Internal Medicine Admissions Research Articles

Prolonged Boarding and Racial Discrimination and Dissatisfaction Among Emergency Department Patients

Emergency department (ED) boarding times have increased rapidly, but their health equity outcomes are unknown. To investigate whether prolonged ED boarding is associated with increased perceived racial discrimination and dissatisfaction and whether associations vary between patients from marginalized racial and ethnic groups vs non-Hispanic White patients. This is a cross-sectional study of hospitalized adults who boarded in the ED during internal medicine admissions at a large, urban hospital in Boston, Massachusetts, from June 2023 to January 2024. Equal proportions of non-Hispanic White patients and patients from marginalized racial and ethnic groups (American Indian or Alaska Native, Hispanic, non-Hispanic Black and/or African American, and multiracial) were selected randomly. The duration of ED boarding was categorized as less than 4 hours (reference), 4 to less than 24 hours, and 24 or more hours. Primary outcomes were odds of reporting (1) discrimination via the Discrimination in Medical Settings scale, and (2) dissatisfaction via the adapted Picker Patient Experience-15 questionnaire. Marginalized race and ethnicity was tested as an effect modifier. Multivariable logistic regression models adjusted for patient age, sex, language, and insurance payer. Of 598 patients approached, 527 were enrolled, and 525 completed the surveys (response rate, 87.8%). The mean age (SD) was 60.6 (18.7) years, 300 patients (57.1%) were female, 246 patients (47.3%) identified as non-Hispanic White, and 274 (52.7%) were from a marginalized racial or ethnic group. In total, 135 (25.7%) boarded less than 4 hours (reference), 202 (38.5%) boarded 4 to less than 24 hours, and 188 (35.8%) boarded 24 hours or longer. Compared with less than 4 hours, boarding 24 hours or longer was associated with increased perceived discrimination (odds ratio [OR], 1.84; 95% CI, 1.14-2.99; P = .01). An increased association was observed in the subgroup of patients from racial and ethnic marginalized groups (OR, 2.36; 95% CI, 1.20-4.65; P = .01); effect modification was not significant (P for interaction, .10). For all patients, boarding 24 hours or longer was associated with increased dissatisfaction with care (OR, 1.77; 95% CI, 1.03-3.06; P = .04); effect modification was not significant (P for interaction, .80). In this cross-sectional study, hospitalized patients who boarded in the ED 24 hours or longer reported more discrimination and dissatisfaction with care, which may disproportionately affect patients from marginalized racial and ethnic groups. As ED boarding times increase nationally, it is critical to recognize their potential to exacerbate health inequities and to respond with equity-focused solutions.

Using the Elixhauser risk adjustment model to predict outcomes among patients hospitalized in internal medicine at a large, tertiary-care hospital in Israel

BackgroundIn Israel, internal medicine admissions are currently reimbursed without accounting for patient complexity. This is at odds with most other developed countries and has the potential to lead to market distortions such as avoiding sicker patients. Our objective was to apply a well-known, freely available risk adjustment model, the Elixhauser model, to predict relevant outcomes among patients hospitalized on the internal medicine service of a large, Israeli tertiary-care hospital.MethodsWe used data from the Shaare Zedek Medical Center, a large tertiary referral hospital in Jerusalem. The study included 55,946 hospitalizations between 01.01.2016 and 31.12.2019. We modeled four patient outcomes: in-hospital mortality, escalation of care (intensive care unit (ICU) transfer, mechanical ventilation, daytime bi-level positive pressure ventilation, or vasopressors), 30-day readmission, and length of stay (LOS). We log-transformed LOS to address right skew. As is usual with the Elixhauser model, we identified 29 comorbid conditions using international classification of diseases codes, clinical modification, version 9. We derived and validated the coefficients for these 29 variables using split-sample derivation and validation. We checked model fit using c-statistics and R2, and model calibration using a Hosmer–Lemeshow test.ResultsThe Elixhauser model achieved acceptable prediction of the three binary outcomes, with c-statistics of 0.712, 0.681, and 0.605 to predict in-hospital mortality, escalation of care, and 30-day readmission respectively. The c-statistic did not decrease in the validation set (0.707, 0.687, and 0.603, respectively), suggesting that the models are not overfitted. The model to predict log length of stay achieved an R2 of 0.102 in the derivation set and 0.101 in the validation set. The Hosmer–Lemeshow test did not suggest issues with model calibration.ConclusionWe demonstrated that a freely-available risk adjustment model can achieve acceptable prediction of important clinical outcomes in a dataset of patients admitted to a large, Israeli tertiary-care hospital. This model could potentially be used as a basis for differential payment by patient complexity.

Association between hospital internal medicine physician workforce and patient admissions during the COVID-19 pandemic in Japan

BackgroundHospital physician workforce in Japan is the lowest among developed countries. Many patients with novel coronavirus disease 2019 (COVID-19) with high risk of mortality could not be hospitalized during case surges in Japan and only about 5% of total acute care beds were used as COVID-19 beds nationwide. However, the relationship between the number of hospital physicians and patient admissions remains unclear. Thus, we aimed to evaluate this relationship in areas with the highest incidences during the surges.MethodsData collection was performed for teaching hospitals accredited with the specialty of internal medicine in three prefectures which experienced the highest COVID-19 incidences in Japan (Tokyo, Osaka, Okinawa). Association was examined between the number of full-time physicians (internal medicine staff physicians and residents) and admissions of internal medicine patients through ambulance transport from April 2020 to March 2021. Analysis was conducted separately for community hospitals and university hospitals because the latter have roles as research institutions in Japan. Community hospitals included private, public, and semi-public hospitals.ResultsOf 117 teaching hospitals in three prefectures, data from 108 teaching hospitals (83 community hospitals and 25 university hospitals) were available. A total of 102,400 internal medicine patients were admitted to these hospitals during the one-year period. Private hospitals received the greatest mean number of patient admissions (290 per 100 beds), followed by public hospitals (227) and semi-public hospitals (201), and university hospitals (94). Among community hospitals, a higher number of resident physicians per 100 beds was significantly associated with a greater number of patient admissions per 100 beds with beta coefficient of 11.6 (95% CI, 1.5 to 21.2, p = 0.025) admissions by one physician increase per 100 beds. There was no such association among university hospitals.ConclusionsCommunity hospitals with many resident physicians accepted more internal medicine admissions through ambulance transport during the COVID-19 pandemic. An effective policy to counter physician shortage in hospitals in Japan may be to increase internal medicine resident physicians among community hospitals to save more lives.

Mandatory Caprini Score Documentation and Incidence of Hospital VTE

ASH Abstract Submission: Background: Hospital acquired VTE continues to be a source of morbidity and mortality for patients. The Caprini risk score is a risk assessment tool for the occurrence of venous thromboembolism. Though initially developed for use among surgical patients, it is now being applied to many hospitalized patients. It involves 20 variables and it is derived from a prospective study of general surgery patients published in 1991. After adding Caprini score documentation to internal medicine admission order sets and general surgery pre-procedural order sets, the 90 day incidence of hospital acquired VTE went from 67 to 0. Prior to the change, documentation of Caprini score was poor and ordered VTE prophylaxis did not align with the documented Caprini score, ultimately effecting compliance to prophylaxis and affecting patient safety. Methods: In order to decrease the rate of VTE throughout the Orlando Health hospital system, changes were made to the electronic medical record (EMR) to better improve selection of proper VTE prophylaxis. Because VTE prophylaxis was frequently not ordered appropriately, the ability to personalize order sets for VTE was removed 5/3/2022. We implemented a mandatory order set requiring documentation of Caprini score in two admission order sets. Subsequent VTE prophylaxis was ordered depending on the calculated score. The EMR changes were implemented 6/8/2022 as a pilot program within both internal medicine admission order sets and general surgery pre-procedure admission order sets. Incidence of hospital acquired VTE as well as re-admission rates were monitored over the subsequent period. Results: In the period immediately prior to implementation of this program, there were 67 hospital acquired DVT/PE events. After the pilot program went live 6/8/22, there were 0 preventable hospital acquired VTE for the subsequent period. VTE prophylaxis was ordered within 24hrs of admission 81% of the time. During the whole study phase there were 95 total readmissions due to DVT/PE, 35 from DVT, 29 from PE, and 25 from DVT/PE. Of these, only 3 occurred after implementation of pilot program. Conclusions: Addition of Caprini score documentation to internal medicine admission order set and pre-procedural general surgery order set prevented hospital acquired VTE across the hospital system over a 30 day period, and dramatically decreased readmission rate due to VTE/PE. These results have a direct effect on patient safety and quality of patient care.

Reducing Unnecessary 'Admission' Chest X-rays: An Initiative to Minimize Low-Value Care.

Introduction Internal medicine admission services often request a baseline admission chest X-ray (CXR) for patients already admitted to the emergency department (ED) and who are waiting for inpatient beds, despiterarely providing clinical value. Adverse consequences of such CXRs include unnecessary radiation exposure, cost, time, and false positives, which can trigger a diagnostic cascade. Extraneous CXRs performed on already-admitted ED patients can delay inpatient transfer, thereby increasing boarding and crowding, whichin turnmay affect mortality and satisfaction. In 2016, our ED and internal medicine hospitalist services implemented guidelines (reflecting those of the American College of Radiology) to reduce unnecessary admission CXRs. All relevant providers were educated on the guideline. The primary aim of this study was to determine if there were changes in the percentage of patients with pre-admission and admission CXRs following guideline implementation. Our secondary aim was to determine which patient characteristics predict getting a CXR. Methods All ED and internal medicine hospitalist providers were educated once about the guideline. We performed a retrospective analysis of pre- vs. post-guideline data. Patients were included if admitted to the internal medicine service during those timeframes with an admission diagnosis unrelated to the cardiac or pulmonary systems. A CXR performed during ED evaluation prior to the admission disposition time was recorded as "pre-admission," andif performed after disposition time it was recorded as "admission." A CXR was "unwarranted" if the admission diagnosis did not suggest a CXR was necessary. The numerator was the number of unnecessary admissionCXRs ordered on patients with diagnoses unrelated to the cardiac or pulmonary systems (minus those with a pre-admission CXR); the denominator was the number of such admissions (minus those with a pre-admission CXR). Variables of interest that might influence whether a CXR was ordered were age, gender, respiratory rate ≥20,cardiac- or pulmonary-related chief complaint, ED diagnosis category, or past medical history. Results Among admitted patients with diagnoses that did not suggest a CXR was warranted, there was no change in the percentage of admission CXRs (21.7% to 25.6%, p = 0.2678), whereas the percentage with pre-admission CXRs decreased (66.6% to 60.7%, p = 0.0152). This decrease was driven by fewer CXRs being performed on patients whose chief complaint did not suggest one was indicated (p = .0121). In multivariate analysis, risk factors for an unwarranted CXR were age >40 (risk ratio (RR) = 2.9) and past medical history of cardiovascular disease (e.g., myocardial infarction, atrial fibrillation), renal disease, or hyperkalemia. Conclusion This educational initiative was not associated with the intended decrease in ordering unwarranted admission CXRs among ED boarding patients, though there was an unanticipated decrease in pre-admission CXRs. This decrease was driven by fewer CXRs being performed on patients whose chief complaint did not suggest one was indicated. Organizations interested in reducing processes with little clinical value might adopt a similar program while emphasizing the lack of benefit to admitted patients through iterative educational programs on hospital admitting services.

Impact of the COVID-19 pandemic on emergency outpatient consultations and admissions of non-COVID-19 patients (ECCO)-A cross-sectional study.

During the first year of the COVID-19 pandemic, healthcare facilities worldwide struggled to adequately care for the increasing number of COVID-19 patients while maintaining quality of care for all other patients. The aim of this study was to investigate the displacement and underuse of non-COVID-19 patient care in a medical department of a tertiary hospital in Switzerland. In this retrospective cross-sectional study, internal medicine admissions from 2017 to 2020, emergency outpatient visits from 2019 to 2020 and COVID-19 admissions in 2020 were analyzed and compared using a regression model. Internal medicine admissions were also stratified by diagnosis. A questionnaire was used to assess the pandemic experience of local general practitioners, referring hospitals, and nursing homes. The total number of admissions decreased during the 1st and 2nd waves of the pandemic but increased between the two waves. Elective admissions decreased in 2020 compared to pre-pandemic years: they represented 25% of total admissions in 2020 versus 30% of the total admissions during 2017-2019, p <0.001. Admissions for emergency reasons increased: 71% in 2020 versus 65% in 2017-2019, p < 0.001. Emergency outpatient consultations decreased in 2020 compared to 2019, 62.77 (14.70), mean (SD), weekly visits in 2020 versus 74.13 (13.98) in 2019, p<0.001. Most general practitioners and heads of referring hospitals also reported a decrease in consultations, especially during the 1st wave of the pandemic. Mental illnesses, anxiety or burn-out were perceived in both patients and staff in general practices and nursing homes. In conclusion, the COVID-19 pandemic negatively affected the care of non-COVID-19 patients, particularly those with chronic illnesses. A shift of health care resources from non-COVID patients to COVID patients was observed. These findings could help institutions better manage such a situation in the future.

Abstracts for the 40th emergencies in medicine conference

Abstracts for the 40^th emergencies in medicine conference

Burden of COVID-19 on Italian Internal Medicine Wards: Delphi, SWOT, and Performance Analysis after Two Pandemic Waves in the Local Health Authority "Roma 6" Hospital Structures.

Background: COVID-19 causes major changes in day-to-day hospital activity due to its epidemiological characteristics and the clinical challenges it poses, especially in internal medicine wards. Therefore, it is necessary to understand and manage all of the implicated factors in order to maintain a high standard of care, even in sub-par circumstances. Methods: This was a three-phase, mixed-design study. Initially, the Delphi method allowed us to analyze the causes of poor outcomes in a cohort of an aggregate of Italian COVID-19 wards via an Ishikawa diagram. Then, for each retrieved item, a score was assigned according to a pros/cons, opportunities/threats system. Scores were also assigned according to potential value/perceived risk. Finally, the performances of MCs (Medicine-COVID-19 wards) and MCFs (Medicine-COVID-19-free: Internal Medicine wards) units were represented via a Barber’s nomogram. Results: MCFs hospitalized 790 patients (−23.90% compared to 2019 Internal Medicine admissions). The main risk factors for mortality were patients admitted from local facilities (+7%) and the presence of comorbidities (>3: 100%, ≥5: 24.7%). A total of 197 (25%) patients were treated with non-invasive ventilation (NIV). The most deaths (57.14%) occurred in patients admitted from local facilities. Conclusions: Medicine-COVID-19 wards show higher complexity and demand compared to non-COVID-19 ones and they are comparable to sub-intensive therapy wards. It is necessary to promote the use of NIV in such settings.

A comprehensive assessment of patient experience and disease-related awareness in multiple sclerosis: A questionnaire-based nation-wide survey in Turkey

Background: Comprehensive assessment of multiple sclerosis (MS) patients in terms of patient profile, clinical and disease-related factors has great epidemiological value. This study aimed to evaluate patient experience and disease-related awareness in MS patients through a nation-wide survey in TurkeyMethods: A total of 1379 MS patients participated in this cross-sectional questionnaire survey conducted between November 2018 and December 2018. The online questionnaire form included items on sociodemographic, disease-related, first-admission, treatment and follow up characteristics as well as the disability status.Results: Patients were diagnosed at median 28.0 years of age, while the average time from admission to diagnosis and time from diagnosis to treatment were 1.2 years and 2.5 months, respectively. Neurology (45.4%) and ophthalmology (23.3%) were the most common clinics for the first admission, while numbness-weakness in lower and upper extremities (37.6%) and double vision-visual problems (30.6%) were the most common symptoms on initial admission. Treatment was initiated after the diagnosis in 1213(88.0%) patients, while 166 (12.0%) patients were treatment-naïve. Treatment discontinuation, treatment switch and use of alternative treatment methods were reported by 31.3%, 49.3% and 22.8% of patients, respectively. The ophthalmology admissions (with double vision or visual problems) were associated with the shortest time from presentation to diagnosis as compared with neurosurgery and internal medicine admissions (median 1.0 vs. 3.0 and 4.0 months, p<0.001). The neurology admissions (with numbness-weakness in extremities) were associated with more prompt (median 0.3 vs. 0.5 months, p=0.032) and more frequent onset of treatment after diagnosis (64.5% vs. 2.2% to 15.2%, p<0.001). Time from presentation to diagnosis was longer in patients aged >50 years (median 6.0 months vs. 2.0 months, p<0.001), in patients using alternative medicine (median 3.0 months vs. 1 month, p=0.001) and in patients admitted to a non-MS-center (median 3.0 months vs. 2.0 months, p=0.002). Median (min-max) age at diagnosis was significantly lower in patients with vs. without treatment discontinuation for any reason (26.0(10-56) vs. 29.0(3-60) years, p<0.001) and treatment switching (27.0(5-93) vs. 30.0(3-60) years, p<0.001).Conclusions: In conclusion, our findings revealed higher likelihood of earlier diagnosis and earlier treatment in patients admitted to an MS-center and in those presenting with ocular problems and sensory-motor deficits, respectively. Our findings also emphasize the association of older patient age with higher likelihood of diagnostic delay, and increased likelihood of treatment discontinuation for any reason and/or treatment switching in case of older patient age, younger age at diagnosis and diagnostic delay. In this regard, our findings highlight the need for improved awareness among patients as well as clinicians on initial manifestations of MS to enable admission or referral to an MS-center and to prevent delay in diagnosis, particularly for onset symptoms other than ocular or sensory-motor characteristics.

Impact of New Orleans Saints Football Games on Internal Medicine Admissions.

Background: Various studies have reported a decrease in emergency department admissions in correlation with major sporting events. However, these studies limit the investigation of selected variables to the 24-hour periods on game days. For our study, we assessed the impact of New Orleans Saints football team games on medical admissions on game days and also on post-game days.Methods: We collected Saints game results from the 2013-2014 to 2019-2020 season and admissions data from 3 local hospitals during the same 7-year period. We compared the average daily census of game days vs non-game days as our control group using a 2-sample t test with unequal variances.Results: The results demonstrate a statistically significant reduction in the average number of internal medicine admissions on game days (19.6%, P=0.0001). This reduction in admissions was not observed on post-game days (5.84%, P>0.05). On post-game days following a Saints victory, we found a statistically significant increase in the average number of admissions compared to when the team lost the previous day (18.2%, P=0.0105).Conclusion: To our knowledge, the relationship between a recurring major sporting event and inpatient internal medicine admissions has not been previously quantified. Our study of the impact of the New Orleans Saints football games on internal medicine admissions provides insights into the relationship between social sporting events and health outcomes in the city. While our results may not be directly generalizable to other locations—particularly those that are not in a National Football League team market—we showed that during a 7-year period, Saints football games correlated with a 19.6% decrease in internal medicine admissions on the day of the game. This finding suggests that Saints games may serve as a protective factor associated with decreased negative health outcomes among residents in the city.

Validation and Comparison of a Modified Elixhauser Index for Predicting In-Hospital Mortality in Italian Internal Medicine Wards.

PurposeBurden of comorbidities appears to be related to clinical outcomes in hospitalized patients. Clinical stratification of admitted patients could be obtained calculating a comorbidity score, which represents the simplest way to identify the severity of patients’ clinical conditions and a practical approach to assess prevalent comorbidities. Our aim was to validate a modified Elixhauser score for predicting in-hospital mortality (IHM) in internal medicine admissions and to compare it with a different one derived from clinical data previously used in a similar setting, having a good prognostic accuracy.Patients and MethodsA single-center retrospective study enrolled all patients admitted to internal medicine department between January and June 2016. A modified Elixhauser score was calculated from chart review and administrative data; moreover, a second prognostic index was calculated from chart review only. Comorbidity scores were compared using c-statistic.ResultsWe analyzed 1614 individuals without selecting the reason for admission, 224 (13.9%) died during hospital stay. Deceased subjects were older (83.3±9.1 vs 78.4±13.5 years; p<0.001) and had higher burden of comorbidities. The modified Elixhauser score calculated by administrative data and by chart review and the comparator one was 18.13±9.36 vs 24.43±11.27 vs 7.63±3.3, respectively, and the c-statistic was 0.758 (95% CI 0.727–0.790), 0.811 (95% CI 0.782–0.840) and 0.740 (95% CI 0.709–0.771), respectively.ConclusionThe new modified Elixhauser score showed a similar performance to a previous clinical prognostic index when it was calculated using administrative data; however, its performance improved if calculation was based on chart review.

Emergency Department Waiting Times and Determinants of Prolonged Length of Stay in a Botswana Referral Hospital

Introduction: Emergency medicine is a critical component of quality public health service. In fact length of stay and waiting times in the Emergency department are key indicators of quality. The aim of this study was to determine waiting times and determinants of prolonged length of stay (LOS) in the Princess Marina Hospital Emergency Department. Methods: This was a retrospective observational study. It was done at Princess Marina, a referral hospital in Gaborone, Botswana. Triage forms of patients who presented between 19/11/ 2018 and 18/12/2018 were reviewed. Data from patient files was used to determine time duration from triage to being reviewed by a doctor, time duration from review by emergency doctor to patients’ disposition and the time duration from patient’s triage to disposition (length of stay). Prolonged length of stay was defined as duration > 6 hours. Results: A total of 1052 files repre- senting patients seen over a 1-month period were reviewed. 72.5% of the patients had a prolonged length of stay. The median emergency doctor waiting time was 4.5 hours (IQR 1.6 - 8.3 hours) and the maximum was 27.1 hours. The median length of stay in the emergency department was 9.6 hours (IQR 5.8 - 14.6 hours) and the maximum was 45.9 hours. Patient’s age (AOR 1.01), mental status (AOR 0.61), admission to internal medicine service (AOR 5.12) and pediatrics admissions (AOR 0.11) were significant predictors of prolonged length of stay in the emergency department. Conclusion: Princess Marina Hospital emergency department waiting times and length of stay are long. Age, normal mental status and internal medicine admission were independent predictors of prolonged stay (>6 hours). Admission to the pediatrics service was associated with shorter length of stay. There is a need for interventions to address the long waiting times and length of stay. Interventions should particularly focus on the identified predictors.

Lack of Association Between Meteorological Factors and Internal Medicine Admissions in New Orleans: Residents Perceptions Differ.

Lack of Association Between Meteorological Factors and Internal Medicine Admissions in New Orleans: Residents Perceptions Differ.

Is the Wireless Monitoring a Technological Innovation Suitable in Internal Medicine Units?

In recent years, the Internal Medicine (IM) Ward has been receiving an increasingly heterogeneous group of patients, many affected by acute or chronic diseases of varying severity, who are often elderly, frail, with co-morbidities, requiring intensive care due to epidemiological transition. Hospitalization of medical patients in large wards without prior stratification of severity, complexity, level of dependence, co-morbidities and without a proper assessment of the risk of rapid clinical deterioration, can lead to suboptimal treatment, resulting in prolonged hospital stay and increased care costs. Continuous monitoring of Emergency Room activity data has shown an increasing trend, regardless of the season, in ER presentation and subsequent hospitalization of patients over 65 years with exacerbation of chronic diseases such as a 1% increase in ER presentations could result in a 10% increase in Internal Medicine admissions, causing overcrowding both ER and IM ward [1].

Characteristics of short general internal medicine hospital stays: a multicentre cross-sectional study.

Short hospital stays may represent opportunities to avert unnecessary admissions or expedite inpatient care. To inform the design of interventions that target patients with potentially avoidable hospital admissions or brief stays, we examined the patient, physician and situational characteristics associated with short stays among patients admitted to general internal medicine wards and describe the use of hospital resources by these patients. This was a multicentre cross-sectional study conducted between Apr. 1, 2012, and Mar. 31, 2015, at 5 teaching hospitals in Toronto. We included all general internal medicine admissions through the emergency department. We examined patient, physician and situational predictors of a short hospital stay, which was defined as the patient's being discharged home alive in 2 possible time windows: less than 24 hours, or 72 hours or less. The final study sample included 56 055 admissions and 37 700 unique patients. Patients discharged in less than 24 hours and in 72 hours or less accounted for 4245 (7.6%) and 13 442 (31.6%) admissions, respectively. After we controlled for patient factors, patients of female physicians were less likely than those of male physicians to have stays lasting less than 24 hours (adjusted odds ratio [OR] 0.80, 95% confidence interval [CI] 0.74-0.86) or 72 hours or less (adjusted OR 0.82, 95% CI 0.79-0.86). Patients admitted at night or on a weekday were significantly more likely than those admitted at other times to have stays lasting less than 24 hours (night: adjusted OR 2.73, 95% CI 2.44-3.06; weekday: adjusted OR 1.26, 95% CI 1.17-1.36) or 72 hours or less (night: adjusted OR 1.29, 95% CI 1.22-1.37, weekday: adjusted OR 1.05, 95% CI 1.01-1.10). Among stays lasting less than 24 hours and 24-72 hours, intravenously administered medications were ordered for 2788 (65.7%) and 10 722 (79.8%) patients, respectively, and computed tomography scans were performed for 1561 (36.8%) and 5354 (39.1%) patients, respectively. Short general internal medicine hospital stays were common and were associated with patient, physician and situational factors. Interventions to avert hospital admission or reduce length of stay may be more effective if they are accessible outside typical working hours and provide access to intravenous therapy and radiological investigations.

Comparative Analysis of Short-Term Outcomes of Patients With Heart Failure With a Mid-Range Ejection Fraction After Acute Decompensation

To determine short-term outcomes after an episode of acute heart failure in patients with mid-range ejection fraction (40%-49%; HFmrEF) compared with patients with reduced (<40%) and preserved (>49%) ejection fractions (HFrEF and HFpEF, respectively) and according to their final destination after emergency department (ED) care. This is an exploratory, secondary analysis of the Epidemiology of Acute Heart Failure in the Emergency departments Registry, which includes consecutive acute heart failure patients diagnosed in 41 Spanish EDs. Patients with echocardiography data were included and divided into HFrEF, HFmrEF, and HFpEF. The primary outcome was 30-day all-cause mortality, and secondary outcomes were in-hospital all-cause mortality, hospital length of stay >10 days, and 30-day postdischarge ED revisit due to AHF and combined end point (ED revisit and/or death). We included 6,856 patients (age 79 [10]; 52.1% women): 21.6% had HFrEF, 14.3% HFmrEF, and 64.1% HFpEF. The main destinations for the 982 HFmrEF patients after ED management were internal medicine (293, 29.8%), cardiology (194, 19.9%) and not hospitalized (241, 24.5%), whereas the remaining 254 patients were admitted to other departments, including geriatric wards, short-stay units and intensive care units. Outcomes for HFmrEF did not differ compared with either HFrEF or HFpEF. Compared with HFmrEF admitted to cardiology, internal medicine admission or direct ED discharge increased the 30-day postdischarge ED revisit (hazard ratio [HR] 1.713, 95% confidence interval [CI] 1.042 to 2.816; and HR 1.683, 95% CI 1.046 to 2.708, respectively) and the 30-day postdischarge combined end point (HR 1.732, 95% CI 1.070 to 2.803; and HR 1.727, 95% CI 1.083 to 2.756, respectively). In conclusion, patients in the newly created HFmrEF category suffering from an acute decompensation have similar short-term outcomes as those in the classical HFrEF and HFpEF categories; nonetheless, HFmrEF patients handled in cardiology wards during decompensation obtain better outcomes, and reasons for these differences have to be unmasked and corrected.

Long-Term Survival of Young Patients Surviving ICU Admission With Severe Sepsis.

Sepsis remains a disease with a high mortality rate. The study goal was to assess long-term survival of severe sepsis in young patients. Retrospective cohort study. Patients admitted with sepsis to ICUs in seven tertiary hospitals between 2003 and 2011. A total of 409 patients less than 45 years who survived to hospital discharge were age and sex matched with 818 patients with infectious disease without sepsis selected from internal medicine or surgical department admissions. None. The median age in sepsis patients and the comparison group was 31 and 32 years, respectively. The proportions of patients surviving after hospital discharge were significantly lower in the sepsis group compared with the control group; among survivors, 6-month, 1-year, and 3-year mortality rates were 0.7% versus 0%, 4.5% versus 0.7%, 7.9% versus 1.2%, and 10.8% versus 1.8%, respectively (p < 0.001 for all). In a multivariate Cox proportional hazards regression model, sepsis was associated with an increased risk of mortality (hazard ratio, 3.79; 95% CI, 2.27-6.32), while controlling for age, Charlson Comorbidity Index, history of stroke, and congestive heart failure. Past the 24-month landmark, sepsis was not found to be an independent risk for mortality (hazard ratio, 1.79; 95% CI, 0.67-4.79). Based on cause of death analysis, chronic underlying comorbidities might explain the excess mortality in patients with sepsis. Young patients experiencing an episode of severe sepsis continue to be at higher risk of long-term mortality. The highest mortality rates were observed during the first 24 months following discharge.

Patient characteristics, resource use and outcomes associated with general internal medicine hospital care: the General Medicine Inpatient Initiative (GEMINI) retrospective cohort study.

The precise scope of hospital care delivered under general internal medicine services remains poorly quantified. The purpose of this study was to describe the demographic characteristics, medical conditions, health outcomes and resource use of patients admitted to general internal medicine at 7 hospital sites in the Greater Toronto Area. This was a retrospective cohort study involving all patients who were admitted to or discharged from general internal medicine at the study sites between Apr. 1, 2010, and Mar. 31, 2015. Clinical data from hospital electronic information systems were linked to administrative data from each hospital. We examined trends in resource use and patient characteristics over the study period. There were 136 208 admissions to general internal medicine involving 88 121 unique patients over the study period. General internal medicine admissions accounted for 38.8% of all admissions from the emergency department and 23.7% of all hospital bed-days. Over the study period, the number of admissions to general internal medicine increased by 32.4%; there was no meaningful change in the median length of stay or cost per hospital stay. The median patient age was 73 (interquartile range [IQR] 57-84) years, and the median number of coexisting conditions was 6 (IQR 3-9). The median acute length of stay was 4.6 (IQR 2.5-8.6) days, and the median total cost per hospital stay was $5850 (IQR $3915-$10 061). Patients received at least 1 computed tomography scan in 52.2% of admissions. The most common primary discharge diagnoses were pneumonia (5.0% of admissions), heart failure (4.7%), chronic obstructive pulmonary disease (4.1%), urinary tract infection (4.0%) and stroke (3.6%). Patients admitted to general internal medicine services represent a large, heterogeneous, resource-intensive and growing population. Understanding and improving general internal medicine care is essential to promote a high-quality, sustainable health care system.

Decrease Hospital Spending: There's an App for That! A Retrospective Analysis of Implementation of a Mobile Resident Handbook on Hospital Costs and Disposition.

Patient care involves time sensitive decisions. Matching a patient's presenting condition with possible diagnoses requires proper assessment and diagnostic tests. Timely access to necessary information leads to improved patient care, better outcomes, and decreased costs. This study evaluated objective outcomes of the implementation of a novel Resident Handbook Application (RHAP) for smart phones. The RHAP included tools necessary to make proper assessments and to order appropriate tests. The RHAPs effectiveness was accessed using the Military Health System Military Mart database. This database includes patient specific aggregate data, including diagnosis, patient demographics, itemized cost, hospital days, and disposition status. Multivariable analysis was used to compare before and after RHAP implementation, controlling for patient demographics and diagnosis. Internal medicine admission data were used as a control group. There was a statistically significant decrease in laboratory costs and a strong trend toward statistically significant decreases in the cost of radiology performed after implementation of RHAP (p value of <0.02 and <0.07, respectively). There was also a decrease in hospital days (3.66-3.30 days), in total cost per admission ($18,866-$16,305), and in cost per hospital day per patient ($5,140-$4,936). During the same time period a Control group had no change or increases in these areas. The use of the RHAP resulted in decreases in costs in a variety of areas and a decrease in hospital bed days without any apparent negative effect upon patient outcomes or disposition status.

A modified Elixhauser score for predicting in-hospital mortality in internal medicine admissions

BackgroundIn-hospital mortality (IHM) is an indicator of the quality of care provided. The two most widely used scores for predicting IHM by International Classification of Diseases (ICD) codes are the Elixhauser (EI) and the Charlson Comorbidity indexes. Our aim was to obtain new measures based on internal medicine ICD codes for the original EI, to detect risk for IHM. Material and methodsThis single-center retrospective study included hospital admissions for any cause in the department of internal medicine between January 1, 2000, and December 31, 2013, recorded in the hospital database. The EI was calculated for evaluation of comorbidity, then we added age, gender and diagnosis of ischemic heart disease. IHM was our outcome. Only predictors positively associated with IHM were taken into consideration and the Sullivan's method was applied in order to modify the parameter estimates of the regression model into an index. ResultsWe analyzed 75,586 admissions (53.4% females) and mean age was 72.7±16.3years. IHM was 7.9% and mean score was 12.1±7.6. The points assigned to each condition ranged from 0 to 16, and the possible range of the score varied between 0 and 89. In our population the score ranged from 0 to 54, and it was higher in the deceased group. Receiver operating characteristic curve of the new score was 0.721 (95% CI 0.714–0.727, p<0.001). ConclusionsIn order to make prognostic assessment, the use of a score could be of help in targeting interventions in older adults, identifying subjects at high risk for IHM.