetes, rheumatoid arthritis and certain cancers have also been linked to vitamin D deficiency. The general medical inpatient population is a group at increased risk of vitamin D deficiency. These patients often have coexistent risk factors for its consequences. This study aims to document a point prevalence of vitamin D deficiency in this population. Two cross-sectional audits of patients admitted to general medicine units were carried out--the first in mid-November at the end of winter and the second in mid-April and May at the end of summer. Information regarding patients' comorbidities, medication usage, previous falls and fractures was obtained and serum 25-hydroxyvitamin D, parathyroid hormone and calcium levels were measured. A total of 129 patients was studied (65 in winter and 64 in summer). Ninety-four patients (74%) had 25-hydroxyvitamin D levels < or = 50 nmol/L. Seven patients had severe deficiency (levels < or = 12.5 nmol/L). Average vitamin D levels were lower at the end of winter (35 vs 43 nmol/L, P = 0.007). Of the 37 patients receiving vitamin D supplements, 20 (54%) had 25-hydroxyvitamin D levels < or = 50 nmol/L. Low vitamin D levels were common in this general medical inpatient population. The average vitamin D level was lower in the patient group tested in November following winter. Supplementation of vitamin D did not uniformly prevent deficiency.

Audit of Literacy of Medical Patients in North Glasgow

We aimed to assess the scale of the problem of illiteracy among our hospital's general medical in-patients and investigate any influence on literacy from gender, age, socioeconomic status, disease process and number of prescribed medications. We employed a shortened version of the previously validated Rapid Estimate of Adult Literacy in Medicine (REALM) tool with medical in-patients at Glasgow Royal Infirmary. We also recorded gender, date of birth and clinical problem. Socioeconomic status was estimated from the patient's postcode using the Scottish Index of Multiple Deprivation (SIMD). 60 patients were invited to participate, however six (10%) declined. We therefore gathered data for 54 patients (54% male) with a mean age of 67 years. The female group had a significantly higher mean age of 73 years versus 62 years in men. The mean SIMD quintile was 3.5 (1 least deprived, 5 most deprived) and the mean number of medications was 7.55% of our patients had a mean score of < 60 which represents low health literacy. There were no significant differences in literacy between men (median score 59) and women (median score 60). Reading ability was not found to be associated with socioeconomic group, diseased body system or number of medications on the drug chart (data not shown). Low level health literacy is prevalent. Affected individuals may have difficulty understanding patient-orientated health literature, medication instructions, clinic appointment cards and hospital signage.

Unintended Consequences of Regionalizing Specialized VA Addiction Services

Unintended Consequences of Regionalizing Specialized VA Addiction Services

Heparin for Prophylaxis: Two or Three Times Daily?

Unfractionated and low-molecular-weight heparins are both used for prophylaxis against thromboembolism in general medical inpatients. When

The inter-rater reliability of mental capacity assessments

Background Assessing mental capacity involves complex judgements, and there is little available information on inter-rater reliability of capacity assessments. Assessment tools have been devised in order to offer guidelines. We aimed to assess the inter-rater reliability of judgements made by a panel of experts judging the same interview transcripts where mental capacity had been assessed. Method We performed a cross sectional study of consecutive acute general medical inpatients in a teaching hospital. Patients had a clinical interview and were assessed using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and Thinking Rationally About Treatment (TRAT), two capacity assessment interviews. The assessment was audiotaped and transcribed. The raters were asked to judge whether they thought that the patient had mental capacity based on the transcript. We then divided participants into three groups — those in whom there was unanimous agreement that they had capacity; those in whom there was disagreement; and those in whom there was unanimous agreement that they lacked capacity. Results We interviewed 40 patients. We found a high level of agreement between raters' assessments (mean kappa = 0.76). Those thought unanimously to have capacity were more cognitively intact, more likely to be living independently and performed consistently better on all subtests of the two capacity tools, compared with those who were unanimously thought not to have capacity. The group in whom there was disagreement fell in between. Conclusions This study indicates that clinicians can rate mental capacity with a good level of consistency.

Thromboprophylaxis of Adult Medical Inpatients in St. John's Newfoundland.

Introduction: Venothromboembolic disease (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), are causes of significant morbidity and mortality in hospitalized patients. Medical inpatients often have multiple risk factors for developing VTE and as a population have been shown to have significant rates of VTE ranging from 5–15% with approximately 75% of in hospital VTE occurring in non-surgical patients. Recent large randomized controlled trials have demonstrated the safety and efficacy of low molecular weight heparins (LMWH) in the prevention of VTE in this population. Despite the evidence of the effectiveness of this prophylactic treatment, numerous studies have demonstrated its underutilization in many at risk medical inpatient populations. We aim to establish rates of VTE prophylaxis in the population of at risk general medical inpatients in two acute care adult hospitals in the St. John's area to assess if similar underutilization exists and if there is a need for future interventions to improve outcomes.Methods: We used a modification of the inclusion/exclusion criteria of the MEDENOX trial to retrospectively identify consecutive medical inpatients at The General Hospital/St. Clare's Mercy Hospital who were appropriate to receive VTE prophylaxis during January and February of 2005. Data was collected on demographics, VTE risk factors, and the use of any duration of low dose subcutaneous unfractionated heparin or low dose LMWH during their hospitalization. Two tailed t-tests were performed to identify any significant differences in demographics or VTE risk factors between the prophylaxis and non-prophylaxis groups.Results: 114 medical inpatients were identified as being appropriate to receive pharmacologic VTE prophylaxis between Jan.1, 2005 and Feb. 28, 2005. 26 patients (23%) received some form of pharmacologic VTE prophylaxis. Of those who received prophylaxis, 19 patients (73%) received subcutaneous unfractionated heparin and 7 patients (27%) received LMWH. The only significant difference between the prophylaxis and non prophylaxis group was a higher proportion of patients with malignancy (27% vs 11% p=0.05) in the prophylaxis group.Conclusion: This data demonstrates a significant underutilization of VTE prophylaxis in all at risk general medical patients in the two major adult acute care centres of the Eastern Health Board of Newfoundland. The data is consistent with the growing body of literature that exhibits that VTE prophylaxis in medical inpatients is deficient, with previously reported prophylaxis rates of only 20%–50%. Thus future work needs be done in translating “best practice” into “usual practice” as it relates to VTE prophylaxis.

Severe hyponatraemia in medical in-patients: aetiology, assessment and outcome

Hyponatraemia is the most commonly identified electrolyte abnormality. Published data on severe hyponatraemia in general medical in-patients is lacking. To determine the aetiology, adequacy of assessment, and outcome of severe hyponatraemia in general medical in-patients. Retrospective case-note review. All general medical in-patients (n = 108) with serum sodium < or =125 mmol/l were identified from the clinical chemistry database, over a six-month period. A full review of notes and computer records was undertaken at the index date and a pre-determined follow-up date. Follow-up data were available in 105 patients. There was a wide range of aetiologies: diuretic therapy (loop and thiazide), congestive cardiac failure and liver disease were the most common, and 75.3% of patients had multiple causes. None of the 48% of patients whose history suggested a possible diagnosis of the syndrome of inappropriate anti-diuretic hormone (SIADH) met the generally accepted diagnostic criteria. Overall mortality was 20% during the index admission and 44.6% at follow-up, vs. 7.1% and 22%, respectively, for other patients admitted to the same directorate over the same time period (p < 0.001). Mortality was linked to aetiology, but not to reduced absolute serum sodium concentration at admission. Severe hyponatraemia in general medical patients is associated with a complex, multifactoral aetiology and a very poor prognosis. Outlook is governed principally by aetiology, and not by serum sodium level. Assessment of patients with hyponatraemia requires a practical clinical algorithm for diagnosing SIADH.

A Retrospective Evaluation of Adherence to Guidelines for Prevention of Thromboembolic Events in General Medical Inpatients

ABSTRACT Background: Venous thromboembolism is a frequently occurring disorder associated with significant morbidity, mortality, and resource expenditure. Although most venous thromboembolic incidents occur in medical patients, standardized protocols for thromboprophylaxis in such patients have not been implemented at the authors’ institutions. Objective: To compare institutional thromboprophylactic practices for medical patients with current guidelines. Methods: A chart review was performed for patients admitted to the medical wards of 2 university-affiliated hospitals over a 7-month period. Patients were included if they had one major risk factor and/or at least 2 minor risk factors for venous thromboembolism. The primary endpoint was the rate of thromboprophylaxis during hospital admission. Results: A total of 131 subjects were included in the analysis. The rate of thromboprophylaxis was 21%, was similar in subjects with and without major or minor contraindications to pharmacologic prophylaxis, and did not differ by age. Two patients, both of whom received thromboprophylaxis, experienced a venous thromboembolic event. In patients who received thromboprophylaxis, unfractionated heparin was the most common agent. Of patients who received thromboprophylaxis, approximately 7% experienced a minor bleed and 7% experienced a major bleed. Conclusions: Among medical patients at the authors’ institutions with risk factors for venous thromboembolism, a small proportion received thromboprophylaxis, which reflects poor adherence to current guidelines. The low rate of prophylaxis was not explained by contraindications to prophylaxis or the age of the subjects. ABSTRACT Historique : La thromboembolie veineuse est une affection frequente qui entraine de la morbidite, de la mortalite et des depenses en ressources significatives. Bien que la plupart des accidents thromboemboliques veineux surviennent chez les patients admis aux services de medecine, des protocoles de thromboprophylaxie standardises pour de tels patients n’ont pas ete mis en oeuvre dans les etablissements ou sont rattaches les auteurs. Objectif : Comparer les pratiques de thromboprophylaxie utilisees chez les patients admis aux services de medecine dans ces etablissements a celles des lignes directrices actuelles. Methodes : On a evalue les dossiers medicaux des patients admis aux unites de medecine de deux hopitaux universitaires sur une periode de sept mois. Les patients etaient retenus s’ils presentaient un facteur de risque principal et (ou) au moins deux facteurs de risque secondaires de thromboembolie veineuse. Le critere d’evaluation primaire etait le taux de thromboprophylaxie durant le sejour a l’hopital. Resultats : Au total, 131 sujets ont ete inclus dans l’analyse. Le taux de thromboprophylaxie a ete de 21 %, et etait semblable que les sujets aient eu ou non des contre-indications mineures ou majeures de la prophylaxie medicamenteuse, et ne differait pas selon l’âge. Deux patients, qui ont tous deux recu une thromboprophylaxie, ont eu un accident thromboembolique veineux. Chez les patients qui ont recu une thromboprophylaxie, l’heparine non fractionnee etait l’agent le plus souvent utilise. Parmi les patients qui ont recu une thromboprophylaxie, environ 7 % ont eu des saignements mineurs et 7 % des saignements majeurs. Conclusions : Une faible proportion des patients admis aux services de medecine dans les etablissements ou sont rattaches les auteurs et presentant un risque de thromboembolie veineuse ont recu une thromboprophylaxie, ce qui reflete une timide adhesion aux lignes directrices actuelles. Le faible taux de prophylaxie ne pouvait etre explique par des contre-indications de la prophylaxie ou l’âge des sujets.

The magnitude of an iatrogenic disorder:A systematic review of the incidence of venous thromboembolism for general medical inpatients

Venous thromboembolism (VTE) is recognized as a potential serious complication of hospitalization, and anticoagulant prophylaxis is widely recommended for medical inpatients. The purpose of this review was to systematically inspect the literature to determine the incidence of VTE without anticoagulant prophylaxis for hospitalized general medical patients. A systematic review was performed using MEDLINE and Cochrane Collaboration searches of the English-language literature. References of the retrieved articles were reviewed for additional studies, and pharmaceutical companies were contacted directly to identify unpublished studies. Studies were eligible if they reported the incidence of symptomatic or asymptomatic VTE in hospitalized general medical patients and included a group which did not receive prophylaxis. Eight trials were identified. Study design, quality, and results were heterogeneous. The incidence of symptomatic VTE without prophylaxis was examined in three trials; the incidence was 2.3% in the only randomized trial, and was 0.8% and 6.2% in two observational studies. The incidence of asymptomatic VTE ranged from 3.7% to 26.0% (median 12.8%). Risk factors identified were older age, prior VTE, and obesity. Though there is little high quality evidence, the best estimate of the incidence of hospital-acquired VTE for general medical patients is approximately 2% for patients at moderate to high risk and <1% for patients at low risk. Further studies are needed to more precisely define a low risk group for whom anticoagulant prophylaxis is unnecessary.

Long‐term use of acid suppression started inappropriately during hospitalization

Practitioners routinely misuse acid suppression medications on general medical floors and inappropriately continue the drug at discharge. To: (i) retrospectively study the appropriateness of acid suppression use on the general medical floors; (ii) characterize the patient population discharged on unnecessary acid suppression and (iii) evaluate whether patients discharged on unnecessary acid suppression continue the medicine long term. Retrospective chart review of general medical patients admitted to an in-patient teaching service over 6 consecutive months. About 60% of patients lacked an indication for initiation of acid suppression and 34% of these patients were discharged on the medicine. The only independent predictor of continuation of acid suppression at discharge was longer length of stay. Multivariate analysis did not identify a characteristic distinguishing those patients discharged inappropriately on acid suppression. At 3 and 6 months of follow-up, 80% and 50% of patients, respectively, remained on acid suppression therapy without an appropriate indication. Our data verifies that practitioners routinely start general medical in-patients on acid suppression without an appropriate indication. Many of these prescriptions are continued at discharge for no apparent reason, leading to their long-term misuse.

How Do Delirium and Dementia Increase Length of Stay of Elderly General Medical Inpatients?

The purpose of this study was to identify the proximate causes through which dementia and delirium extend length of stay (LOS) in elderly general hospital patients. Among 93 patients age >/=65 years admitted to a tertiary-care teaching hospital through the emergency department, admission ratings of cognitive impairment, delirium, and dementia predicted the emergence of mental and behavioral manifestations of delirium and dementia in the hospital and greater LOS. Mental and behavioral manifestations also predicted greater LOS. On average, mental manifestations appeared first and were followed by behavioral manifestations, and the appearance of both types of manifestations occurred before the mean LOS. The results suggest that elderly patients with dementia and/or delirium who become symptomatic after admission to a general hospital first show mental signs and symptoms, then show behavioral disturbances, which appear to be the proximate causes of greater LOS.

Reassessment of the CAGE questionnaire by ROC/Taguchi methods.

The clinical assessment efficiency of the CAGE questionnaire for alcohol abuse based on diagnostic accuracy has not been fully established to date because of the varied and inconclusive gold standards used as diagnostic criteria. CAGE has also been highlighted to miss almost half of the risk-drinkers due to the use of inadequetly set criteria for the positive recognition of alcohol abuse. This study aims to establish the diagnostic accuracy of CAGE at different treatment settings. A hybrid of the receiver operating characteristic (ROC) and the Taguchi method was used, as this approach proved to evaluate the diagnostic performance and accuracy in hypothetical clinical settings. Data were used from three cross-clinical treatment settings, i.e., general medicine outpatients, medical inpatients, and psychiatric inpatients, and analyzed by means of a step-wise application of managable number of statistical indices such as the area under the ROC curve (AUC), leveling factor (p'), and signal-to-noise ratios (S/N; standardized S/N [SS/N]). The selected settings yielded similar AUCs but portrayed different trade-offs on the ROC curves signaling the presence of different critical CAGE scores. Analysis of the sensitivity and specificity data of i, ii, iii by p', S/N, SS/N and their dependent relation resulted in the critical CAGE scores of 1,1, and 2; and high diagnostic accuracy levels of 76.84 percent, 86 percent, and 76.84 percent, respectively. By setting these critical CAGE scores as the minimum detection levels of alcohol abuse, early intervention before the onset of serious alcohol-related problems is possible. This will decrease the health-care costs of the patient and, in addition, reduce the psychological and social burdens inherent to alcohol abuse both on the patient and society. Having its critical scores reliably identified and diagnostic accuracy fully determined, CAGE can now improve the detection rate of problem drinking individuals substantially.

Musculoskeletal assessment of general medical inpatients

Musculoskeletal assessment of general medical inpatients