Patients In General Wards Research Articles

Correlations between first documented cardiac rhythms and preceding telemetry in patients with code blue events

Among in-hospital cardiac arrest (IHCA) patients, the first cardiac rhythm documented on resuscitation records (FDR) is often used as a surrogate for arrest etiology. Although the FDR generally represents the electrical activity at the time of cardiopulmonary resuscitation initiation, it may not be the ideal rhythm to infer the arrest etiology. We hypothesized that a rhythm present earlier-at the time of the code blue call-would frequently differ from the FDR, because the FDR might represent the later stage of a progressive cardiopulmonary process. To evaluate agreement between FDR and telemetry rhythm at the time of code blue call. Cross-sectional study. A 750-bed adult tertiary care hospital and a 240-bed adult inner city community hospital. Adult general ward patients monitored on the hospital's telemetry system during the 2 minutes prior to a code blue call for IHCA. None. Agreement between FDR and telemetry rhythm. Among 69 IHCAs, agreement between FDR and telemetry was 65% (kappa = 0.37). Among 17 events with FDRs of ventricular tachyarrhythmia (VTA), telemetry showed VTA in 12 (71%) and other organized rhythms in 5 (29%). Among 12 events with first documented rhythms of asystole, telemetry showed asystole in 3 (25%), VTA in 1 (8%), and other organized rhythms in 8 (67%). The FDR had only fair agreement with the telemetry rhythm at the time of code blue call. The telemetry rhythm may be a useful adjunct to the FDR when investigating arrest etiology.

A comparative study of varying doses of enoxaparin for thromboprophylaxis in critically ill patients: a double-blinded, randomised controlled trial

IntroductionCritically ill patients are predisposed to venous thromboembolism. We hypothesized that higher doses of enoxaparin would improve thromboprophylaxis without increasing the risk of bleeding. Peak anti-factor Xa (anti-Xa) levels of 0.1 to 0.4 IU/ml reflect adequate thromboprophylaxis for general ward patients. Studies conducted in orthopaedic patients demonstrated a statistically significant relationship between anti-Xa levels and wound haematoma and thrombosis. Corresponding levels for critically ill patients may well be higher, but have never been validated in large studies.MethodsEighty critically ill patients weighing 50 to 90 kilograms were randomised in a double-blinded study to receive subcutaneous (sc) enoxaparin: 40 mg once daily (QD), 30 mg twice daily (BID), 40 mg BID, or 1 mg/kg QD, each administered for three days. Anti-Xa activity was measured at baseline, and daily at 4, 12, 16 and 24 hours post administration. Antithrombin, fibrinogen, and platelets were measured at baseline and twice daily thereafter.ResultsTwo patients were transferred prior to participation. On day 1, doses of 40 mg QD (n = 20) and 40 mg BID (n = 19) yielded mean peak anti-Xa of 0.20 IU/ml and 0.17 IU/ml respectively. A dose of 30 mg BID (n = 20) resulted in much lower levels (0.08 IU/ml). Patients receiving 1 mg/kg QD (n = 19) achieved near steady-state mean peak anti-Xa levels from day 1 (0.34 IU/ml). At steady state (day 3), mean peak anti-Xa levels of 0.13 IU/ml and 0.15 IU/ml were achieved with doses of 40 mg QD and 30 mg BID respectively. This increased significantly to 0.33 IU/ml and 0.40 IU/ml for doses of 40 mg BID and 1 mg/kg QD respectively. Thus anti-Xa response profiles differed significantly over the three days between enoxaparin treatment groups (P <0.0001). Doses of 40 mg BID and1 mg/kg QD enoxaparin yielded target anti-Xa levels for over 80% of the study period. There were no adverse effects.ConclusionsDoses of 40 mg QD enoxaparin (Europe) or 30 mg BID (North America) yield levels of anti-Xa which may be inadequate for critically ill patients. A weight-based dose yielded the best anti-Xa levels without bioaccumulation, and allowed the establishment of near steady-state levels from the first day of enoxaparin administration.Trial registrationCurrent Controlled Trials ISRCTN91570009.

Dietary salt intake and stroke

Dietary salt intake and stroke

Bioactivity of enoxaparin in critically ill patients with normal renal function

Venous thromboembolism is a frequent complication in critically ill patients that has a negative impact on patient outcomes. Critically ill patients have significantly lower plasma anti-factor-Xa activity levels compared with control patients after administration of subcutaneous heparin. The clinical relevance of the different anti-factor-Xa levels after prophylactic doses of low molecular weight heparin (LMWH) in critically ill patients is not completely understood. The standard dose of 40 mg enoxaparin led to a significant increase in anti-FXa levels in this selected cohort of ICU patients with normal renal function. This study found only subtle pharmacokinetic differences, but a comparable pharmacodynamic action, after enoxaparin administration in critically ill and normal medical ward patients. Thrombin generation with TGA RC-low and TGARC-high reagents was significantly reduced in ICU and normal ward patients after receiving LMWH. Both readouts appear equally useful for estimating the pharmacodynamics of enoxaparin. The ex vivo model of thrombosis was used for the first time in patients to evaluate the anti-thrombotic activity of LMWH. This method did not show any difference in thrombus formation after administration of enoxaparin in the individual group of patients. In critically ill patients, reduced anti-FXa plasma activity following subcutaneous administration of enoxaparin or nadroparin has been described. In this study, we aimed to investigate the bioactivity of enoxaparin in critically ill patients and controls. A prospective, controlled, open label study was performed on a medical intensive care unit (ICU) and a general medical ward. Fifteen ICU patients (male = 12, median age 52 years [IQR 40-65], with a median Simplified Acute Physiology Score of 30 [IQR 18-52]) and sex- and age-matched medical ward patients were included. The anti-FXa plasma activity was measured after a single subcutaneous dose of40 mg enoxaparin. The thrombus size of a clot formed in an ex vivo perfusion chamber and endogenous thrombin potential (ETP) were measured. The anti-FXa plasma activity increased significantly after enoxaparin administration, with peak levels at 3 h after treatment, but was comparable between the ICU and medical ward groups (median 0.16 IU ml-1 [IQR 0-0.22 IU ml-1] vs. 0.2 IU ml-1 [IQR 0.15-0.27 IU ml-1],respectively, P = 0.13). The area under the anti-FXa activity curve from 0–12 h was similar between the groups (median 0.97 IU ml-1 h [IQR0.59-2.1] and 1.48 IU ml-1 h1 [IQR 0.83-1.62], P = 0.42 for the ICU group compared with the control group, respectively). The ETP was lower in the ICU group (P < 0.05) at baseline, but it was comparable at 3 h between the groups. Thrombus size decreased at 3 h compared with pre-dose (P = 0.029) and was not different between the groups. Similar bioactivity was achieved with a standard dose of subcutaneous enoxaparin in this selected cohort of ICU and general ward patients with normal renal function.

Where do we draw the line on providing a ‘home from home’ environment on a PICU?

Background: A proposal to introduce metal cutlery onto a PICU in order to create a more homely environment prompted staff concerns about safety.Aims: Based on the premise that past behaviour is a strong predictor of future behaviour, we undertook a pilot audit of history of weapon use as a measure to guide decision making on weapons security on our PICU.Methods: Retrospective case note audit of 30 PICU patients to determine historical rates of weapon use. Secondary measures included level and type of weapon use, and mental disorder. 30 ‘non PICU pathway’ general ward patients were sampled as a ‘control’.Results: 19/30 patients on the PICU had a history of weapon use, compared to 7/30 on the general ward. There were 23 recorded incidents in the PICU sample and 7 on the general ward.Conclusions: The majority of the PICU sample had a history of weapon use, often recent, including improvised and bladed weapons, at times of acute disturbance and non-compliance with medications. Comparison with the non-PICU group indicates that the measure had good construct validity as rates in this group were significantly lower. Therefore history of weapon use could be a useful measure in guiding decision making about security protocols on PICU, however, further research is required.

Quality of end-of-life care for patients with metastatic non-small-cell lung cancer in general wards and palliative care units in Japan

Patients with lung cancer in Japan often receive aggressive care near the end of life and die in an acute care hospital. We describe the differences in end-of-life care for metastatic non-small-cell lung cancer (NSCLC) patients between general wards and a palliative care unit (PCU). A retrospective analysis was conducted using data from patients who received at least second-line chemotherapy between 2002 and 2007 in a single institute. Among 72 eligible patients, we categorised patients into two groups, those who died in general wards (n = 57) and those who died in the PCU (n = 15), and examined end-of-life care including chemotherapy, do-not-resuscitate (DNR) decision making and treatment in the last 48h of life. Mean number of days between the last chemotherapy and death was shorter in general wards than in the PCU (P = 0.019). Furthermore, 25% of patients in general wards received chemotherapy within the last 2weeks of life. Rates of multiple hospitalisations in the last month of life appeared higher in general wards than in the PCU. Mean number of days between documentation of DNR and death was shorter in general wards than in the PCU (P = 0.0010). Patients in general wards received a greater volume of hydration than those in the PCU (P < 0.001). Patients with metastatic NSCLC in general wards receive inappropriate care near the end of life. Further studies are needed to develop interventions for making decisions regarding end-of-life care.

Accuracy of an expanded early warning score for patients in general and trauma surgery wards (Br J Surg 2012; 99: 192–197)

Accuracy of an expanded early warning score for patients in general and trauma surgery wards (<i>Br J Surg</i> 2012; 99: 192–197)

Proton-Pump Inhibitors Often Are Prescribed Inappropriately at U.S. Teaching Hospitals

Stress ulcer prophylaxis has demonstrated efficacy in critically ill patients who are at high risk for gastrointestinal bleeding (e.g., mechanical ventilation >48 hours, coagulopathy). Prophylaxis in general ward patients also has become common, despite the lack of evidence to support this practice. Researchers performed a retrospective review of administrative data for hospitalized adult …

Accuracy of an expanded early warning score for patients in general and trauma surgery wards

Early warning scores (EWS) may aid the prediction of major adverse events in hospitalized patients. Recently, an expanded EWS was introduced in the Netherlands. The aim of this study was to assess the relationship between this EWS and the occurrence of major adverse clinical events during hospitalization of patients admitted to a general and trauma surgery ward. This was a prospective cohort study of consecutive patients admitted to the general and trauma surgery ward of a university medical centre (March-September 2009). Follow-up was limited to the time the patient was hospitalized. Logistic regression analysis was used to assess the relationship between the EWS and the occurrence of the composite endpoint consisting of death, reanimation, unexpected intensive care unit admission, emergency surgery and severe complications. Performance of the EWS was analysed using sensitivity, specificity, predictive values and receiver operating characteristic (ROC) curves. A total of 572 patients were included. During a median follow-up of 4 days, 46 patients (8.0 per cent) reached the composite endpoint (two deaths, two reanimations, 17 intensive care unit admissions, 44 severe complications, one emergency operation). An EWS of at least 3, adjusted for baseline American Society of Anesthesiology classification, was associated with a significantly higher risk of reaching the composite endpoint (odds ratio 11·3, 95 per cent confidence interval (c.i.) 5·5 to 22·9). The area under the ROC curve was 0·87 (95 per cent c.i. 0·81 to 0·93). When considering an EWS of at least 3 to be a positive test result, sensitivity was 74 per cent and specificity was 82 per cent. An EWS of 3 or more is an independent predictor of major adverse events in patients admitted to a general and trauma surgery ward.

AP104 MET system for the observation areas in comparison to general ward patients

AP104 MET system for the observation areas in comparison to general ward patients

EICS (Extended Intensive Care Service): Looking outside the ICU

Early warning systems (EWS) identify patients at risk with a view to improving morbidity and mortality rates using early therapeutic and transfer actions. We have recently implemented an EWS that focuses on two main aspects: the guidance of care after discharge from the ICU, and recognition of the onset of deteriorating health among adult patients in general wards through physiologically based early warning scores.

A Review of Current and Emerging Approaches to Address Failure-to-Rescue

Failure-to-Rescue, defined as hospital deaths after adverse events, is an established measure of patient safety and hospital quality. Until recently, approaches used to address failure-to-rescue have been focused primarily on improvement of response to a recognized patient crisis, with limited success in terms of patient outcomes. Less attention has been paid to improving the detection of the crisis. A wealth of retrospective data exist to support the observation that adverse events in general ward patients are preceded by a significant period (on the order of hours) of physiologic deterioration. Thus, the lack of early recognition of physiologic decline plays a major role in the failure-to-rescue problem.

Post-PEG feeding time: A web based national survey amongst gastroenterologists

Background Literature suggests early post-percutaneous endoscopic gastrostomy (PEG) feeding is as safe as delayed feeding. No consensus exists regarding feeding initiation after PEG placement. We performed a national survey to assess current practice regarding feeding initiation after PEG placement as well as clinical and practitioner based factors associated with early or delayed feeding. Methods A survey assessing feeding initiation in general ward and intensive care unit patients, current literature knowledge, motility agent use, number of PEG placed per year, along with physician demographics was emailed to 5256 gastroenterologists. Statistical analysis was done using SAS software (V.9). Results 28% of gastroenterologists responded. Amongst respondents, 59% were private consultants, 25% academic physicians and 16% trainees. Private gastroenterologists initiated feeding earlier (≤12 h) compared to academic gastroenterologists in general ward and intensive care unit patients ( p < 0.0001). Amongst respondents, 41% of physicians were aware of current literature on post-PEG feeding times. Physicians aware of current literature started feeding earlier (<12 h) compared to those not aware in general ward and intensive care unit patients ( p = 0.0002). Male physicians instituted feeding earlier than females ( p < 0.0001). Conclusions Feeding initiation after PEG placement varies amongst gastroenterologists. Further studies are required to explore obstacles in standardizing post-PEG feeding practices.

SECI (Servicio Extendido de Cuidados Intensivos): Mirando fuera de la UCI

Early warning systems (EWS) identify patients at risk with a view to improving morbidity and mortality rates using early therapeutic and transfer actions. We have recently implemented an EWS that focuses on two main aspects: the guidance of care after discharge from the ICU, and recognition of the onset of deteriorating health among adult patients in general wards through physiologically based early warning scores.

Improved outcome of critically ill patients treated by the Rapid Response Team outside the intensive care unit

Due to the limited number of intensive care unit (ICU) beds in Brazilian public hospitals, many critically ill patients are treated in hospital wards while waiting to be transferred to the ICU. Care for these patients is provided by ward staff, while waiting for ICU bed availability. These healthcare providers are not trained in critical care and are not as experienced in caring for ICU patients. In the Londrina University Hospital, the Rapid Response Team (RRT) staff is composed of intensivist healthcare providers who help to deliver specialized care to critically ill patients in general hospital wards.

Accidental and Non-Accidental Ingestion of Methadone and Buprenorphine in Childhood: A Single Center Experience, 1999-2009

To assess the effect of recent availability (due to more home use) of methadone and buprenophine has had on the accidental and non-accidental misuse by children. A retrospective review of all pediatric (< 18 years old) admissions for methadone or buprenorphine ingestion at Eastern Maine Medical Center (EMMC) from September 1, 1999 to August 31, 2009 was performed. Data recorded included age, sex, accidental or non-accidental ingestion, source of drug, ward or pediatric intensive care unit (PICU) admission, treatment given and length of hospital stay. Relation to pediatric emergency department (ED) visits, general pediatric ward admissions and patients on opioid maintenance treatment in the area was also assessed. There were 22 children (12 female) admitted for methadone (10, 46%) or buprenorphine (12, 54%) ingestion, with ingestions tripling in the later five year period compared with the earlier five years. The trend was statistically significant, unrelated to pediatric ED visits or ward admissions but statistically related to number of patients on opioid maintenance treatment in the region. Of the 22 children with ingestion, six (27%) were adolescents (mean age 15.2 years) and ingestion was intentional (three suicide, three recreational) and 16 were infants or toddlers (mean age 21.6 months) whose ingestions were accidental. The drug source was family and friend (18, 82%) or unknown (four, 18%). There were six patients admitted to the ward and 16 patients (74%) admitted to the PICU. Two patients had observation only, seven had anticipatory intravenous (IV) line placement, nine patients were given IV line and naloxone (bolus + IV infusion), and four patients required endotracheal intubation, IV placement and naloxone. There were no fatalities and mean hospital stay was one to seven days, mean 2.3 days. All families were referred to family services. Accidental and non-accidental ingestion of methadone and buprenorphine by children is increasing in proportion to increased clinical use and availability. Health providers should be aware of this increased risk and be able to provide appropriate treatment and family support.

EDITORIAL: Addiction medicine: a new medical specialty in a new age of medicine

EDITORIAL: Addiction medicine: a new medical specialty in a new age of medicine

Inpatient care and microbial surveillance during year 2007-2008; retrospective evaluation of hospital-acquired pneumonia (HAP) in General Hospital Pulau Pinang, Malaysia

Patient care is a concerning issue representing the nosocomial infection transmission especially hospital-acquired pneumonia (HAP). This study aims to identify the percentage statistics of HAP among the hospitalised patients of general ward. Also, among the objectives is to investigate the etiological pattern with the prescribed antibiotics in the concomitant treatment. A two-year retrospective cohort analysis was made from January 2007 to December 2008 in General Hospital Pulau Pinang, Malaysia. Results identified the increase rate of HAP and secondary increase rate of mortality with diagnosed pathogen. More profound analysis showed the inappropriate use of antibiotics that can be the possible cause of HAP and lead to future increase in resistance pattern in pathogens. Conclusion has been made on the recommendation of the clinical evidence-based treatment as to reduce the risk of other morbidities in a clause to reduce the spread of nosocomial infections.

Infective endocarditis at a hospital in Saudi Arabia: epidemiology, bacterial pathogens and outcome

BACKGROUND AND OBJECTIVE:Data on infective endocarditis prevalence, epidemiology and etiology from Saudi Arabia and the Gulf region are sparse. We undertook this study to describe the pattern and the causative agents of endocarditis at a hospital in Saudi Arabia.METHODS:We conducted a retrospective analysis of all reported endocarditis cases at the Dhahran Health Center from January 1995 to December 2008.RESULTS:Of the 83 cases of endocarditis, 54 (65%) were definite endocarditis and the remaining 29 (35%) were possible endocarditis based on the Duke criteria. Patients with definite endocarditis included 39 males and 15 females (ratio of 2.6:1) with a mean age (SD) of 59.7 (18.2) years. Of the definite endocarditis cases, native valve endocarditis occurred in 44 (81.5%) cases of and prosthetic valve endocarditis was observed in 10 (18.5%). The most commonly involved valves were mitral (n=24; 44.4%) and aortic (n=20; 39.2%). The most common organisms were S aureus (n=23; 42.6%), Enterococcus faecalis (n=12; 22.2%) and viridans streptococci (n=9; 16.7%). Surgical intervention was required in 17 (31.4%) cases and the in-hospital mortality rate was 29.4% (n=15). Of all the patients, 3 (5.5%) had embolic stroke as a complication.CONCLUSION:Native valve endocarditis is the predominant type of endocarditis. The patients were older adults and the most common organisms were S aureus, E faecalis and viridans streptococci.

Patient Dissatisfaction With Acute Stroke Care

Riks-Stroke, the Swedish Stroke Register, was used to explore patient characteristics and stroke services as determinants of patient dissatisfaction with acute in-hospital care. All 79 hospitals in Sweden admitting acute stroke patients participate in Riks-Stroke. During 2001 to 2007, 104,876 patients (87% of survivors) responded to a follow-up questionnaire 3 months after acute stroke; this included questions on satisfaction with various aspects of stroke care. The majority (>90%) were satisfied with acute in-hospital stroke care. Dissatisfaction was closely associated with outcome at 3 months. Patient who were dependent regarding activities of daily living, felt depressed, or had poor self-perceived general health were more likely to be dissatisfied. Dissatisfaction with global acute stroke care was linked to dissatisfaction with other aspects of care, including rehabilitation and support by community services. Patients treated in stroke units were less often dissatisfied than patients in general wards, as were patients who had been treated in a small hospital (vs medium or large hospitals) and patient who had participated in discharge planning. In multivariate analyses, the strongest predictor of dissatisfaction with acute care was poor outcome (dependency regarding activities of daily living, depressed mood, poor self-perceived health). Dissatisfaction with in-hospital acute stroke care is part of a more extensive complex comprising poor functional outcome, depressive mood, poor self-perceived general health, and dissatisfaction not only with acute care but also with health care and social services at large. Several aspects of stroke care organization are associated with a lower risk of dissatisfaction.