Inpatient Hospital Setting Research Articles

Clinical perspective on the Clinical Pharmacogenetics Implementation Consortium Updated 2014 guidelines for CYP2D6 and codeine.

As pharmacogenomics makes further advances into clinical practice, the Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines provide considerable assistance in clinical decision making. The new 2014 CPIC guidelines on CYP2D6 and codeine (1) have an update on considerations for clinicians and healthcare providers. The previous CPIC guidelines provided recommendations primarily on codeine and tramadol. The new guidelines maintain the dosing recommendations for codeine—specifically, to avoid codeine in both CYP2D6 poor and ultrarapid metabolizers; however, the guidelines take another step forward by noting that, not only may tramadol be problematic, but hydrocodone and oxycodone are also not considered good analgesic alternatives when metabolic concerns exist with CYP2D6. Additionally, this update recommends alternatives with the following statement: “To avoid treatment complications, opioids that are not metabolized by CYP2D6, including morphine, oxymorphone, buprenorphine, fentanyl, methadone, and hydromorphone, along with nonopioid analgesics, may be considered as alternatives for use in CYP2D6 poor metabolizers and in ultrarapid metabolizers….” Although appropriate from a CYP2D6 metabolic standpoint, these recommendations may present some challenges to healthcare providers when applied to some clinical settings. Pain is one of the leading reasons a patient presents to healthcare providers, which includes physicians, dentists, physician assistants, and nurse practitioners in both inpatient hospital and outpatient clinic community settings. Many healthcare providers follow a WHO ladder “type” approach for the treatment of pain (2). In this paradigm, depending on the severity of the pain, a nonopioid drug is considered as a first step in pain management (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs). The second step employs an opioid commonly used for moderate pain (e.g., tramadol, codeine, hydrocodone, and possibly oxycodone), often in combination with acetaminophen or nonsteroidal anti-inflammatory drugs. The third step includes the use of an opioid usually reserved for severe pain presentation (e.g., morphine, oxymorphone, fentanyl, methadone, and hydromorphone). Of concern, the new …

Abstract T P125: Does the Stroke Impact Scale-16 (SIS-16) PositivelyCorrelate with the Functional Independence Measure ( FIM) During AcuteInpatient Rehabilitation Following Stroke?

Background and Purpose: For patients who require acute inpatient rehabilitation after stroke, affect and level of motivation are important for successful outcomes. Conversely, patients who have decreased insight into their deficits are more likely to have negative rehabilitation outcomes, including poorer function and longer hospital stay. Previous research has shown a significant correlation between Stroke Impact Scale(SIS) and Functional independence Measure(FIM) scores in patients undergoing rehabilitation 3 to 6 months after stroke. There is no data on whether these scores correlate immediately after stroke. The purpose of this study is to determine if SIS-16 scores positively correlate with FIM scores after stroke, during acute rehabilitation. Methods: Using a self-reported survey methodology, 70 adult patients with a primary medical diagnosis of stroke who were admitted to an inpatient rehabilitation hospital were surveyed using the Stroke Impairment Scale-16 at the time of admission and again at discharge. During the same time intervals, patients were assessed using the Functional Independence Measure. Data of the two assessment tools were analyzed using a Pearson Correlation Coefficient. Results: Based on the data analysis, the data demonstrated good correlation between SIS-16 average and FIM total motor scores on admission(r = .66) and discharge(r = .67). Additionally, The SIS-16 score change, showed good correlation with the total FIM score change(r = .31) and motor FIM change(r = .34). Interestingly, the degree of functional cognitive ability did not correlate to the same level of perceived impairment.(r = .17/.06) Conclusions: As found in previous research involving patients 3-6 months status post stroke, this study found that the SIS-16 and FIM demonstrate a direct correlation in patients within the inpatient rehabilitation hospital setting. Future research into interventions to improve the correlation between SIS-16 and the cognitive FIM scores are warranted.

Multiplex gastrointestinal pathogen panels: implications for infection control

In the acute care hospital inpatient setting, there is a wide variety of causes for both infectious and noninfectious diarrhea. However, without molecular assays for the wide range of agents causing gastroenteritis, there is no reliable way to determine which individuals should be placed in contact precautions, as recommended by CDC. We tested 158 inpatient diarrheal stool specimens with the FilmArray GI Panel (BioFire Diagnostics, Salt Lake City, UT, USA) that had been stored at −70°C after testing negative by conventional methods for Clostridium difficile and/or rotavirus. We found that 22.2% had at least 1 other infectious agent detected, and 60% of these patients were never placed in appropriate isolation for a total of 109 patient-days. In addition, 20.3% of patients with negative GI panel results could have been removed from isolation. Use of multiplex gastrointestinal panels may improve decisions regarding patient isolation and reduce nosocomial transmission.

Trends in lumbar puncture over 2 decades: a dramatic shift to radiology.

The purpose of this study is to evaluate national trends in lumbar puncture (LP) procedures and the relative roles of specialty groups providing this service. Aggregated claims data for LPs were extracted from Medicare Physician Supplier Procedure Summary master files annually from 1991 through 2011. LP procedure volumes by specialty group and place of service were studied. Between 1991 and 2011, the overall numbers of LP procedures increased, with a slight increase in diagnostic LP procedures (90,460 vs 90,785) and a marked increase in therapeutic LP procedures (2868 vs 6461) in Medicare fee-for-service beneficiaries. Although radiologists performed 11.3% (n = 10,533) of all LP procedures in 1991, they performed 46.6% (n = 45,338) in 2011. For diagnostic LPs, radiology (11.4% [n = 10,272] in 1991 and 48.0% [n = 43,601] in 2011) now exceeds emergency medicine, neurosciences, and all others as the dominant provider group. For therapeutic LP procedures, radiology now performs the second greatest number of LP procedures (9.0% [n = 261] in 1991 and 26.9% [n = 1737] in 2011). Although volumes remain small (< 10% of all procedures), midlevel practitioners have experienced over 100-fold growth for most services. The inpatient hospital setting remains the dominant site of service (71,385 in 1991 vs 44,817 in 2011: -37%), followed by procedures performed in the emergency department (297 in 1991 vs 26,117 in 2011: 8794%). Over the last 2 decades, LP procedures on Medicare beneficiaries have increased, with radiology now the dominant overall provider. Although this trend may have relatively negative financial implications for radiology practices in current fee-for-service payment models, it has the potential to cement radiology's more central position through direct involvement in patient care in emerging accountable care organizations.

A retrospective audit of spirituality assessment in palliative care patients in Singapore

IntroductionSpirituality is essential and forms a critical factor in the way palliative care patients cope with their illnesses. It has been recognized as a major and important component of palliative care. There is little data in Singapore on the current state of spiritual care at the end of life.Materials and methodsA retrospective case-notes audit of the current state of spirituality assessment was conducted in the home care as well as hospital in-patient setting. The case-notes audit was selected from patients who were seen by the palliative medicine teams between June and July 2013.ResultsA total of 108 home care patient case notes and 182 hospital in-patient case notes were analyzed during the period of this study. Only 24.1% of home care patients and 30.2% of hospital in-patients had spirituality assessments conducted, of which most patients (77.8%) had these assessments completed during the first initial clinical review. The common spiritual themes identified were fairly equally distributed among the 81 palliative care patients in whom a spirituality assessment was performed.ConclusionOur audit shows that less than one-third of patients have had a spiritual assessment conducted, similar to the results of other studies elsewhere. It is hoped that this spirituality assessment rate can be improved by putting in place a structured spiritual programme in future.

Antimicrobial stewardship programs in inpatient hospital settings: a systematic review.

Evaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes. Systematic review. Search of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel. Few intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence of Clostridium difficile infection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed. Numerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.

Antimicrobial Stewardship Programs in Inpatient Hospital Settings: A Systematic Review

ObjectiveEvaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes.DesignSystematic review.MethodsSearch of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel.ResultsFew intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence ofClostridium difficileinfection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed.ConclusionsNumerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.

Potential Benefits of Dialectical Behavioral Therapy for Adolescents Receiving Treatment for Borderline Personality Disorder Traits: Implications for Psychiatric Nurses

Borderline personality disorder (BPD) involves a complex constellation of symptoms including suicidal threats, suicidal gestures, and self-harming behaviors. There are limited effective treatment options for adolescent patients with BDP or BDP traits in the inpatient hospital setting. This paper discusses BPD and BPD traits in adolescents, examines challenges faced by inpatient nurses, summarizes evidence supporting Dialectical Behavioral Therapy (DBT) for adolescents with BPD traits, and proposes specific inpatient setting programming to address the needs of this population. This paper suggests that DBT may be successfully implemented to optimize outcomes. DBT has typically been used in adult outpatient settings. However, research suggests that the integration of DBT strategies in inpatient settings serving adolescents could facilitate effective outcomes. Nurses in particular are critical members of the hospital treatment paradigm. Outcomes could be enhanced if nurses have a better understanding of DBT and if they received training to enable them to contribute to DBP programming.

The Effect of Sleep Disruption on Postoperative Pain

Objectives: (1) Identify the amount of sleep disruption that occurs in the postoperative inpatient hospital setting. (2) Determine the relationship between sleep disruption and the use of postoperative narcotic for pain. (3) Determine if the postoperative hospital course is impacted by sleep disruption. Sleep disturbance is a common complaint among hospitalized patients. Decreased sleep and poor sleep quality have been found to be correlated with poor hospital outcomes and decreased wound healing. Methods: Prospective cohort study. Fifty patients undergoing total hip or knee arthroplasty at Henry Ford Hospital in Detroit, Michigan, between January 2013 and November 2013 were asked to wear an actigraph during their postoperative hospital stay. Total sleep time, sleep efficiency, awake index, narcotic use, visual analog pain scores, and postoperative complications were analyzed. Results: A significant correlation was found between lower self-reported pain scores and total sleep time ( P =.03). Spearman correlations between the number of minutes of sleep, sleep efficiency, and awake index were made with the narcotic use on postoperative days (PODs) 0 and 1. None of the results were statistically significant. Narcotic use on POD 0 and sleep on POD 1was marginally significant ( P = .09). Longer hospital stay was associated with decreased sleep efficiency ( P = .01). Complication rates were not statistically different when compared to other sleep parameters. Conclusions: Better control of a patient’s pain improves sleep efficiency and total sleep time. Attention to decreased sleep disruption for hospitalized patients has the potential to improve patient satisfaction with hospital care and decrease length of stay.

Quality Measures and the Practicing Pediatrician: Perspectives From the American Academy of Pediatrics

Quality measurement is an important step for improving the quality of health care for children. The recent implementation of the Affordable Care Act, with its emphasis on improving quality of health care, further underscores the urgency and need for developing robust quality measures that have a strong evidence base and that can successfully measure and improve the quality of pediatric health care in multiple settings, including hospital inpatient and outpatient settings, communities, and community practice.

Randomized Controlled Trials of Psychopharmacological Interventions of Children and Adolescents with Conduct Disorder: A Descriptive Analysis

This study reviews and assesses published psychopharmaceutical randomized controlled trials targeting youths with the singular diagnosis of conduct disorder. Computerized database searches were completed to identify all randomized controlled trials. Fifteen studies were located and reviewed. Of the 15 studies, none were longer than 10 weeks in length, and none had more than 100 participants. The majority were conducted in inpatient hospital settings, with all-male participants. Methodological quality reporting of trials was poor and inconsistent. Findings indicate that there is a need to plan and implement future, lengthy conduct disorder medication trials that follow the Consolidated Standards of Reporting Trials guidelines. The relevance for social work practice and policy is discussed.

Interrater reliability of the Observer Rating of Medication Taking scale in an inpatient mental health facility.

Non-adherence to medication remains a major barrier to recovery from mental illnesses. Identification of those patients likely to experience adherence difficulties is best undertaken during inpatient treatment, prior to discharge into the community. More objective assessments of adherence behaviours might assist staff to more effectively target support to those patients most in need. This study investigated the interrater reliability of an inpatient behavioural observation scale of patient engagement with medication: the Observer Rating of Medication Taking (ORMT) scale. Eight mental health nurses working in a psychiatric hospital inpatient setting were trained in the use of the ORMT using video-based vignettes. Working in pairs, staff then independently rated adherence behaviours of 13 inpatients in a rehabilitation unit (total of 160 ratings) over a 1-week period. Concurrently, two expert raters also undertook independent ratings of patient medication-taking behaviour using the ORMT. Interrater reliability was assessed across both staff and expert raters. The results indicated that the ORMT has satisfactory interrater reliability, and can be appropriately used in an inpatient setting. The observational location of raters on the ward influenced the range of medication-taking behaviours observed, and thus the extent of concordance between raters. Further research to determine if the ORMT predicts adherence in the community is warranted.

Financial incentive of home continuous positive airway pressure machine use in the inpatient hospital setting

Obstructive sleep apnea (OSA) is increasingly recognized as a significant factor in perioperative and inpatient health. Because of this, hospitalized OSA patients are encouraged to utilize continuous positive airway pressure (CPAP) therapy while inpatients. We investigated the cost difference of patient-owned versus hospital-provided CPAP machine use by admitted adult patients with OSA. Prospective cohort study at a tertiary academic center. All new-patient admissions >18 years of age who were prescribed CPAP while inpatients over a 2-month period were included. Demographic information was collected, and cost analysis was performed. CPAP was used for 162 (1.2%) admissions. Mean patient age was 59 ± 13 years; the majority were white (56.8%) and male (64.2%). Average CPAP utilization was 5.3 ± 5.5 nights. The differential cost per day for patients using hospital-provided CPAP was $416.10 more than for patients using home CPAP machines. This cost included direct costs of an extended respiratory therapy (RT) initial visit, machine rental fee ($27.50), and additional RT evaluation time (mean, 85-145 relative value units). The base initial visit was the same for all patients. Over the 2-month study period, the total cost difference in charges was $195,912; this extrapolates to $1,175,471 yearly. This is the first study to characterize the magnitude of cost savings from utilization of home versus hospital-provided CPAP machines in patients requiring inpatient CPAP machine use. The use of patient-owned CPAP machines may reflect an opportunity to provide cheaper care while maintaining high patient safety and quality care. The actual economic impact to an individual hospital would vary based on the insurance payer mix.

Die Qualität der stationären Versorgung von Menschen mit Depressionen im Alter

There are highly effective treatments either in inpatient or day hospital settings available for elderly with major depression. It is important to consider some specific needs of elderly people (e. g. higher somatic comorbidities). On the base of a large routine data set (139 307 patients in hospital treatment) differences between elderly and younger people with major depression are investigated. Elderly with major depression receive significantly less day hospital treatment and psychotherapy. Surprisingly, the mean length of hospital stay was significantly longer in younger patients with major depression. The results from such routine data should be interpreted with caution. Never the less our results suggest that there is still room for improvement for elderly people with major depression.

Nurses’ Knowledge of Inhaler Technique in the Inpatient Hospital Setting

High rates of inhaler misuse in patients with chronic obstructive pulmonary disease and asthma contribute to hospital readmissions and increased healthcare cost. The purpose of this study was to examine inpatient staff nurses' self-perception of their knowledge of proper inhaler technique compared with demonstrated technique and frequency of providing patients with inhaler technique teaching during hospitalization and at discharge. A prospective, descriptive study. A 495-bed urban academic medical center in the Midwest United States. A convenience sample of 100 nurses working on inpatient medical units. Participants completed a 5-item, 4-point Likert-scale survey evaluating self-perception of inhaler technique knowledge, frequency of providing patient education, and responsibility for providing education. Participants demonstrated inhaler technique to the investigators using both a metered dose inhaler (MDI) and Diskus device inhaler, and performance was measured via a validated checklist. Overall misuse rates were high for both MDI and Diskus devices. There was poor correlation between perceived ability and investigator-measured performance of inhaler technique. Frequency of education during hospitalization and at discharge was related to measured level of performance for the Diskus device but not for the MDI. Nurses are a key component of patient education in the hospital; however, nursing staff lack adequate knowledge of inhaler technique. Identifying gaps in nursing knowledge regarding proper inhaler technique and patient education about proper inhaler technique is important to design interventions that may positively impact patient outcomes. Interventions could include one-on-one education, Web-based education, unit-based education, or hospital-wide competency-based education. All should include return demonstration of appropriate technique.

The Perinatal Anxiety Screening Scale: development and preliminary validation

The purpose of this study is to develop a scale (Perinatal Anxiety Screening Scale, PASS) to screen for a broad range of problematic anxiety symptoms which is sensitive to how anxiety presents in perinatal women and is suitable to use in a variety of settings including antenatal clinics, inpatient and outpatient hospital and mental health treatment settings. Women who attended a tertiary obstetric hospital in the state of Western Australia antenatally or postpartum (n = 437) completed the PASS and other commonly used measures of depression and anxiety. Factor analysis was used to examine factor structure, and ROC analysis was used to evaluate performance as a screening tool. The PASS was significantly correlated with other measures of depression and anxiety. Principal component analyses (PCA) suggested a four-factor structure addressing symptoms of (1) acute anxiety and adjustment, (2) general worry and specific fears, (3) perfectionism, control and trauma and (4) social anxiety. The four subscales and total scale demonstrated high to excellent reliabilities. At the optimal cutoff score for detecting anxiety as determined by ROC analyses, the PASS identified 68 % of women with a diagnosed anxiety disorder. This was compared to the EPDS anxiety subscale which detected 36 % of anxiety disorders. The PASS is an acceptable, valid and useful screening tool for the identification of risk of significant anxiety in women in the perinatal period.

Supervising the Beginning Group Leader in Inpatient and Partial Hospital Settings

This paper provides a guide for supervisors in inpatient and partial hospital settings who train beginning group therapists in a variety of group modalities. It addresses basic issues facing the neophyte therapist, including structural aspects of the group, problematic member behaviors, and useful interventions that maximize member engagement and increase overall therapeutic effectiveness.

Outcomes After Transanal Endoscopic Microsurgery With Intraperitoneal Anastomosis

Transanal endoscopic microsurgery has gained increasing popularity as a treatment alternative for early stage rectal neoplasms. With continued advances in technique and experience, more proximal rectal tumors are being surgically managed by using transanal endoscopic microsurgery with an intraperitoneal anastomosis. The purpose of this study was to review the outcomes of patients who have undergone intraperitoneal anastomosis with the use of the transanal endoscopic microsurgery technique. A prospective, single-surgeon database documented 445 consecutive patients undergoing transanal endoscopic microsurgery from October 1, 1996 through January 1, 2012. We retrospectively reviewed information from all patients who underwent transanal endoscopic microsurgery with an intraperitoneal anastomosis in this prospective database. All procedures took place in an inpatient hospital setting. All patients satisfied workup criteria to undergo surgery for rectal neoplasm. All patients underwent transanal endoscopic microsurgery for rectal neoplasm. Size and pathology of lesion, length of procedure, hospital stay, estimated blood loss, margin status, and complications were the outcomes measured. Twenty-eight patients who underwent transanal endoscopic microsurgery had definitively documented intraperitoneal entry and anastomosis. Median follow-up was 12 months (range, 0.5-111 months). There were no operative mortalities. Procedure-related complications included urinary retention (11%), fever (11%), and fecal seepage (4%). Four patients (14%) had positive margins on final pathology. One patient (3%) required abdominal exploration for an anastomotic leak but did not require diversion. Although this study analyzes prospectively collected data, it is nonetheless a retrospective analysis that can introduce bias. Because this is a single-center study with a relatively homogenous population, the results may not be generalizable. Our sample size may also be underpowered to detect clinically significant outcomes. Transanal endoscopic microsurgery with intraperitoneal anastomosis can be safely performed without fecal diversion by experienced surgeons.

Day‐to‐day activities of clinical dietitians working in the inpatient and outpatient settings in a group of New South Wales public hospitals: The results of a direct observational study

AbstractAimTo describe the daily tasks undertaken by dietitians working within the inpatient and outpatient sectors within the NSW public hospital system.MethodsThis study used an ethnographic methodology that employed a direct, non‐participatory, discontinuous, observational technique to observe hospital dietitians, in both outpatient and inpatient settings, during a typical work shift. Trained volunteer observers collected the data over a three‐year period (2008, 2009 and 2010). The data were combined and then sorted into five categories including: direct patient care, indirect patient care, communication, administration and education of self or others.ResultsA total of 609 hours and 21 minutes were observed across a three‐year time period 2008–2010. On average, the dietitians in both inpatient and outpatient settings spent 18.3–32.2% of their time in direct patient care activities. The majority of time was spent in indirect patient care activities such as: information collection, documentation and discussion with other health‐care professionals. A comparison between the two work settings showed that those dietitians working in the inpatient setting spent less time in direct patient care (18.3% vs 33.1%, P &lt; 0.05), and more time in indirect care activities (41.7% vs 23.3%, P &lt; 0.05) and in communication about patient care (22.7% vs 14.4%, P &lt; 0.05).ConclusionsThe findings show that dietitians spend most of their time doing activities that support patient care, but these activities occur away from the patient.

Can the Inpatient Hospital Setting Be a Golden Opportunity to Improve Colon Cancer Screening Rates in the United States?

Colorectal cancer is the third most common cancer in the United States. Despite efforts to increase colorectal cancer screening, the rate of compliance with the recommended screening remains relatively suboptimal according the American Cancer Society (53%). To assess whether the time of hospitalization is a suitable opportunity for patients to receive counseling and for recruiting patients to undergo screening colonoscopy for colon cancer. In 2009, we conducted a cross-sectional survey of hospitalized adults age 50 to 80 years in order to assess their responses on a modified version of the Health Information National Trends Survey. We conducted χ(2) analyses on these data to examine the differences in patients' knowledge of colorectal cancer screening and prior adherence to screening guidelines and to assess whether they would be willing to undergo a screening in the near future if prompted by their physicians. We enrolled a total of 332 participants to complete the study questionnaire. About 94% of the subjects had heard about colon cancer, and 83.4% had heard of any screening tests to detect colorectal cancer. About 66% of subjects reported the colonoscopy to be the most effective screening test for colon cancer. Approximately 55% of the total sample group adhered to recommended screening guidelines for colon cancer using the colonoscopy. The time of hospitalization is a potential "golden opportunity" to counsel patients and promote colon cancer screening.