Long-stay Patients Research Articles

A retrospective study of the incidence and characteristics of long-stay adult inpatients with hospital-acquired malnutrition across five Australian public hospitals.

While malnutrition is prevalent in hospitals, little is known about patients who first become malnourished during the hospital stay. This study aimed to determine the incidence and describe the characteristics of patients who developed hospital-acquired malnutrition (HAM) across five Australian public hospitals. A retrospective clinical audit of hospital data was conducted. Adult patients (aged ≥ 18 years) with a length of stay (LOS) > 14 days in a Metro South Health hospital between July 2015 and January 2019 were eligible. Demographic and clinical data were sourced from hospital data and medical records. Dietitians reviewed the medical records of patients clinically coded with malnutrition to determine HAM incidence. Univariate and logistic regression analyses were used to determine patient descriptors associated with HAM, compared with those not malnourished or those malnourished on admission. A total of 17,717 patients were eligible (45% F, 63 ± 20 years, LOS 24 (15-606) days). HAM incidence in long-stay patients was 1%, with an overall malnutrition prevalence of 18%. Patients with HAM had an ~26 days longer LOS than patients who were malnourished on admission or not malnourished (p < 0.001). Longer LOS; patient inter-hospital transfer from or to another hospital; or experiencing cognitive impairment, pressure injury or a fall while in hospital were associated with HAM (OR 1.006-3.6, p < 0.05). Incidence of HAM, defined as malnutrition first diagnosed >14 days after admission, was in the low end of the published range. HAM was significantly associated with long LOS, transferring between hospitals and developing a cognitive impairment, pressure injury or fall during admission.

Epidemiology of long-stay patients in the pediatric intensive care unit: prevalence, characteristics, resource consumption and complications.

BackgroundThe impact of pediatric intensive care unit (PICU) utilization and resource consumption among long-stay patients has not been characterized recently. This study aimed to describe the resource consumption and characteristics of long-stay patients in a PICU.MethodsThis was a single-center descriptive cohort study of 1309 patients admitted to a PICU in 2017. The main outcome was ICU length of stay (LOS). Patients were divided into prolonged LOS (PLS) and non-PLS groups if they had an LOS of ≥ 28 or < 28 days, respectively. Two groups were compared to characterize PLS.ResultsThirty-two (2.4%) patients had a PLS and utilized 33% of PICU bed days. Factors associated with PLS with odds ratio [95% confidence interval (CI)] were being a neonate (7.8 [2.5–25.4], p = <0.001), being an infant (2.9 [1.0–9.0], p = 0.04), admission for a respiratory ailment (7.3 [1.6–44.2], p = 0.003), cardiovascular dysfunction (24.1 [4.8–152.1], p = <0.001), post-cardiac operation (8.0 [1.7–50.1], p = 0.003), post-cardiopulmonary arrest (22.8 [1.7–211.9], p = 0.01), and transfer from another facility (4.2 [1.8–10.7], p = 0.001). PLS patients developed more nosocomial infections and disproportionately received monitoring and therapeutic resources.ConclusionsA PLS was associated with substantial PICU utilization and complication rates. Future studies should aim to alleviate both institutional and patient-related issues in the affected population harboring possible risk factors for PLS.

Supported Housing as a recovery option for long-stay patients with severe mental illness in a psychiatric hospital in South India: Learning from an innovative de-hospitalization process.

Individuals with severe mental illness have long been segregated from living in communities and participating in socio- cultural life. In recent years, owing to progressive legislations and declarations (in India and globally), there has been a growing movement towards promoting social inclusion and community participation, with emphasis on the need to develop alternative and inclusive care paradigms for persons with severe mental illness. However, transitions from inpatient care to community settings is a complex process involving implications at multiple levels involving diverse stakeholders such as mental health service users, care providers, local communities and policy makers. This article studies how the transition from a hospital setting to a community-based recovery model for personals with severe mental illness can be facilitated. It reflects on the innovative process of creating a Supported Housing model in South India, where 11 MH Service users transitioned from a psychiatric ECRC to independent living facilities. Experiences in various phases of the project development, including care provider- and community level responses and feedback were scrutinised to understand the strategies that were employed in enabling the transition. Qualitative methods (including in-depth interviews and naturalistic observations) were used with residents and staff members to explore the challenges they encountered in stabilizing the model, as well as the psychosocial benefits experienced by residents in the last phase. These were complemented with a Brief Psychiatric Rating Scale (BPRS) and WHO Quality of Life scale to compare baseline and post-assessment results and an increase of quality of life. Results display a significant reduction of psychiatric symptoms in patients (p< 0.5). It also describes the challenges encountered in the current context, and strategies that were used to respond and adapt the model to address these concerns effectively. Positive behavioural and psycho-emotional changes were observed amongst the residents, significant amongst those being enhanced in their mobility and participation. The article concludes by discussing the implications of this study for the development of innovative community-based models in wider contexts.

Changing care pathways and between-center practice variations in intensive care for traumatic brain injury across Europe: a CENTER-TBI analysis

PurposeTo describe ICU stay, selected management aspects, and outcome of Intensive Care Unit (ICU) patients with traumatic brain injury (TBI) in Europe, and to quantify variation across centers.MethodsThis is a prospective observational multicenter study conducted across 18 countries in Europe and Israel. Admission characteristics, clinical data, and outcome were described at patient- and center levels. Between-center variation in the total ICU population was quantified with the median odds ratio (MOR), with correction for case-mix and random variation between centers.ResultsA total of 2138 patients were admitted to the ICU, with median age of 49 years; 36% of which were mild TBI (Glasgow Coma Scale; GCS 13–15). Within, 72 h 636 (30%) were discharged and 128 (6%) died. Early deaths and long-stay patients (> 72 h) had more severe injuries based on the GCS and neuroimaging characteristics, compared with short-stay patients. Long-stay patients received more monitoring and were treated at higher intensity, and experienced worse 6-month outcome compared to short-stay patients. Between-center variations were prominent in the proportion of short-stay patients (MOR = 2.3, p < 0.001), use of intracranial pressure (ICP) monitoring (MOR = 2.5, p < 0.001) and aggressive treatments (MOR = 2.9, p < 0.001); and smaller in 6-month outcome (MOR = 1.2, p = 0.01).ConclusionsHalf of contemporary TBI patients at the ICU have mild to moderate head injury. Substantial between-center variations exist in ICU stay and treatment policies, and less so in outcome. It remains unclear whether admission of short-stay patients represents appropriate prudence or inappropriate use of clinical resources.

Rehabilitation of long-stay patients in state mental hospitals: Role for social welfare sector

Barriers to discharge long-stay patients with mental illness (PWMI) are complex and involve social factors. Recent legislations emphasize community living and creation of facilities by Government for PWMI without social support. The Honorable Supreme Court has dealt with the need for setting up rehabilitation homes for long-stay PWMI who do not require hospitalization. In such cases, nominated representative from social welfare sector needs to be involved in discharge planning. The social welfare sector needs to play a bigger role in the rehabilitation of long-stay PWMI.

Coronavirus disease 2019 pandemic: Ethical concerns for the treatment of individuals with substance use disorders in India.

Sir, The coronavirus disease 2019 (COVID-19) has been declared as a pandemic in March 2020. The contagious nature of the illness and the nonavailability of any specific treatment or vaccines compel the governments to impose preventive measures ranging from quarantine and social distancing to nationwide lockdown.[1] To adapt to this changing scenario, the healthcare system focused on limiting the public gathering, leading to various degrees of suspension of nonemergency services including treatment for substance use disorders (SUDs).[2] This created unforeseen ethical dilemmas. Telemedicine is emerging as an alternative platform for virtual interaction between patients and clinicians. The limited ability to perform a physical examination during teleconsultation may affect the diagnosis of comorbid physical illness and management of the same. This may potentially breach the principle of nonmaleficence. If a patient uses someone else's audiovisual device for teleconsultation, privacy and confidentiality might also be at stake Psychotropics in the Schedule H1 List (Drugs and Cosmetics Act) and Narcotic Drugs and Psychotropic Substances Act cannot be prescribed through teleconsultation. Therefore, medications for opioid agonist treatment, i.e. buprenorphine and methadone fall under this prohibited category. This inadvertently affects the treatment of opioid use disorder.[3] It might be viewed as discrimination against people with SUD. The Substance Uses and Mental Health Services Administration of the United States has temporarily allowed the prescription of controlled substances (including buprenorphine and methadone) through telemedicine, without the need for a face-to-face consultation The lockdown imposed unwarranted restrictions of patients' movement by the suspension of public transport, closure of state borders, and curfew.[2] As, in some cases, patients are unable to come for follow-up, medications are to be dispensed by proxy. This practice complies with the principle of beneficence, but it might result in a breach of confidentiality. One extreme form of such breach happens when a government official acts as a proxy collector of medication for a couple of villages/taluks (it is actually happening). While medications for some chronic noncommunicable diseases (like diabetes mellitus) could efficiently be dispensed this way, but for stigmatized and sometimes criminalized SUDs, this practice might lead to significant harm to patients. To impose stringent lockdown, everyone is routinely checked at several police posts on the way to and from the hospital. This certainly leads to a breach of confidentiality, and among patients with illicit SUD, fear of legal action may limit service utilization The lockdown caused an abrupt cessation of supply of substances, especially of alcohol, resulting in a sudden increase in patients with severe withdrawal symptoms, and possible intoxication with nonconsumable alcohols and suicide attempts.[4] During the third phase of the lockdown, the prohibition on alcohol was lifted, which might have resulted in increased rates of relapse. In spite of the increased treatment need, treatment provisions and opportunities are restricted. This is like an ethical “double whammy,” breach of both nonmaleficence and beneficence Inpatient treatment, too, is largely limited due to restriction of bed availability (e.g., conversion of various healthcare systems into COVID-19 hospitals) and also for the fear of nosocomial transmission of the infection.[2] This restriction interferes with the patients' autonomy to avail of inpatient treatment. At the same time, long-stay patients with dual diagnoses in the residential settings are at a higher risk of developing COVID-19 (due to overcrowding and poorer general health condition).[5] Despite the risk, it is difficult to discharge patients, because of their limited acceptance in the society, whereas there is a risk of the rapid spread of infection in the inpatient setups. The basic tenets of medical ethics are beneficence, nonmaleficence, autonomy, and justice.[6] The Mental Healthcare Act, 2017 revolves around autonomy, which allows the patient's right for confidentiality, the right to choose or refuse a particular treatment modality, and the right to community living. The government must ensure these rights, but the psychiatrist is endowed with the implementation of the rights.[7] In this extraordinary situation of the pandemic, the state is not able to ensure these rights, but the psychiatrists stand at the crossroads. Here, beneficence conflicts with the patient's autonomy and confidentiality. It warrants a rational prioritization from the mental healthcare providers. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Advancing Complex Case Management Competencies in a Health Care System.

The purpose of this literature review is to evaluate evidence to support advanced education for hospital-based nurse case managers to address the discharge needs of medically complex patients who have extended hospital stays. Acute care hospital and hospital systems. Studies on hospital length of stay are prevalent as are studies of effective case management and the importance of a comprehensive education program. Correlating effective case management to successful disposition of long-stay patients and efficacy of discharge planning education is the focus of this review of evidence. Creation of advanced case management competency education will benefit patients, staff, and the health care system by increasing the skill level to promote early recognition of discharge barriers in complex long-stay patients. Continued focus on affordability in health care will keep management of hospital length of stay high on the priority list. Pressure to create efficient patient management strategies leading to timely discharge disposition of medically complex patients through barrier mitigation and intervention requires effective case management tools.

Trends in long-stay admissions to a UK paediatric intensive care unit

ObjectiveProlonged admission to a paediatric intensive care unit (PICU) consumes significant healthcare resource. An increase in the number of long-stay admissions and bed utilisation has been reported elsewhere in the...

Understanding implementation fidelity in a pragmatic randomized clinical trial in the nursing home setting:a mixed-methods examination

BackgroundThe Pragmatic Trial of Video Education in Nursing Homes (PROVEN) is one of the first large pragmatic randomized clinical trials (pRCTs) to be conducted in U.S. nursing homes (N = 119 intervention and N = 241 control across two health-care systems). The trial aims to evaluate the effectiveness of a suite of videos to improve advance care planning (ACP) for nursing home patients. This report uses mixed methods to explore the optimal and suboptimal conditions necessary for implementation fidelity within pRCTs in nursing homes.MethodsPROVEN’s protocol required designated facility champions to offer an ACP video to long-stay patients every 6 months during the 18-month implementation period. Champions completed a video status report, stored within electronic medical records, each time a video was offered. Data from the report were used to derive each facility’s adherence rate (i.e., cumulative video offer). Qualitative interviews held after 15 months with champions were purposively sampled from facilities within the highest and lowest adherence rates (i.e., those in the top and bottom quintiles). Two researchers analyzed interview data thematically using a deductive approach based upon six domains of the revised Conceptual Framework for Implementation Fidelity (CFIF). Matrices were developed to compare coded narratives by domain across facility adherence status.ResultsIn total, 28 interviews involving 33 champions were analyzed. Different patterns were observed across high- versus low-adherence facilities for five CFIF domains. In low-adherence nursing homes, (1) there were limited implementation resources (Context), (2) there was often a perceived negative patient or family responsiveness to the program (Participant Responsiveness), and (3) champions were reticent in offering the videos (Recruitment). In high-adherence nursing homes, (1) there was more perceived patient and family willingness to engage in the program (Participant Responsiveness), (2) champions supplemented the video with ACP conversations (Quality of Delivery), (3) there were strategic approaches to recruitment (Recruitment), and (4) champions appreciated external facilitation (Strategies to Facilitate Implementation).ConclusionsCritical lessons for implementing pRCTs in nursing homes emerged from this report: (1) flexible fidelity is important (i.e., delivering core elements of an intervention while permitting the adaptation of non-core elements), (2) reciprocal facilitation is vital (i.e., early and ongoing stakeholder engagement in research design and, reciprocally, researchers’ and organizational leaders’ ongoing support of the implementation), and (3) organizational and champion readiness should be formally assessed early and throughout implementation to facilitate remediation.Trial registrationClinicalTrials.gov, NCT02612688. Registered on 19 November 2015.

Outcomes of Stenotrophomonas maltophilia hospital-acquired pneumonia in intensive care unit: a nationwide retrospective study

BackgroundThere is little descriptive data on Stenotrophomonas maltophilia hospital-acquired pneumonia (HAP) in critically ill patients. The optimal modalities of antimicrobial therapy remain to be determined. Our objective was to describe the epidemiology and prognostic factors associated with S. maltophilia pneumonia, focusing on antimicrobial therapy.MethodsThis nationwide retrospective study included all patients admitted to 25 French mixed intensive care units between 2012 and 2017 with hospital-acquired S. maltophilia HAP during intensive care unit stay. Primary endpoint was time to in-hospital death. Secondary endpoints included microbiologic effectiveness and antimicrobial therapeutic modalities such as delay to appropriate antimicrobial treatment, mono versus combination therapy, and duration of antimicrobial therapy.ResultsOf the 282 patients included, 84% were intubated at S. maltophilia HAP diagnosis for duration of 11 [5–18] days. The Simplified Acute Physiology Score II was 47 [36–63], and the in-hospital mortality was 49.7%. Underlying chronic pulmonary comorbidities were present in 14.1% of cases. Empirical antimicrobial therapy was considered effective on S. maltophilia according to susceptibility patterns in only 30% of cases. Delay to appropriate antimicrobial treatment had, however, no significant impact on the primary endpoint. Survival analysis did not show any benefit from combination antimicrobial therapy (HR = 1.27, 95%CI [0.88; 1.83], p = 0.20) or prolonged antimicrobial therapy for more than 7 days (HR = 1.06, 95%CI [0.6; 1.86], p = 0.84). No differences were noted in in-hospital death irrespective of an appropriate and timely empiric antimicrobial therapy between mono- versus polymicrobial S. maltophilia HAP (p = 0.273). The duration of ventilation prior to S. maltophilia HAP diagnosis and ICU length of stay were shorter in patients with monomicrobial S. maltophilia HAP (p = 0.031 and p = 0.034 respectively).ConclusionsS. maltophilia HAP occurred in severe, long-stay intensive care patients who mainly required prolonged invasive ventilation. Empirical antimicrobial therapy was barely effective while antimicrobial treatment modalities had no significant impact on hospital survival.Trial registrationclinicaltrials.gov, NCT03506191

Five-year mortality and morbidity impact of prolonged versus brief ICU stay: a propensity score matched cohort study

PurposeLong-term outcomes of critical illness may be affected by duration of critical illness and intensive care. We aimed to investigate differences in mortality and morbidity after short (<8 days) and...

Long-stay patients in pediatric intensive care unit: Diagnostic-specific definition and predictors.

AimsTo stipulate a new definition for long-stay patients (LSPs) in pediatric intensive care unit (PICU). We defined LSPs as the 10% of patients with the longest PICU length-of-stay (LOS) for each age and diagnostic group. To assess whether the thresholds (days of PICU stay) for the definition of LSPs in PICU significantly differ among diagnostic and age categories. To determine whether independent associations exist between patients’ characteristics at admission and LSPs diagnosis in pre-specified diagnostic and age groups.MethodsThis was a multicenter retrospective cohort study including all PICUs in Switzerland. Multivariable regression analysis was used to seek for association between patients’ variables at admission and LSPsResultsWe included 22,284 patients with a median (IQR) age of 12 (1–84) months. Significantly different thresholds across diagnostic and age subgroups are identified. Readmission to PICU, higher PIM2 and NEMS (a score used to quantify nursing workload at intensive care unit level) at admission were associated with higher likelihood of becoming LSPs.ConclusionsOur results showed a significantly different definitions of LSPs for specific diagnoses and age categories. Readmission to PICU and higher acuity at admission are associated with longer PICU length-of-stay in the majority of diagnostic groups. A more personalized definition of LSPs in children based on actual patients’ characteristics should probably be used in an effort to optimize care and reduce costs.

The experience of long-stay patients in a forensic psychiatric hospital in China: a qualitative study

BackgroundLong stay in forensic psychiatric hospitals is common in patients who are defined as “not criminally responsible on account of mental disorder”. However, little is known about how these patients experience and perceive the long stay within these settings. The aim of this study is to explore the perception and needs of long-stay patients in forensic psychiatric hospitals in China.MethodsIn-depth semi-structured interviews were conducted with 21 participants who had lived in the forensic psychiatry hospital for more than 8 years. We used thematic analysis strategies to analyse the qualitative data.ResultsParticipants’ perceptions clustered seven themes: hopelessness, loneliness, worthlessness, low mood, sleep disturbances, lack of freedom, and lack of mental health intervention.ConclusionsThe views and opinions expressed by long-stay patients showed that psychological distress is prevailing in forensic psychiatric hospitals. Adequate and effective care and mental health interventions are recommended to be tailored for their special needs.

Facilitating Aadhaar and Voting for Long-Stay Patients: Experience from a Tertiary Care Center.

Facilitating Aadhaar and Voting for Long-Stay Patients: Experience from a Tertiary Care Center.

Long-stay pediatric patients in Japanese intensive care units: their significant presence and a newly developed, simple predictive score

BackgroundThe length of stay (LOS) in intensive care units (ICUs) has been used as a good indicator not only for resource consumption but also for health outcomes of patients. However, data regarding pediatric LOS in Japanese ICUs are limited. The primary aim of this study was to characterize the Japanese pediatric ICU patients based on their LOS. Second, we aimed to develop a simple scoring system to predict long-stay pediatric ICU patients on admission.MethodsWe performed a retrospective cohort study using consecutive pediatric data (aged < 16 years) registered in the Japanese Registry of Pediatric Acute Care (JaRPAC) from October 2013 to September 2016, which consisted of descriptive and diagnostic information. The factors for long-stay patients (LSPs; LOS > 14 days) were identified using multiple regression analysis, and subsequently, a simple predictive scoring system was developed based on the results. The validity of the score was prospectively tested using data from the JaRPAC registration from October 2016 to September 2017.ResultsOverall, 4107 patients were included. Although LSPs were few (8.0% [n = 330]), they consumed 38.0% of ICU bed days (9750 for LSPs versus 25,659 overall). Mortality was seven times higher in LSPs than in short-stay patients (9.1% versus 1.3%). An 11-variable simple predictive scoring system was constructed, including Pediatric Index of Mortality 2 ≥ 1 (2 points), liver dysfunction (non-post operation) (2 points), post-cardiopulmonary resuscitation (1 point), circulatory disorder (1 point), post-operative management of liver transplantation (1 point), encephalitis/encephalopathy (1 point), myocarditis/cardiomyopathy (1 point), congenital heart disease (non-post operation) (1 point), lung tissue disease (1 point), Pediatric Cerebral Performance Category scores ≥ 2 (1 point), and age < 2 years (1 point). A score of ≥ 3 points yielded an area under the receiver operating characteristic curve (AUC) of 0.79, sensitivity of 87.0%, and specificity of 59.4% in the original dataset. Reproducibility was confirmed with the internal validation dataset (AUC 0.80, sensitivity 92.6%, and specificity 60.2%).ConclusionsPediatric LSPs possess a significant presence in Japanese ICUs with high rates of bed utilization and mortality. The newly developed predictive scoring system may identify pediatric LSPs on admission.

The Effects of Sampling Methods on Machine Learning Models for Predicting Long-term Length of Stay

The ability to predict the patients with long-term length of stay (LOS) can aid a hospital's admission management, maintain effective resource utilization and provide a high quality of inpatient care. Hospital discharge data from the Rhode Island Department of Health from the time period between 2010 to 2013 reveals that inpatients with long-term stays, i.e. two weeks or more, costs about six times more than those with short stays while only accounting for 4.7% of the inpatients. With the imbalance in the distribution of long-stay patients and short-stay patients, predicting long-term LOS patients becomes an imbalanced classification problem. Sampling methods—balancing the data before fitting it to a traditional classification model—offer a simple approach to the problem. In this work, the authors propose a new resampling method called RUBIES which provides superior predictive ability when compared to other commonly used sampling techniques.

A hospital recreation room quality improvement intervention.

Patients with extended hospital admissions had no recreation facilities in the ward. They were often confined to spaces around their beds, using the ward corridor for rehabilitation. The purpose of this paper is to outline a quality improvement (QI) intervention-provision of a recreational space for long-stay patients. An exploratory quantitative pre-, post-test design was utilised, and executed in three phases: patients, visitors and staff survey to explore recreation and comfort needs and preferences; store room refurbishment; and patient, visitor and staff satisfaction with the recreation room. Overall, 77 questionnaires were completed (n=49 staff; n=28 patient/visitor). Almost two-thirds (64.7 per cent; n=11) of patients had a stay greater than six weeks. Insufficient private space and concerns about disturbing other patients were identified as barriers to taking part in activities. Consequently, a store room was refurbished as a recreation room (9.0 m × 6.0 m) and furnished in three distinct areas. Following refurbishment, over 90 per cent (n=24) of respondents agreed that there was a suitable space where patients could "go and chat" and spend time with family and visitors or speak to the healthcare team. The physical environment in acute hospitals is seldom prioritised. Needs-based QI projects can improve patient hospital experiences. This case study highlights how nursing staff can be informed by patients' and families' needs and preferences, and initiate QI projects that improve patient hospital experiences.

OR17-1 Changes in the Hypothalamic-Pituitary-Adrenal Axis during Pediatric Critical Illness

Critical illness in adults is hallmarked by prolonged hypercortisolism and a rapid decrease in ACTH. The high cortisol is explained by reduced cortisol breakdown and a decrease in cortisol binding proteins, rather than by adrenal production. In critically ill children, the evolution of the changes in the HPA axis and underlying mechanisms remain to be studied. Also, the impact hereon of nutritional management is unknown. In the PEPaNIC RCT, accepting low macronutrient intake up to day 8 in the pediatric intensive care unit (PICU) by withholding early supplemental parenteral nutrition (PN) accelerated recovery as compared with initiating supplemental PN early. In this preplanned secondary analysis of the PEPaNIC RCT, we assessed the changes over time in the HPA axis and their prognostic value during critical illness in children and investigated the impact on these changes of withholding early PN. We quantified plasma ACTH, total cortisol, CBG and albumin and calculated free cortisol upon PICU admission, day 3 and last PICU day for 223 short-stay (<3 days) and 309 long-stay patients (≥3 days) who did not receive corticosteroids before sampling, in comparison with 64 matched healthy children. Upon admission, ACTH was elevated in short-stay patients (P=0.02) and comparable with healthy children in long-stay patients (P=0.75), whereas total and free cortisol were elevated in both groups (P<0.0001). In short-stay patients, ACTH became subnormal on the last day (P<0.0001). Also total and free cortisol decreased, but remained higher than in healthy children (P=0.003-0.005). In long-stay patients, ACTH decreased towards day 3 (P<0.0001) and remained low on the last day (P<0.0001), whereas total and free cortisol were normal on day 3 (P=0.37-0.62) and on the last day (P=0.30-0.74). CBG and albumin were low throughout PICU stay in both groups. The rapid decrease in cortisol over time in PICU likely excludes negative feedback by cortisol on pituitary ACTH secretion as cause of the decrease in ACTH. In multivariable analysis, the decrease in ACTH was also not associated with drugs commonly used in PICU, that have been suggested to affect the HPA axis in adults. High total and free cortisol upon admission were associated with 90-day mortality and prolonged length of stay in univariable analysis. This association disappeared when adjusting for baseline risk factors. Withholding early PN did not affect the changes in the HPA axis from admission to day 3 or to last day for short-stay patients. In conclusion, the time course of the changes in the HPA axis during critical illness in children differs from that in adults, with a rapid normalization of cortisol together with a decrease in ACTH over time. Further investigation of the mechanism underlying this ACTH decrease is warranted, since it might be iatrogenic or related to a possibly more immature central secretion during critical illness in children as compared with adults.

Addressing Psychosocial Barriers to Hospital Discharge: A Social Work Led Model of Care

ABSTRACTAustralian hospitals regularly care for patients who cannot be discharged routinely due to complex psychosocial needs that manifest as barriers to discharge. These long-stay or “stranded” patients are at risk of detrimental health outcomes resulting from their extended stay while also potentially delaying admission for those who need acute care. This article discusses a new social work led model of care developed at an Australian metropolitan hospital that targets long-stay patients with psychosocial barriers to discharge. The model of care, overseen by a specialist social worker and assistant, demonstrates how the social work profession can take leadership within the psychosocial realm to improve both organisational and patient outcomes.

Clinical predictors of protracted length of stay in Ontario Complex Continuing Care hospitals

BackgroundPost-acute care hospitals are often subject to patient flow pressures because of their intermediary position along the continuum of care between acute care hospitals and community care or residential long-term care settings. The purpose of this study was to identify patient attributes associated with a prolonged length of stay in Complex Continuing Care hospitals.MethodsUsing information collected using the interRAI Resident Assessment Instrument Minimum Data Set 2.0 (MDS 2.0), a sample of 91,113 episodes of care for patients admitted to Complex Continuing Care hospitals between March 31, 2001 and March 31, 2013 was established. All patients in the sample were either discharged to a residential long-term care facility (e.g., nursing home) or to the community. Long-stay patients for each discharge destination were identified based on a length of stay in the 95th percentile. A series of multivariate logistic regression models predicting long-stay patient status for each discharge destination pathway were fit to characterize the association between demographic factors, residential history, health severity measures, and service utilization on prolonged length of stay in post-acute care.ResultsRisk factors for prolonged length of stay in the adjusted models included functional and cognitive impairment, greater pressure ulcer risk, paralysis, antibiotic resistant and HIV infection need for a feeding tube, dialysis, tracheostomy, ventilator or a respirator, and psychological therapy. Protective factors included advanced age, medical instability, a greater number of recent hospital and emergency department visits, cancer diagnosis, pneumonia, unsteady gait, a desire to return to the community, and a support person who is positive towards discharge. Aggressive behaviour was only a risk factor for patients discharged to residential long-term care facilities. Cancer diagnosis, antibiotic resistant and HIV infection, and pneumonia were only significant factors for patients discharged to the community.ConclusionsThis study identified several patient attributes and process of care variables that are predictors of prolonged length of stay in post-acute care hospitals. This is valuable information for care planners and health system administrators working to improve patient flow in Complex Continuing Care and other post-acute care settings such as skilled nursing and inpatient rehabilitation facilities.