Inpatient Medical Setting Research Articles

Home healthcare utilization among older adults

Depression has been documented to cause an increase in healthcare utilization in medical inpatient and outpatient settings, but little is known of the use of services of older adults in home healthcare agencies. The objective for this study is to determine the home healthcare utilization of older adults who screen positive for depression compared to those who screen negative.

Measuring What We Value: Quantifying the Impact of the Physician Extender in Surgical Care

h T d a 8 a s a e a t c t n t e t q v T t r v c a t The utility of integrating physician extenders into the medical team has been a topic of debate for several decades. It is a debate that has taken place in numerous countries and across a wide variety of medical specialties. Although the private sectors of medicine have a fairly substantial history of implementing the role of physician extenders, academic centers have not generally followed with the same frequency until recently.1 However, in light of the Accreditation Council for Graduate Medical Education (ACGME’s) 2003 mandate to cap resident work hours, the stakes for academic institutions to strive for the highest possible efficiency of resource (ie, provider) management has never been higher. Resident work-hour restrictions have forced academic centers to find ways to compensate for the decreased workforce.2 Nowhere is this issue more glaring than in surgical specialties. Surgical specialties are somewhat unique within the inpatient medical setting because when the attending physician (surgeon) is at his/her most productive state (operating), he/she is unlikely to be available to spend large amounts of time with, or promptly evaluate, hospitalized patients in times of acute need. This gap in availability has traditionally been filled by residents. However, as residents have become less and less available, the drive for institutions to remedy this issue with physician extenders is rapidly increasing, and has already somewhat altered the face of the inpatient medical team.3 It is now considered commonplace in our practices to use the physician extender for all phases of surgical care. Like any other change in surgery, whether it is a novel operation or pathway of care, the value of new practices should be studied. Therefore, the impact of adding physician extenders to the medical team

Predictors of Discharge to Acute Care after Inpatient Rehabilitation in Severely Affected Stroke Patients

This study aimed to determine the predictors of discharge to acute care after inpatient rehabilitation in severely affected stroke patients. This was a retrospective study using data from the Uniform Data System for Medical Rehabilitation (UDSMR) between 2008 and 2009. The main outcome variable was discharge location, which included discharge to acute care or discharge to the community after inpatient rehabilitation. The study sample included 223 of the most severely affected stroke patients (Case-Mix Group 0110 of Medicare reimbursement classification), of whom 86 were discharged to acute care from after the inpatient medical rehabilitation setting; 137 similarly classified stroke patients were discharged to the community after inpatient medical rehabilitation. The variables examined were Functional Independence Measure ratings, co-morbid medical conditions, and four groups of stroke-related neurologic deficits (hemiparesis, dysphagia, language deficits, and other stroke-related neurologic deficits). The groups were devised based on International Classification of Diseases, 9th Revision codes. There were no significant demographic differences between the two groups-those discharged to the acute care hospital and those discharged to the community. There was a difference in admission Functional Independence Measure ratings, whereby patients discharged to acute care were significantly lower (P < 0.05) on admission motor and cognitive function than were patients discharged to the community. When controlling for 19 groups of co-morbid medical conditions and 4 groups of stroke-related neurologic deficits, there was no significant difference between patients being discharged to an acute care hospital and those discharged to the community. In the current study, controlling for impairment (stroke), severity of condition, demographic variables, inpatient rehabilitation admission day of the week and discharge day of the week, prehospitalization living setting, prehospitalization living with (alone, family, other), payer (secondary insurance coverage), onset days, co-morbid medical conditions, and classification of stroke-related neurologic deficits, the only variable predictive of discharge to the acute care hospital from an inpatient rehabilitation facility is function at admission, mainly the admission motor Functional Independence Measure rating. If clinicians routinely assess the functional status of patients during the preadmission screening process, it may aid in identifying whether the patient is at an increased risk of being readmitted to the acute care hospital.

Establishing a Pediatric Cognitive Rehabilitation Program: Insurance Issues and Clinical Rationale

Technological and medical advances have greatly improved survival rates for many disorders; therefore, more attention is being given to functional outcomes in individuals who have been diagnosed with neurological diseases or disorders. One example of such an endeavor consists of a cognitive rehabilitation program to improve attentional abilities. The current study uses a modification of the original Cognitive Remediation Program to address attentional deficits in children with a variety of neurological disorders. The abbreviated program is designed as a focused, time-limited program that can be easily implemented in inpatient, partial day, or outpatient medical settings using third party payment to fund the program. This article seeks to inform psychologists about how to establish a cognitive rehabilitation program with emphasis placed on providing information about insurance reimbursement and billing procedures. Information is presented regarding billing codes, materials required for reimbursement, the denial/approval process, and percent of the Usual Customary Reasonable charge that was covered. Recommendations to improve the timeliness and efficiency of the reimbursement process, as well as to increase the amount of reimbursement, are highlighted. Directions for future research, including continued documentation of the effectiveness of cognitive rehabilitation programs to establish credibility for procurement of third party payment, are also offered.

Evaluating Transitions of Care of Hospitalized Medical Patients to Long-Term Care Facilities

Venous thromboembolism (VTE) is a significant but preventable cause of hospital-related morbidity and mortality. Prevention of in-hospital VTE, thus, has become a major quality improvement initiative within hospitals. However, addressing VTE prophylaxis rates and appropriateness on transition to other facilities has not been fully characterized to date. The authors of this study retrospectively evaluated VTE prophylaxis on transfer from medical inpatient settings to long-term care facilities. Analysis indicated that on transfer to other facilities, VTE prophylaxis recommendations were not routinely documented. Interfacility communication is crucial to ensure that appropriate prophylaxis recommendations are addressed during transitions of care. New processes evaluating VTE prophylaxis recommendations at the time of care transfer warrant further study.

PC-FACS

PC-FACS

Identifying the ‘right patient’: Nurse and consumer perspectives on verifying patient identity during medication administration

Accurate verification of patient identity during medication administration is an important component of medication administration practice. In medical and surgical inpatient settings, the use of identification aids, such as wristbands, is common. In many psychiatric inpatient units in Victoria, Australia, however, standardized identification aids are not used. The present paper outlines the findings of a qualitative research project that employed focus groups to examine mental health nurse and mental health consumer perspectives on the identification of patients during routine medication administration in psychiatric inpatient units. The study identified a range of different methods currently employed to verify patient identity, including technical methods, such as wristband and photographs, and interpersonal methods, such as patient recognition. There were marked similarities in the perspectives of mental health nurses and mental health consumers regarding their opinions and preferences. Technical aids were seen as important, but not as a replacement for the therapeutic nurse-patient encounter.

The Mixed Evidence for Brief Intervention in Emergency Departments, Trauma Care Centers, and Inpatient Hospital Settings: What Should We Do?

This qualitative review is based on a symposia presented at the 2009 annual conference of the Research Society on Alcoholism (Baird et al., 2009; Field et al., 2009; Monti et al., 2009; Saitz et al., 2009a). The purpose is to describe the mixed evidence supporting brief interventions in the emergency department, trauma care, and in-patient medical care settings; examine potential moderators of treatment outcome in light of the mixed evidence; and identify methods to move the research and practice of brief interventions beyond their current state. By drawing upon existing reviews and selected individual studies, we provide examples that reflect the current complexity of research in this area and propose steps for advancing the field. Emergency departments, inpatient hospital settings, and trauma care settings represent three unique contexts within which brief interventions have been tested. While the general efficacy of brief alcohol interventions in these settings has been recognized, the evidence is increasingly mixed. Recent studies investigating potential moderators of treatment outcomes suggest that a more sophisticated approach to evaluating the effectiveness of brief interventions across varying patient populations is needed to further understand its effectiveness. Current dissemination efforts represent a significant advance in broadening the base of treatment for alcohol problems by providing an evidence-based intervention in health care settings and should not be curtailed. However, additional research is required to enhance treatment outcomes, refine current practice guidelines, and continue to bridge the gap between science and practice. Given the current state of research, a multisetting clinical trial is recommended to account for potential contextual differences while controlling for study design.

Medical clerkships do not reduce common prescription errors among medical students

Prescribing correctly represents one of the most essential skills of a doctor when it comes to patient safety. Unfortunately, prescribing errors still account for a large proportion of avoidable drug-related problems (DRP). Despite this shortcoming, many medical schools do not provide specific prescribing training and assume that students acquire sufficient prescribing skills during regular medical clerkships. We therefore investigated whether there is an association between the individual time spent by students in internal-medicine clerkships and the number of prescription errors committed in a standardized prescribing test for common drug-related problems in a medical inpatient setting. Seventy-four fifth-year medical students (25 +/- 3 yrs, 24 m, 50 f) who had completed their formal pharmacology training filled in prescription charts for two standardized patient paper cases. The charts were rated by two blinded consultants from the field of internal medicine using a checklist for common prescription errors. Students were divided into three groups according to the number of weeks previously spent in internal-medicine clerkships. Group differences in the number of prescription errors made were subsequently examined. Students committed 69% +/- 12% of all possible prescription mistakes. There was no significant difference between the group without clerkships in internal medicine (G1) (71 +/- 9%), the group with one to four weeks (G2) (67 +/- 15%), and the group with more than five weeks of clerkships (G3) (71 +/- 10%), p = .76. Medical students do not seem to acquire the necessary skills to avoid common prescription errors during regular clerkships in internal medicine. This study provides evidence to suggest that specific prescription training within medical education is warranted in order to prevent DRP.

Teamwork on inpatient medical units: assessing attitudes and barriers

BackgroundDiscrepant attitudes about teamwork among nurses and physicians exist in operating rooms and intensive care units. Little is known about teamwork attitudes on general medical services.ObjectiveTo assess ratings of teamwork...

Routine alcohol screening and brief interventions in general hospital in-patient wards: Acceptability and barriers

Aims: To explore the acceptability and barriers to the introduction of nurse-led routine screening and brief interventions (SBI) for alcohol misuse on general in-patient hospital wards.Methods: Screening was introduced on an in-patient ward at three general hospitals. Screening rates, numbers of referrals to alcohol liaison nurses (ALNs), brief interventions conducted and patients’ access to specialist alcohol services at follow-up were measured. Semi-structured qualitative interviews were conducted to explore staff/patient attitudes.Findings: Screening rates ranged from 17.7% to 36.6% in the three wards. The highest rates of screening and positive screening scores were recorded on a gastrointestinal (GI) ward. Attitudes of staff and patients towards the SBI process were generally positive; however, a number of current barriers to its implementation were identified.Conclusions: In order for the SBI approach to be incorporated into routine procedures in in-patient medical settings it may be necessary to provide ongoing support and training from specialist alcohol workers, and to have mechanisms that ensure the screen remains part of routine nursing documentation.

Validation Of The Sentence Repetition Test As A Measure Of Suspect Effort

It has been suggested that the Sentence Repetition Test (SRT) could serve as an adequate embedded symptom valid ity measure identifying suspect effort during neuropsychological testing. However, very little research has examined sensitivity and specificity rates when using this measure in a variety of clinical settings. The SRT was administered to 1031 patients referred for neuropsychological assessment in outpatient, inpatient, and independent medical evaluation settings. These patients were diagnosed with a wide range of psychiatric, developmental, and neurological disorders. The results of this study reveal that the SRT is a valid measure of suspect effort for the vast majority of these patients (sensitivity = 56.8% and specificity = 95.8% in combined clinical settings). However, analyses also indicate that the SRT is not a valid effort measure for individuals with mental retardation or dementia due to specificity rates falling well below 90% for both groups. Furthermore, the validity of the SRT as an effort measure is questionable for individuals with English as a second language, with a verbal learning disability, with a left cerebrovascular accident, or with an expressive-receptive language disorder due to small sample sizes or borderline specificity rates. Sensitivity, specificity, positive predictive accuracy, and negative predictive accuracy rates are provided for varying cutoff scores in inpatient, outpatient, and IME settings. The results of this extensive study confirm that the SRT can be a useful measure in detecting suspect effort in neuropsychological testing while also providing valuable clinical information.

Collaboration between pharmacists, physicians and nurse practitioners: A qualitative investigation of working relationships in the inpatient medical setting

While collaborative, team-based care has the potential to improve medication use and reduce adverse drug events and cost, less attention is paid to understanding the processes of well functioning teams. This paper presents the findings from key informant interviews and reflective journaling from pharmacists, physicians and nurse practitioners participating in a multicentre, controlled clinical trial of team-based pharmacist care in hospitalized medical patients. A phenomenological approach guided the data analysis and content analysis was the primary tool for unitizing, categorizing and identifying emerging themes. Pharmacists experienced highs (developing trusting relationships and making positive contributions to patient care) and lows (struggling with documentation and workload) during integration into the medical care team. From the perspective of the participating pharmacists, nurse practitioners and physicians, the integration of pharmacists into the teams was felt to have facilitated positive patient outcomes by improving team drug-therapy decision-making, continuity of care and patient safety. Additionally, the study increased the awareness of all team members' potential roles so that pharmacists, nurses and physicians could play a part in and benefit from working together as a team. Focussed attention on how practice is structured, team process and ongoing support would enable successful implementation of team-based care in a larger context. (ClinicalTrials.gov number, NCT00351676)

Comobid Medical and Psychiatric Disorders: Clinical and Economic Impact and Systems of Care

Psychiatric disorders are more commonly seen in the general medical outpatient and inpatient settings than in community samples. This group is at particular risk for resistance to general medical and psychiatric treatment, increased complications of disease, high use of health care services, and disability. Several randomized, controlled studies have shown that medical and psychiatric treatment is clinically and economically effective. For this reason, integrated physical and mental-health primary care models and inpatient models should receive greater attention as we attempt to improve the quality of care and health outcomes for patients with comorbid medical and psychiatric disorders. Because there are too few consultating psychiatrists to deliver services to the many medically ill patients with psychiatric disorders, we should consider new efficient and effective proactive approaches in the future rather than relying on the current reactive psychiatric consultation system. For cost-effective treatment in these budget- and manpower-limited environments, a multidisciplinary team approach, which coordinates psychiatric service delivery under specially trained psychiatrists, should be used. Specially trained psychiatrists should be multidisciplinary team leaders who support and encourage interventions by other behavioral health specialists with selected skills.

Electrical stimulation of wrist and fingers for sensory and functional recovery in acute hemiplegia

Objective: To investigate the effects of a short-term electrical stimulation in conjunction with neurodevelopmental exercises on sensory and functional recovery of hemiparetic upper limb in acute stroke patients. Design: Controlled clinical trial with alternate allocation. Setting: Acute inpatient medical care setting of a university hospital. Subjects: Thirty-six acute stroke patients (18 TENS group; 18 control group) who experienced their first stroke were studied. Intervention: Both groups received 1 h/day neurodevelopmental exercises in accordance with Bobath for 10 days. In addition to exercises the TENS group received electrical stimulation of the wrist and finger extensors for 1 h. Main outcome measures: Kinaesthesia and position sense tests, a hand function test and a hand movement scale were performed before and after treatment. Results: Both groups showed considerable improvement in kinaesthesia sense and position sense after treatment. Comparison of the two groups after treatment revealed that this difference was not significant (P>0.05). Both groups showed improvement in hand movement scores (P<0.05), whereas hand function improved only in the TENS group (P<0.05). Conclusion: The results of this study indicated that additional stimulation of the hand and fingers leads to an improved sensorimotor outcome immediately after the intervention.

Verbal Processing within the Music Therapy Relationship

ABSTRACT: This article is intended to establish an introductory foundation for the continued development of theory and methods in the use of verbal processing in music therapy. Verbal processing may contribute toward client awareness of internal sensations, feelings and thoughts related to external events and relationships, as well as contribute toward therapist understanding of the affective, cognitive and relational material which surfaces during the musical experiences in music therapy. In addition to these functions, verbal processing provides a means for the music therapist to gather information, to test an observation, provide assessment information, stimulate activity within a therapy group, or provide feedback that can enable a return to the music. Issues that may present as resistances to the music therapist's use of verbal processing will also be explored. Case examples are provided to present demonstrations and application of the purposes of verbal processing. Finally, the article concludes with suggestions that may help the music therapist's focus on the direction of intervention in the use of verbal processing. It is suggested that music therapists continue to develop methods of verbal processing since it seems to be an integral part of a great deal of music therapy practice. Verbal processing, for the purposes of this paper, relates to the talking that facilitates the therapeutic process during, and in response to, music making or music listening. Two purposes are suggested for the use of verbal processing in music therapy. First, verbal processing provides the opportunity to increase awareness or understanding about internal (thoughts, observations, and feelings) and external events (within the music and interpersonal areas of experience). Thus, verbal processing allows for the client to integrate non-verbal with verbal realms of experience, such as when a client develops awareness, or a connection, between personal and interpersonal events experienced through the music therapy process and patterns that occur in his or her everyday world (Nolan, 1989, p. 177). A second suggested purpose of verbal processing is that it can provide the therapist with a way to gather additional information. This verbal information may verify and/or broaden the therapist's understanding of the client. Or, information gleaned from the verbal processing may contradict, or contrast, with information derived from musical experiences. In this later purpose, verbal processing may also help the music therapist become aware of countertransference material. As a result of verbal processing, the client and the therapist are able to re-enter into the musical experience (expressive or receptive) with new insights, and a more developed therapeutic alliance. This article explores verbal processing from both of these suggested perspectives. The ideas and suggestions in this article are based primarily upon the author's twenty five years of music therapy clinical experience with adults and children in inpatient and outpatient psychiatric and medical settings and through clinical and academic supervisory experience as a music therapy clinical training director and university educator. References from the literature serve to reinforce the author's perspective and to demonstrate diversity in the practice of verbal processing in music therapy. Verbal processing may occur in a wide range of expressive and receptive, also known as active and passive, music therapy approaches. At times, verbal processing may include only the therapist's words or may occur in the form of the client or therapist's spontaneous singing (Austin, 2001 ). It is not restricted to spoken discourse. It is not used as a literal translation of the musical events into words. Therapist and client discussion ought not to shadow the aesthetic, spiritual, and other ineffable manifestations of the music playing or listening experience. In some music therapy orientations, or approaches, it is believed that verbal processing is contraindicated or unnecessary due to the tenant that the musical experience intrinsically contains all that is needed for client change or growth. …

Accuracy of Referring Psychiatric Diagnosis on a Consultation-Liaison Service

The authors determined the accuracy of the initial psychiatric diagnosis of primary medical providers requesting psychiatric consultation in a general medical inpatient setting. A retrospective review of 346 consecutive psychiatric consultations was conducted in which the initial diagnostic impression of primary medical providers was compared with the final psychiatric diagnosis. Accuracy rates for cognitive disorders, substance use disorders, and depressive disorders were 100%, 88.9%, and 53.6%, respectively. Thus, initial diagnoses of a cognitive or substance use disorder by primary medical providers are likely to be accurate, whereas an initial diagnosis of a depressive disorder will be inaccurate in approximately half of the cases.

More than meets the eye: How examiner training affects the reliability of the MacNeill–Lichtenberg decision tree in geriatric rehabilitation patients

Bank AL, MacNeill SE, Hall EM, Nadjarian RK, Zaccagnini AV, Lichtenberg PA. More than meets the eye: how examiner training affects the reliability of the MacNeill–Lichtenberg decision tree in geriatric rehabilitation patients. Arch Phys Med Rehabil 2002;83:405-11. Objective: To examine the effect of examiner training on the test-retest reliability of the MacNeill–Lichtenberg Decision Tree (MLDT), a tool for guiding clinicians' decision making for referrals for mental health problems. Design: Correlational analyses and chi-squares were used to examine the influence of demographic variables on MLDT performance and the test-retest reliability of its cognitive and affective components. Setting: Rehabilitation unit of a large, freestanding, urban hospital. Participants: In study 1, 39 older, medical rehabilitation patients consecutively referred to the neuropsychology service. In study 2, 57 older, consecutively admitted medical rehabilitation patients. Interventions: In study 1, patients underwent testing with the MLDT by a novice examiner. In study 2, patients were tested by trained examiners. Both sets of results were compared with those obtained by experienced examiners. Main Outcome Measures: The temporal stability of participants' performance on the cognitive and affective components of the MLDT was compared between the 2 studies. Results: Training was associated with high test-retest reliability on both the cognitive and affective components. A lack of training was associated with reduced reliability in depression screening. Conclusion: These findings support the use of the MLDT as a mental health triage tool for older adults in inpatient medical settings. Its use is dependent on training and accurate administration. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

A taxometric analysis of MMPI-2 Infrequency scales [F and F(p)] in clinical settings.

The typology of overreporting, which is a deliberate attempt to amplify symptoms, simulate psychopathology, or understate coping capacities, was examined using taxometric procedures with Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Infrequency scales [F and F(p)] in psychiatric inpatient and Veterans Affairs (VA) medical center treatment settings. Overreporting was identified as a taxon using several taxometric procedures, and the multiple estimates of the taxon base rate were consistent within each sample. Mean base-rate estimates were .27 and .19 for the psychiatric inpatient and VA medical center settings, respectively. Overall classification rates ranged from .80 to .97 across the 2 settings, which supports the use of F and F(p) in the identification of overreporting on the MMPI-2 in psychiatric inpatient and VA medical center settings.

Changing Addictive Behavior: Bridging Clinical and Public Health Strategies,

Changing Addictive Behavior: Bridging Clinical and Public Health Strategies,