General Ward Care Research Articles

Economic assessment of tirofiban in the management of acute coronary syndromes in the hospital setting: an analysis based on the PRISM PLUS trial.

We analysed whether generalized use of tirofiban plus heparin and aspirin might save direct healthcare costs, as compared with heparin and aspirin alone, in patients with acute coronary ischaemic syndromes in Switzerland. We conducted an incremental cost-consequence analysis from the perspective of the admitting hospital for the period of the first 7 days. Costs were analysed for the management of refractory ischaemic conditions and myocardial infarctions, including incremental days on the general ward or intensive care unit, as well as necessary revascularization procedures, and expressed in Swiss francs (CHF) and European currency units (ECU). Drug costs were based on a loading dose of 0.4 micro x kg(-1) x min(-1)and a maintenance dose of 0.1 micro x kg(-1) x min(-1)for tirofiban at a cost of CHF 273.55 (ECU 166.50) per vial. Heparin was administered at a loading dose of 5000 U and a maintenance dose of 1000 U x h(-1). All calculations were standardized to 100 treated patients. The costs of managing ischaemic complications were based on typical practice patterns in Swiss hospitals. The incremental costs per patient of managing unstable angina patients with recurrent ischaemia or myocardial infarction were calculated as CHF 23 325 (ECU 14 198) and CHF 18 599 (ECU 11 321), respectively. The incremental drug costs amounted to CHF 82 065 (ECU 49 954). The additional use of tirofiban resulted in net savings of CHF 54 899 (ECU 33 418) per 100 patients, achieved through a reduction in the cost of treating refractory ischaemic conditions (CHF 79 306, ECU 48 275) and myocardial infarctions (CHF 57 658, ECU 35 097). Tirofiban is cost-saving in acute coronary ischaemic syndromes and improves the economics of managing these patients during the initial hospitalization.

A Reevaluation of the Radiographically Detectable Complications of Percutaneous Venous Access Lines Inserted by Four Subcutaneous Approaches

As a result of prior studies elucidating the potential complications associated with the use of central venous access lines, the Food and Drug Administration and the manufacturers themselves have published guidelines and warnings outlining these dangers and describing the safest insertion techniques. We will attempt to determine whether this improved education has altered the number and type of complications, comparing the results from different types of hospitals, among the various medical services and among operators with varying degrees of experience. This is a prospective analysis of all central venous pressure (CVP) and Swanz-Ganz catheters (SGCs) inserted between July 1, 1995, and February 30, 1996, at a regional Veteran's Affairs hospital and an inner city university medical center. Three hundred seventy-five inpatients underwent 417 new percutaneous venous catheter placements while in the medical or surgical intensive care units or in the general care wards. A portable chest radiograph was obtained immediately after each procedure, and the position of the catheter and any associated complications were recorded, initially by the radiology resident in the emergency suite and subsequently as confirmed by a chest radiology attending. CVP lines were considered malpositioned when the tip was not located in the superior vena cava, and SGCs were recorded as misplaced when the tip was not found within the main, left main, right main, or either lower lobe pulmonary artery within 2 cm of the cardiac border. For patients undergoing CVP line placement, the right atrium was the most frequent site of tip malposition with 38 of 69 total misplacements (55%), whereas for SGCs, 22 of 55 malplacements (40%) were too distal in a lower lobe pulmonary artery. Only 1 of 248 CVP lines resulted in a pneumothorax (PTX; 0.4%), whereas 6 of 169 SGC insertions caused a PTX (3.5%), a significant difference (P=0.019). Five of 192 catheters (2.6%) placed via an internal jugular approach resulted in PTX, whereas only 2 of 150 subclavian cannulations (1.3%) caused this complication, revealing a trend, but not reaching statistical significance (P=0.473). However, there was a significant decrease in the rate of catheter misplacements in the third part of the month compared with the first 20 days (35% versus 24%; P=0.031), and the Veteran's Affairs hospital displayed a trend toward more complications for SGC insertions than the university hospital (47% versus 32%), but not for CVP lines. In general, individual medical and surgical services displayed a similar frequency of complications (29-38%), except for CVP lines inserted in the medical intensive care unit. Venous access catheter tip malpositions are very common in all settings, but easily recognized by radiography, whereas PTXs are unusual. In contrast to most older studies, PTXs are more frequently observed with internal jugular as opposed to subclavian cannulations and with SGCs rather than CVP lines. However, our data support prior studies that the right atrium and distal right lower lobe pulmonary artery are the most common sites for CVP and SGC misplacement, respectively, and that there is an improvement in success rates with increasing operator experience.

Survival after in-hospital cardiopulmonary resuscitation. A meta-analysis.

To determine the rates of immediate survival and survival to discharge for adult patients undergoing in-hospital cardiopulmonary resuscitation, and to identify demographic and clinical variables associated with these outcomes. The MEDLARS database of the National Library of Medicine was searched. In addition, the authors' extensive personal files and the bibliography of each identified study were searched for further studies. Two sets of inclusion criteria were used, minimal (any study of adults undergoing in-hospital cardiopulmonary resuscitation) and strict (included only patients from general ward and intensive care units, and adequately defined cardiopulmonary arrest and resuscitation). Each study was independently reviewed and abstracted in a nonblinded fashion by two reviewers. The data abstracted were compared, and any discrepancies were resolved by consensus discussion. For the subset of studies meeting the strict criteria, the overall rate of immediate survival was 40.7% and the rate of survival to discharge was 13.4%. The following variables were associated with failure to survive to discharge: sepsis on the day prior to resuscitation (odds ratio [OR] 31.3; 95% confidence interval [CI] 1.9, 515), metastatic cancer (OR 3.9; 95% CI 1.2, 12. 6), dementia (OR 3.1; 95% CI 1.1, 8.8), African-American race (OR 2. 8; 95% CI 1.4, 5.6), serum creatinine level at a cutpoint of 1.5 mg/dL (OR 2.2; 95% CI 1.2, 3.8), cancer (OR 1.9; 95% CI 1.2, 3.0), coronary artery disease (OR 0.55; 95% CI 0.4, 0.8), and location of resuscitation in the intensive care unit (OR 0.51; 95% CI 0.4, 0.8). When talking with patients, physicians can describe the overall likelihood of surviving discharge as 1 in 8 for patients who undergo cardiopulmonary resuscitation and 1 in 3 for patients who survive cardiopulmonary resuscitation.

Suicide; A Statement of Suffering

This article is designed to focus on the provision of nursing care in general medical wards following the admission of persons who have attempted suicide or who have a previous history of attempting suicide. The authors explore, analyse and synthesize how nurses, as key players in the health care team, may begin by recognizing the uniqueness of the individual, and by cotravelling therapeutically with the person on part of his or her journey towards recovery and healing. Efforts are made to demonstrate how nurses can influence the health gain of this group of people and their families. Professional attitudes and related ethical aspects, such as autonomy, respect for autonomy and paternalism, are also examined within the context of the nursing care of people who have attempted suicide. The need to enhance sensitive and caring communication skills for nurses who work with this group of people is tentatively considered. Some reasoning about why there may be difficulties in specific areas of communication such as empathy are contested and explored.

Suicide: a statement of suffering.

This article is designed to focus on the provision of nursing care in general medical wards following the admission of persons who have attempted suicide or who have a previous history of attempting suicide. The authors explore, analyse and synthesize how nurses, as key players in the health care team, may begin by recognizing the uniqueness of the individual, and by cotravelling therapeutically with the person on part of his or her journey towards recovery and healing. Efforts are made to demonstrate how nurses can influence the health gain of this group of people and their families. Professional attitudes and related ethical aspects, such as autonomy, respect for autonomy and paternalism, are also examined within the context of the nursing care of people who have attempted suicide. The need to enhance sensitive and caring communication skills for nurses who work with this group of people is tentatively considered. Some reasoning about why there may be difficulties in specific areas of communication such as empathy are contested and explored.

Determinants of management errors in acute severe asthma.

BACKGROUND: It is hypothesised that, despite recent initiatives to improve asthma self-management including asthma education, detailed investigation of the sequence of events culminating in hospital admission will lead to the...

Socio-economic disadvantage, quality of medical care and admission for acute severe asthma.

In asthma, socio-economic and health care factors may operate by a number of mechanisms to influence asthma morbidity and mortality. To determine the quality of medical care including the patient perception of the doctor-patient relationship, and the level of socio-economic disadvantage in patients admitted to hospital with acute severe asthma. One hundred and thirty-eight patients (15-50 years) admitted to hospital (general ward or intensive care unit) with acute asthma were prospectively assessed using a number of previously validated instruments. The initial subjects had severe asthma on admission (pH = 7.3 +/- 0.2, PaCO2 = 7.1 +/- 5.0 kPa, n = 90) but short hospital stay (3.7 +/- 2.6 days). Although having high morbidity (40% had hospital admission in the last year and 60% had moderate/severe interference with sleep and/or ability to exercise), they had indicators of good ongoing medical care (96% had a regular GP, 80% were prescribed inhaled steroids, 84% had a peak flow meter, GP measured peak flow routinely in 80%, 52% had a written crisis plan and 44% had a supply of steroids at home). However, they were severely economically disadvantaged (53% had experienced financial difficulties in the last year, and for 35% of households the only income was a social security benefit). In the last year 39% had delayed or put off GP visit because of cost. Management of the index attack was compromised by concern about medical costs in 16% and time off work in 20%. Patients admitted to hospital with acute asthma have evidence of good quality on-going medical care, but are economically disadvantaged. If issues such as financial barriers to health care are not acknowledged and addressed, the health care services for asthmatics will not be effectively utilised and the current reductions in morbidity and mortality may not be maintained.

Do Acute Stroke Units Improve Care?

Background and Purpose: Stroke rehabilitation units have been shown to improve mortality and reduce morbidity and hospital length of stay as compared with conventional medical ward care. In contrast, the effectiveness of acute stroke units (ASUs), which only provide early in-patient care, is unknown. We have compared ASU care with that administered on a general medical or geriatric ward. Methods: Historical comparison of 116 consecutive patients admitted to a new ASU during the 6-month period from February to July 1994 with 128 consecutive patients admitted to general medical or geriatric wards during the previous 6-month period (August 1993 to January 1994). Results: Admission baseline characteristics were similar between the two groups. As compared with conventional general ward care, patients admitted to the ASU had a shorter stay in casualty, 6 h (4–6) versus 7 h (4–11; 2p = 0.03); reduced length of stay in hospital, 20 days (10–55) versus 31 days (13–80; 2p = 0.09); increased carotid Doppler investigation, 40/94 versus 25/101 (2p = 0.013); increased prescription of secondary prevention measures, aspirin 49/94 versus 33/101 (2p = 0.009) or treatment of hypertension 19/50 versus 5/47 (2p = 0.004); improved outcome, home: institution: death, 69:11:18 versus 63:13:32 (2p = 0.049). Conclusion: ASUs appear to contribute to improved care (investigations, secondary prevention) and outcome following stroke whilst patients spend less time in hospital.

Cost and outcome of intensive care

Abstract The measurement of cost and outcome from intensive therapy is difficult. Cost may vary directly with the type and severity of the patient's disease but also with the organisation of the hospital. Cost measurement may not be an accurate estimate of resource consumption because of economic rather than clinical influences. Even so the cost of intensive therapy is high, being between 3–5 times that of general ward care but represents only a part of the total costs of critical illness. Outcome measurement involves more than simple mortality rates on the intensive therapy unit; estimates of long term survival are important because there is significant mortality after discharge, especially if the patients were severely ill. An assessment of the quality of survival is also important but there are few health related utilities designed for use after intensive therapy. Functional outcome may be easier to quantify and studies suggest that the functional recovery from intensive therapy is good. However in general, it is difficult to combine estimates of cost and outcome because of methodological difficulties defining the precise scope of these two aspects of intensive therapy.

AAEM minimonograph #40: Clinical neurophysiology of the respiratory system

Disorders of nerve and muscle are frequent causes of respiratory insufficiency, but current methods often fail to adequately assess the problem. Phrenic nerve conduction and needle electromyography of the diaphragm are of great assistance in identifying the nature and site of the disorder: the various disturbances of central drive, axonal or demyelinating neuropathies of the phrenic nerves, and certain myopathies. These studies may be performed on adults, children, or infants, and in outpatient, general ward, or critical care settings. It is hoped these techniques will stimulate further developments in the field.

EVALUATION OF A DISPOSABLE PATIENT-CONTROLLED ANALGESIA DEVICE IN CHILDREN

A disposable patient-controlled analgesia (PCA) device was evaluated in 20 children after major abdominal, urological and orthopaedic surgery. All patients were given a high dependency level of nursing care in general wards. Efficacy (as assessed by hourly pain scores) was comparable to that achieved in a matched control group of 20 children who used the Graseby PCA system. Safety was confirmed by monitoring arterial oxygen saturation, sedation scores and ventilatory frequency. Morphine consumption was similar with the two techniques, but varied widely between patients. The disposable device has a complementary role to play in the provision of a comprehensive pain relief service for children.

Cost of intensive therapy

SummaryA preliminary study was performed to calculate the cost of intensive therapy on an individual patient basis. The fixed (equipment, supporting services and land opportunity), semi‐fixed (staff) and marginal (treatment) costs of 20 critically ill patients were calculated individually. The results show that there is wide variation in intensive therapy costs. The average daily cost for a spontaneously breathing patient was £399 (95% confidence intervals £388–£460) while that for a ventilated patient was £726 (£656–£795). The mean total cost per patient was £1980, but the cost per survivor increased by 16% (£347) because of four deaths on the intensive care unit. High total costs are associated with increased severity of illness and higher marginal (treatment) costs are associated with increased semi‐fixed (staff) costs. The cost of intensive therapy was three to five times that for general ward care.

Economic and Ethical Considerations in the Intensive Care Unit

Intensive care units (ICUs) sustain life but, in certain cases, this resource becomes a means to prolong dying, with great physical, emotional and financial impact. The cost to care for patients in the ICU is at least three times more than general ward care; thus, ICUs have become one of the largest cost centres in the hospital. Economic pressures require us to be mindful of whom the ICU treats and for how long. Health professionals working in the ICU must critically appraise the ethical basis for their behaviour and actions. In so doing, many are likely to appeal to the patient's right to self-determination and the physician's reliance on the principles of beneficence and non-maleficence as the underpinnings of morality in medicine. One approach is to examine the issues and rights pertinent to an individual case using a circular model. Decisions are based on medical facts and prognosis, a patient's right to self-determination, a patient's best interests and external factors. Health personnel would be compelled to consider all of these issues. Within this framework, prevention or resolution of moral dilemma can take place within the clinical rather than the legal forum.

Predicting outcome of inhospital cardiopulmonary resuscitation

We conducted a prospective study of CPR in our hospital in order to learn more of the factors influencing outcome. In a 7-month period, 71 patients underwent CPR. Twenty-nine (41%) were successfully resuscitated; of these, 13 (18% of the total group) survived to be discharged from the hospital. Factors associated with a successful outcome included occurrence of cardiopulmonary arrest within 24 h of hospitalization, short duration of CPR, and the absence of cardiogenic shock, sepsis, acute renal failure, cancer, and pneumonia. Factors which did not influence outcome included the patients' age, sex, location in hospital during the arrest (general ward vs. intensive cardiac care unit), time of day of the arrest, or the participation of senior physicians or anesthesiologists in the resuscitation.

Routine protective isolation: worth the trouble in neutropenic patients?

Routine protective isolation procedures for granulocytopenic patients may not offer any more protection from infections than general ward care, according to results of a prospective study at the University of Wisconsin Center of Health Sciences, Madison. William M. Nauseef, MD, now a fellow in infectious diseases at Yale-New Haven Hospital, Conn, and coinvestigator Dennis G. Maki, MD, associate professor of medicine at Wisconsin, randomly assigned 37 neutropenic patients—most with a diagnosis of acute nonlymphocytic leukemia—to standard ward accommodations or private rooms with reverse isolation precautions. Protective isolation procedures entailed the usual gown, mask, and glove requirements for all visitors. The only modification of care given the ward patients was handwashing prior to patient contact. Moreover, the ward group was sent for diagnostic studies throughout the hospital without special precautions. Neither group received nonabsorbable antibiotics, sterilized food, or cutaneous disinfectants. Both were given the same antineoplastic therapy and supportive care. Surveillance

Routine protective isolation: Worth the trouble in neutropenic patients?

Routine protective isolation procedures for granulocytopenic patients may not offer any more protection from infections than general ward care, according to results of a prospective study at the University of Wisconsin Center of Health Sciences, Madison. William M. Nauseef, MD, now a fellow in infectious diseases at Yale-New Haven Hospital, Conn, and coinvestigator Dennis G. Maki, MD, associate professor of medicine at Wisconsin, randomly assigned 37 neutropenic patients—most with a diagnosis of acute nonlymphocytic leukemia—to standard ward accommodations or private rooms with reverse isolation precautions. Protective isolation procedures entailed the usual gown, mask, and glove requirements for all visitors. The only modification of care given the ward patients was handwashing prior to patient contact. Moreover, the ward group was sent for diagnostic studies throughout the hospital without special precautions. Neither group received nonabsorbable antibiotics, sterilized food, or cutaneous disinfectants. Both were given the same antineoplastic therapy and supportive care. Surveillance

Myocardial Infarct Stress-of-Transfer Inventory

The Myocardial Infarct Stress-of-Transfer Inventory is a set of measures composed of grouped variables related to patients' perceptions of external support, perceived attitudes and behaviors, and physiological (cardiovascular and autonomit) responses commonly assessed by nurses in typical hospital settings. These measures were designed to evaluate changes in patients' status as a result of transfer from the coronary care unit to a general care ward at the time the patient is presumably out of danger. Direction of change of all parameters is a measure of patient response to transfer as well as a measure of effectiveness of nursing care. The tool consists of observational and nurse questionnaire data collected and averaged for pre- and posttransfer items. Of 48 total items of the tool, 20 are designated “change scores.” Interrater reliability was obtained for 20 percent of the tests with 80 percent agreement. A score of less than 22 is associated with poor transfer outcome; a score of more than 25 is associated with better-than-expected transfer outcome. Midrange from 22 to 25 is the average total score expectation for change as a result of transfer. The instrument was tested on 177 transfers of patients in six hospital settings in five western states (Arizona, Montana, Nevada, Utah, and Washington). The six hospital populations were found to be homogeneous as to patient age, sex, race, diagnosis, and patterns of nursing care. Individual total scores for the tool ranged from 18 to 27 with a mean of 23.175 and S.D. of 1.754. Change scores were adjusted to accommodate the influence of prescores on postscores for the behavioral variables. Factor analysis Indicated 17 factors in the tool with eigen values greater than 1.00. Significant findings were: 1) Cardiovascular signs and symptoms are unstable and arrhythmias are likely to occur in the two-hour period following transfer. Nursing care needs to accommodate this finding. 2) Nurses equated patient acceptance of disconnection of the cardiac monitor with patient “readiness for transfer.” 3) Because family visits had significant effect on patients—sometimes negative, sometimes positive—families should be taught how to visit the patient in order to avoid negative effects. 4) Nursing care plans are associated with patients who are out of danger and are usually not available or not written for patients who are critically ill. 5) The tool proved easy to use. It may lend itself to evaluation of other transfer situations such as transfer front hospital to nursing home.

An Assessment of Intermediate Coronary Care

The effect of intermediate coronary care, with and without ECG monitoring, was compared with general medical ward care on the basis of mortality, resuscitation, and detection and treatment of arrhythmias from days 3 to 14 after admission in 2,095 cases of acute coronary heart disease. Mortality was significantly reduced (P less than .02), and number of successful resuscitations for ventricular fibrillation was increased (P less than .05) but only in the unit with monitoring. Number of arrhythmias detected was significantly increased, particularly incidence of ventricular ectopics and heart block (P less than .02). Number of arrhythmias corrected to sinus rhythm was increased, but not significantly. Death from pulmonary embolism fell (P less than .01). Review of causes of death and autopsies showed an increased proportion of deaths due to intractable heart failure and cardiogenic shock. Not only specially trained nurses, but also ECG monitoring, were necessary to obtain the benefits of this treatment.

A CLINICAL STUDY OF TETANUS

During the early part of the summer of 1932, 3 fatal cases of tetanus in children were observed within a relatively short time. The routine treatment of the patients and of those hospitalized previously had consisted of general ward care, antitoxin administered by the intrathecal route in combination with other routes, emphasis on radical surgical care of the local lesions and variable degrees of attention to sedative therapy. On the suggestion of the staff of the Children's Hospital, I decided to reinvestigate the subject of tetanus in the hope that the treatment might be improved. This presentation gives the results of my study and of the application of certain newer therapeutic measures in the management of 33 patients with tetanus. Table 1 summarizes the significant data of this series. Included as a basis for comparison is a discussion of the observations made on an equal number of patients treated according