Metropolitan Teaching Hospital Research Articles

Disparities in Access to Care Following Traumatic Digit Amputation.

Background: Care of digit amputations ranges from revision amputation to replantation. Many factors determine the treatment type. We looked at the epidemiology of amputation and factors associated with escalation of care after presenting to the emergency department (ED). We hypothesized that disparities in care following digit amputation exist. Methods: We queried the State ED Databases and State Inpatient Databases of the Healthcare Cost and Utilization Project and developed a cohort using the diagnosis codes for thumb and finger amputation. Escalation of care was defined as patients whose disposition from the ED was referral to a higher level hospital or inpatient admission. Bivariate and multivariable analyses were conducted to identify the characteristics associated with escalation of care. Results: Our cohort included 45 586 patients, of which 37 539 (82.4%) were men; 7130 (15.6%) and 38 456 (84.4%) suffered a thumb or finger amputation, respectively. The mean age was 39.3 ± 20.4 years, and 7487 (16.4%) received escalated care. Female sex (odds ratio [OR] = 0.7) was a negative independent predictor of escalation of care, while high income (OR = 1.1), machinery-related mechanism (OR = 1.8), self-harm (OR = 4.2), thumb amputation (OR = 1.7), Medicaid (OR = 1.3) or Medicare (OR = 1.1) insurance, trauma hospitals (OR = 1.3), and metropolitan teaching hospitals (OR = 1.2) were positive predictors. Conclusions: Male patients who suffered a thumb and/or self-inflicted amputation, are from a higher income zip code, have Medicaid or Medicare insurance, and present to a teaching trauma center are more likely to receive escalated care. This highlights differences in care that can serve as a starting point for work on barriers to access.

Development of a physiotherapy-led bronchoscopy service: a regional hospital perspective.

Extended scope of practice (ESoP) and advanced scope of practice (ASoP) physiotherapy roles have been in place in the UK for over 20 years. However, interest in these types of services appears to be only just evolving within Australia. Although ESoP and/or ASoP cardiorespiratory roles in intensive care units (ICU) may be perceived to be more achievable in large metropolitan teaching hospitals, at least 67% of Australian ICUs provide physiotherapy services. Very little has been published on the practicalities (e.g. training pathways, evidence for use and guidelines) of developing advanced or extended scope cardiorespiratory physiotherapy services within Australian ICUs. This report describes the development and implementation of a physiotherapy-led bronchoscopy service from a regional hospital perspective.

Outcomes of induction of labour in nulliparous women at 38 to 39weeks pregnancy by clinical indication: An observational study.

Knowledge of the outcomes of induction of labour for different indications is sparse. To describe the mode of birth and other outcomes for nulliparous women induced at 38-39weeks gestational age by indication for induction of labour. This was a retrospective observational study in a tertiary referral hospital, and a metropolitan teaching hospital in Sydney. The study population was nulliparous women with induction of labour at 38 or 39 completed weeks of pregnancy and a singleton, cephalic presenting baby planning a vaginal birth, from 2009 to 2016. The indication for induction of labour was classified into 12 groups. Mode of birth and other maternal and perinatal outcomes were described in each group, for women who spontaneously laboured at 38 or 39weeks, and for women who gave birth from 40 completed weeks onward. The main outcome measure was mode of birth. There were 3330 women with induction of labour at 38 or 39weeks gestation. Rates of vaginal birth varied widely, ranging from 54% when the indication for induction was suspected large fetus, to 82% when the indication was suspected fetal compromise, and was 74% overall. Indications for caesarean delivery also varied by indication for induction. Among women giving birth ≥40weeks gestational age, 75% had a vaginal birth. In nulliparous women, rates of vaginal birth following induction of labour at 38 or 39weeks gestation vary widely according to the indication for induction. These data are useful for antenatal counselling.

Abstract 242: Incidence, Predictors, Causes, and Costs for 30-day Readmission After In-Hospital Cardiopulmonary Resuscitation Discharge in United States

Background: Readmissions after in-hospital cardiopulmonary resuscitation (ICPR) are common and contribute to increased health care utilization and costs. This is the first study to estimate the burden and patterns of 30-day readmission after ICPR from Nationwide Readmission Database (NRD). Methods and Results: Patients undergoing ICPR (International Classification of Diseases-Ninth Revision-Clinical Modification codes 99.60 and 99.63) between January and November 2014 from NRD were included. Incidence, predictors, causes, and costs of 30-day readmission were analyzed using discharge weights to obtain national estimates. Among estimated 27278 index admissions survived to hospital discharges after ICPR, 5439 (20.0%) were readmitted within 30 days. Length of stay (LOS) ≧15 days during index hospitalization (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.16-1.42), Medicare or Medicaid insurance (HR, 1.34; 95% CI, 1.19-1.51), heart failure (HR, 1.2; 95% CI, 1.1-1.32), and discharge of metropolitan teaching hospital (HR, 1.19; 95% CI, 1.07-1.33) were independent predictors of 30-day readmission. Among 5439 readmissions, Sepsis (13.7%), heart failure (10.8%), respiratory failure (6.4%), and cardiac dysrhythmias (5.2%) were the most common causes. Estimated total costs of readmission were $102 million and mean of $19122 ±30201, which is accounted for 25.7% of total episode of care (index+readmission). The mean LOS was 8.0 ±10.5 days. The patients with readmission revealed high mortality rate of 10.1%. Conclusions: Thirty-day readmissions after ICPR are frequent and are related to baseline comorbidities and hospital characteristics. Awareness of these predictors can help identify and target high-risk patients for interventions, to reduce readmissions and costs.

Clinical Predictors of High Healthcare Utilization Among Patients With Acute Cholangitis: Analysis From the National Readmission Database

Introduction: Without prompt management, acute cholangitis (AC) can be associated with significant morbidity, high risk of readmissions and economic burden. A subgroup of these patients contributes disproportionately to the amount of healthcare spending. We used national readmission database (NRD) to identify the clinical predictors of high utilizers among AC patients. Methods: We conducted a retrospective cohort study of adult patients admitted with AC from 2010-2014 and Q1-Q3 of 2015 by extracting data from NRD. First admission with a primary diagnosis of acute cholangitis (ICD-9 code: 576.1) was considered as the index admission and any admission after index admission was considered a readmission regardless of the primary diagnosis. A high utilizer was defined as a patient who had >2 readmissions within 90 days (figure-1) and was only defined in patients who were discharged between January and September of each year. The temporal trends in readmission rates and associated characteristics were assessed by linear and polynomial linear regression. Multivariable logistic regression analyses were performed to assess the association between index characteristics and high utilizer rates. Results: From 52,906 index admissions for AC, the overall high utilizer rate is 4.6%. The rate of high utilizers (p=0.73) and inflation adjusted hospital charges (p=0.11) did not change significantly across the study period (table-1). On multivariate analysis (table-2), CCI 4-6 vs CCI 0-3 (OR=1.5; CI: 1.08-2.0), admission to metropolitan teaching vs. non-teaching hospital (OR=1.3; 1.09-1.6) and disposition as home health care vs. routine discharge (OR=1.5; CI: 1.1-1.9) were associated with high healthcare utilization. Patients with morbid obesity (OR=0.52; CI: 0.30-0.90) and those with cholelithiasis/ choledocholithiasis (OR=0.47; CI: 0.37-0.61) were less likely to be high utilizers. Conclusion: About one in twenty patients with AC are high healthcare utilizers. CCI of 4-6, admission to a metropolitan teaching hospital and disposition as home health care were associated with high health care utilization. Further studies are needed to understand the reasons and develop strategies to help reduce the costs and improve outcomes in these subgroup of patients.49_A Figure 1. Number of readmissions for high utilizers49_B Figure 2. Trends in readmission rates and associated characteristics49_C Figure 3. Multivariable Analysis of Factors Associated with High Utilization

Trends in Head Computed Tomography Utilization in Children Presenting to Emergency Departments After Traumatic Head Injury.

Although closed head injuries occur commonly in children, most do not have a clinically important traumatic brain injury (ciTBI) and do not require neuroimaging. We sought to determine whether the utilization of computed tomography of the head (CT-H) in children presenting to an emergency department (ED) with a closed head injury changed after publication of validated clinical prediction rules to identify children at risk of ciTBI by the Pediatric Emergency Care Applied Research Network (PECARN). We used the nationwide ED sample (2008-2013) to examine children visiting an ED after a mild closed head injury. Multiple patient and hospital characteristics were assessed. Of the 4,552,071 children presenting to an ED with a mild closed head injury, 1,181,659 (26.0%) underwent CT-H. Care was most commonly received at metropolitan teaching hospitals (43.5%) and varied markedly by geographic region. Overall, there were no significant changes in the nationwide rates of CT-H utilization in the period immediately after publication of the PECARN prediction rules. However, compared with metropolitan teaching hospitals, CT-H utilization increased significantly for patients treated at nonteaching hospitals and at nonmetropolitan hospitals. There was no overall reduction in CT-H utilization after publication of the 2009 PECARN prediction rules. However, patients treated at metropolitan teaching hospitals were significantly less likely to undergo CT-H after 2009, suggesting some penetration of the PECARN tool in that setting. Further research should study patterns of CT-H utilization in nonteaching hospitals and nonmetropolitan hospitals to assess challenges for adoption of validated pediatric ciTBI prediction rules.

The power of policy: trends in emergency department utilization for emergency contraception, 2006-2014

To describe national trends in emergency department (ED) utilization for emergency contraception (EC) following the 2006 US Food and Drug Administration (FDA) approval of levonorgestrel EC without a prescription and coverage expansion for contraceptive services under the Affordable Care Act (ACA). Retrospective cross-sectional study using a nationally-representative, all-payer database. ED utilization for EC was evaluated using the Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality (AHRQ; Rockville, MD). The database was queried for women aged 15-44 yo who presented to the ED with “encounter for emergency contraception counseling and prescription” listed as their primary ICD-09 diagnosis (V25.03). The primary outcome was the number of annual ED visits made between 2006-2014. Parameters assessed included age, payer status, income quartile, patient urban-rural designation, hospital geographic region and hospital teaching status. We compared data to visits by women in the same age range without an EC diagnosis. Z-tests were performed to assess any significant differences between groups. The estimated number of encounters for EC in the ED decreased significantly during the study period. The steepest decline occurred from 2006 (15,039 visits; 95%CI: 11,270 - 18,902) to 2007 (4,370 visits; 95%CI: 3,523 - 5,217). After 2007, visits decreased steadily, reaching 685 visits in 2014 (95%CI: 488 - 881). Overall, this represented a 95% decrease in visits over time. Annual total ED charges decreased from $6.2M in 2006 to $0.65M in 2014. When compared to all other ED visits by women aged 15-44 yo in 2014, ED visits for EC were more likely to be by women aged 15-19 yo (30.7 % vs 13.3%; p<.001), who lived in the Northeast (53.7% vs 17.7%; p<.001), lived in large metropolitan areas (64.2% vs 48.1%; p=0.010), or presented to metropolitan teaching hospitals (64.0% vs 54.4%; p=0.111). The proportion of visits for EC by patients who lived in zip codes with average incomes in the lowest and second income quartiles was 29.9% (95%CI: 20.7%- 39.2%), and 36.2% (95%CI: 23.4%- 49.0%), respectively in 2014. Trends by payer showed that patients with private insurance or self-pay status experienced steeper declines in ED visit counts compared to patients with Medicaid, with estimated percent changes of -98%, -98% and -83% between 2006-2014 respectively. ED utilization for emergency contraception decreased substantially between 2006-2014, demonstrating the influence of policy on these care seeking patterns. This decrease also led to cost-savings in the ED by reducing utilization. Nonetheless, trends by payer indicate a potential disparity in how women currently access (ED vs other outlets) and can pay for EC. Future policies should ensure that patients seeking care for unintended pregnancy are provided timely and cost-effective care.

Using telephone call rates and nurse-to-patient ratios as measures of resilient performance under high patient flow conditions

Patient admissions, discharges, and transfers are high work demand activities that have been associated with 30-day readmissions and increased patient mortality. Most mitigation strategies target peak demand, but variable demand may be more significant. Self-organizing holarchic open systems (SOHOs) and resilience engineering frameworks may explain system behavior, but a few quantitative studies of resilient organizational performance have been published. We used three measures to explore SOHO and resilience engineering constructs. We collected hourly data over 2 years, from five inter-related units in a cardiovascular disease division of a metropolitan teaching hospital. Our results show that information flows (inbound, outbound, answered, and unanswered telephone calls) representing anticipatory management are related to patient flows (patient admissions discharges and transfers) and nurse-staffing levels (nurse-to-patient ratios). We also found overall system stability despite high patient flow effects in lower level units. Unexpectedly, the time to recovery from high patient flow events lasted up to 7 days. We conclude that constructs proposed by resilience engineering can be quantified using simple measures collated within routine operations. The application of nonlinear statistical analyses can uncover important insights about resilient performance that may assist managers in better preparing for managing and recovering from unexpected variation in patient flow.

Variation in National Readmission Patterns After Burn Injury.

A significant proportion of readmissions occurs at a different hospital than the index admission, and is thus missed by current quality metrics. No study has examined all-hospital adult 30-day readmission rates, including different hospitals, following burn injury across the United States. The purpose of this study was to evaluate nationwide readmission rates, potential risk factors, and ultimately the burden of burn injury readmission, including readmission to a different hospital. The 2010-2014 Nationwide Readmissions Database was queried for patients admitted for burn. Multivariate logistic regression identified risk factors and associated cost for 30-day readmission at index and different hospitals. There were 94,759 patients admitted during the study period, with 7.4% (n = 7000) readmitted and of those, 29.2% (n = 2047) readmitted to a different hospital. The most common reason for readmission was infection (29.4% [n = 1990]). Risk factors for unplanned 30-day readmission to any hospital included burn of lower limbs (odds ratio [OR] 1.29, [1.21-1.37], P < .01), third degree burns (OR 1.31, [1.22-1.41], P < .01), Charlson Comorbidity Index ≥2 (OR 1.48, [1.37-1.60], P < .01), depression (OR 1.30, [1.19-1.41], P < .01), and psychoses (OR 1.53, [1.40-1.67], P < .01). Risk factors unique to readmission to a different hospital included: length of stay greater than 7 days (OR 2.07, [1.78-2.40], P < 0.01), and initial admission to a metropolitan teaching hospital (OR 1.50, [1.26-1.78], P < .01). Previously unreported, one in three burn readmissions nationally occur at a different hospital, have unique risk factors, and are costlier. Current hospital benchmarking underestimates readmission by failing to capture this unique subpopulation.

Delay in reviewing test results prolongs hospital length of stay: a retrospective cohort study

BackgroundFailure in the timely follow-up of test results has been widely documented, contributing to delayed medical care. Yet, the impact of delay in reviewing test results on hospital length of stay (LOS) has not been studied. We examine the relationship between laboratory tests review time and hospital LOS.MethodsA retrospective cohort study of inpatients admitted to a metropolitan teaching hospital in Sydney, Australia, between 2011 and 2012 (n = 5804). Generalized linear models were developed to examine the relationship between hospital LOS and cumulative clinician read time (CRT), defined as the time taken by clinicians to review laboratory test results performed during an inpatient stay after they were reported in the computerized test reporting system. The models were adjusted for patients’ age, sex, and disease severity (measured by the Charlson Comorbidity index), the number of test panels performed, the number of unreviewed tests pre-discharge, and the cumulative laboratory turnaround time (LTAT) of tests performed during an inpatient stay.ResultsCumulative CRT is significantly associated with prolonged LOS, with each day of delay in reviewing test results increasing the likelihood of prolonged LOS by 13.2% (p < 0.0001). Restricting the analysis to tests with abnormal results strengthened the relationship between cumulative CRT and prolonged LOS, with each day of delay in reviewing test results increasing the likelihood of delayed discharge by 33.6% (p < 0.0001). Increasing age, disease severity and total number of tests were also significantly associated with prolonged LOS. Increasing number of unreviewed tests was negatively associated with prolonged LOS.ConclusionsReducing unnecessary hospital LOS has become a critical health policy goal as healthcare costs escalate. Preventing delay in reviewing test results represents an important opportunity to address potentially avoidable hospital stays and unnecessary resource utilization.

Nurses' role in recognising and responding to clinical deterioration in surgical patients.

To explore nurse' role in recognising and responding to deteriorating post-operative patients. Clinical deterioration is a significant problem in acute care settings. Nurses play a vital role in post-operative patient monitoring; however, there is limited understanding of the nurses' role in recognising and responding to clinical deterioration in surgical patients. This qualitative exploratory study was conducted at a metropolitan teaching hospital in Melbourne, Australia. Data were collected through focus groups from 1 September to 31 October 2014. Four focus groups of 2-5 surgical nurses (n=14) were conducted to explore the nurses' perception of their role in managing deterioration over the first 72hr postoperatively. Qualitative data were recorded, transcribed and key themes identified. Nurses demonstrated a high level of awareness of their role in recognising and responding to early signs of deterioration. The themes that arose from the focus group interviews were "struggling with blood pressure," and "we know our patient is sick." The nurses were confident about the clinical indicators of deterioration and the appropriate channels to use to escalate care. Using track and trigger observation charts enabled nurses to identify deteriorating patients prior to the patient fulfilling rapid response system escalation criteria. These findings highlight the importance of a collective team approach to preventing, recognising and responding to clinical deterioration across the whole patient journey. Initiatives to ensure accurate written and verbal communication between medical and nursing staff warrants further assessment. Nurses working in acute surgical wards are highly engaged in the process of recognising and responding to clinical deterioration in post-operative patients. Many nurses reported being able to anticipate deterioration occurring but are required by current organisational frameworks to escalate care to rapid response systems. How nurses anticipate and manage deterioration prior to the patient fulfilling rapid response system criteria warrants further investigation.

TCTAP A-021 Clinical Outcomes of Women Undergoing Percutaneous Coronary Intervention at a Metropolitan Australian Teaching Hospital

Prior studies have suggested that women who undergo percutaneous coronary intervention (PCI) are more likely to experience adverse outcomes than men. We sought to compare the clinical outcomes of women and men undergoing PCI at a large metropolitan teaching hospital in Sydney, Australia. Among 721

Causes of Emergency Department Overcrowding and Blockage of Access to Critical Services in Beijing: A 2-Year Study

BackgroundEmergency department (ED) overcrowding is a serious issue worldwide. ObjectivesThis study was done to evaluate the degree of overcrowding in local “teaching hospitals” in Beijing, and to ascertain the apparent root causes for the pervasive degree of overcrowding in these EDs. MethodsThis is a multicenter cross-sectional study. The studied population included all ED patients from 18 metropolitan teaching hospital EDs in Beijing for calendar years 2013 and 2014. Patient characteristics, and the primary reasons that these patients sought care in these EDs, are described. ResultsThe total numbers of annual emergency visits were 1,554,387 and 1,615,571 in 2013 and 2014, respectively. High acuity cases accounted for 4.6% and 5.5% of the total annual emergency visits in 2013 and 2014, respectively. The percentage of patients placed into “Observation” beds, which were created to accommodate patients deemed to have problems too complex to be treated in an inpatient bed, or to accommodate patients simply needing chronic care, was 11.9% and 13.1% in 2013 and 2014, respectively. The ED-boarded patients accounted for 2.71% and 2.6% of the total annual emergency visits in 2013 and 2014, respectively. The average waiting time to admit the ED-boarded patients was 37.1 h and 36.2 h in 2013 and 2014, respectively. Respiratory symptoms were the most common presenting complaints, and an upper respiratory infection was the most common ED diagnosis. Patients who had pneumonia or various manifestations of end-stage diseases, such as advanced dementia or multiple organ dysfunction, were the most common characteristics of patients who had stays in “Observation” units. ConclusionsOne principal reason for ED crowding in Beijing lies in the large numbers of patients who persist in the expectation of receiving ongoing care in the ED for minor illnesses. However, as is true in many nations, one of the other most important root causes of ED crowding is “access block,” the inability to promptly move patients deemed by emergency physicians to need inpatient care to an inpatient bed for that care. However, in our system, another challenge, not widely described as a contributor to crowding in other nations, is that doctors assigned to inpatient services have been empowered to refuse to admit patients perceived to have overly “complex” needs. Further, patients with multisystem illnesses or end-stage status, who need ongoing chronic care to manage activities of daily living, have begun to populate Beijing EDs in increasing numbers. This is an issue with various root causes.

Risk of 12-month mortality among hospital inpatients using the surprise question and SPICT criteria: a prospective study

ObjectivesPeople with serious life-limiting disease benefit from advance care planning, but require active identification. This study applied the Gold Standards Framework Proactive Identification Guidance (GSF-PIG) to a general hospital population...

Reliability of Patient-Led Screening with the Malnutrition Screening Tool: Agreement between Patient and Health Care Professional Scores in the Cancer Care Ambulatory Setting

BackgroundThe prevalence of malnutrition in patients with cancer is reported as high as 60% to 80%, and malnutrition is associated with lower survival, reduced response to treatment, and poorer functional status. The Malnutrition Screening Tool (MST) is a validated tool when administered by health care professionals; however, it has not been evaluated for patient-led screening. ObjectivesThis study aims to assess the reliability of patient-led MST screening through assessment of inter-rater reliability between patient-led and dietitian-researcher–led screening and intra-rater reliability between an initial and a repeat patient screening. Design/participantsThis cross-sectional study included 208 adults attending ambulatory cancer care services in a metropolitan teaching hospital in Queensland, Australia, in October 2016 (n=160 inter-rater reliability; n=48 intra-rater reliability measured in a separate sample). Main outcome measurementsPrimary outcome measures were MST risk categories (MST 0-1: not at risk, MST ≥2: at risk) as determined by screening completed by patients and a dietitian-researcher, patient test–retest screening, and patient acceptability. Statistical analysisPercent and chance-corrected agreement (Cohen’s kappa coefficient, κ) were used to determine agreement between patient-MST and dietitian-MST (inter-rater reliability) and MST completed by patient on admission to unit (patient-MSTA) and MST completed by patient 1 to 3 hours after completion of initial MST (patient-MSTB) (intra-rater reliability). ResultsHigh inter-rater reliability and intra-rater reliability were observed. Agreement between patient-MST and dietitian-MST was 96%, with “almost perfect” chance-adjusted agreement (κ=0.92, 95% CI 0.84 to 0.97). Agreement between repeated patient-MSTA and patient-MSTB was 94%, with “almost perfect” chance-adjusted agreement (κ=0.88, 95% CI 0.71 to 1.00). Based on dietitian-MST, 33% (n=53) of patients were identified as being at risk for malnutrition, and 40% of these reported not seeing a dietitian. Of 156 patients who provided feedback, almost all reported that the MST was clear (92%), questions were easy to understand (95%), and completion time was ≤5 minutes (99%). ConclusionPatient-led screening with the MST is reliable and well accepted by patients. Patient-led screening in the cancer care ambulatory setting has the potential to improve patient autonomy and screening completion rates.

Improving hospital environmental hygiene with the use of a targeted multi-modal bundle strategy.

Improving hospital environmental hygiene can reduce environmental contamination and cross-transmission risk, a precursor to healthcare associated infections (HAI). With poor cleaning practice a demonstrated problem, the process of converting evidence into practice requires investigation. The aim of this study was to assess the effectiveness of an environmental hygiene bundle in terms of changes to HAI rates, cleaning performance and environmental services workers (ESW) knowledge and attitudes. A multi-modal bundle was designed and implemented with ESW in eight wards, in a 400-bed metropolitan teaching hospital, using a prospective, before-and-after study design. This consisted of a three-month pre-intervention phase and six-month intervention phase. This research used an implementation science framework to guide the transition from evidence into practice, with data collected in the pre-intervention phase synthesised to design the implementation strategy. There was no statistically significant change in infection rates in the six-month period. Significant improvements in cleaning performance were observed, with the average proportion of ultraviolet markers removed during cleaning across the wards increasing from 61.1% to 95.4%. Results also demonstrate improvements to both the knowledge and attitudes of ESW. By combining infection prevention and implementation science, this bundle was an effective way to engage environmental services staff and improve hospital cleaning.

Antihypertensive-related adverse drug reactions among older hospitalized adults.

Background Antihypertensive medications are commonly used for a wide range of indications, yet it is unknown to what extent older adults are at risk of adverse drug reactions (ADRs) associated with their antihypertensive medication use. Objective The aim of this study was to determine the prevalence and characteristics of antihypertensive-related ADRs on hospital admission. Setting Metropolitan teaching hospital in Sydney, Australia. Method A retrospective cross-sectional audit of 503 older patients (≥65years) admitted to hospital was conducted. Potential ADRS were identified from the medical record. Two independent clinical pharmacists reviewed each potential ADR using validated tools for causality, severity, preventability and contribution to hospitalization. Characteristics associated with an increased ADR risk among antihypertensive users were identified via logistic regression. Main outcome measure Antihypertensive related ADRs. Results Antihypertensives were used on admission by 68% of the cohort and the prevalence of 'definite/probable' antihypertensive-related ADRs among antihypertensive users was 16.4%. Antihypertensive medications were associated with a threefold ADR risk (OR=3.09, 95% CI 1.85-5.16). Angiotensin II Receptor Blockers (ARB), impaired renal function, recent medication changes and previous history of allergy or ADR were all associated with an increased risk of experiencing an ADR. Conclusions ADRS associated with antihypertensive medicines were relatively common among older adults admitted to hospital. Increased awareness of those older persons who are most at risk of experiencing an antihypertensive-related ADR in the clinical setting may lead to early detection and minimization of ADR associated harms.

Septic Arthritis in Emergency Departments in the US: A National Study of Health Care Utilization and Time Trends.

To assess the health care utilization and emergency department (ED) charges for septic arthritis. We performed a retrospective cohort study of ED visits with septic arthritis as the primary diagnosis using the US Nationwide Emergency Department Sample data from 2009-2012. We examined ED charges, hospitalization, and associated time trends. Multivariable models were adjusted for demographics (age, sex, insurance status, residence, and household income), comorbidity, and hospital characteristics to assess factors associated with ED charges and hospitalization. Septic arthritis was responsible for 16,382 ED visits in 2012 in the US, which constituted 0.01% of all ED visits. The number of ED visits was stable from 2009-2012. Total ED charges were $34.6, $30.6, and $36.9 million in 2009, 2010, and 2012, respectively, and mean ED charges were $2,149, $1,866, and $2,257, respectively. The majority of the patients with an ED visit for septic arthritis were hospitalized: 82%, 83%, and 84% in 2009, 2010, and 2012, respectively. Metropolitan residence and western US location were associated with higher ED charges, and the highest income quartile, renal failure, or osteoarthritis were associated with lower ED charges. Female sex, metropolitan residence, metropolitan teaching hospital status, and medical comorbidity (diabetes mellitus, hyperlipidemia, hypertension, chronic obstructive pulmonary disease, coronary heart disease, gout, osteoarthritis, renal failure, and heart failure) were associated with a higher risk of hospitalization. Comorbidities were associated with a higher risk of hospitalization after an ED visit for septic arthritis, but not higher ED charges. No time trends in ED visit incidence, ED charges, or hospitalization rate for septic arthritis from 2009-2012 were noted.

Clinical Outcomes of Women Undergoing Percutaneous Coronary Intervention at a Metropolitan Teaching Hospital

Clinical Outcomes of Women Undergoing Percutaneous Coronary Intervention at a Metropolitan Teaching Hospital

Non-Exenteration Management of Sino-Orbital Fungal Disease.

To describe the non-exenteration management of sino-orbital fungal infection, a life-threatening condition for which orbital exenteration is generally considered a first-line treatment. A retrospective case series is presented of 7 orbits in 6 consecutive patients admitted and treated at 2 major metropolitan tertiary teaching hospitals in Sydney, New South Wales, Australia. Seven orbits in 6 consecutive patients with sino-orbital fungal infection were treated conservatively with surgical debridement and intravenous antifungal agents. Four patients were immunosuppressed and the other 2 patients were otherwise healthy. All presented with pain, proptosis, or loss of vision. Causative organisms found were Mucormycoses, Aspergillus, and Scedosporium prolificans. Exenteration was avoided in all patients as part of their planned management and 5 patients, including 1 with bilateral disease, survived their disease without exenteration. Medical treatment included intravenous liposomal amphotericin B or voriconazole. A single immunosuppressed patient deteriorated and as a last resort, exenteration was performed, but this made no difference to his clinical course and in retrospect could have been avoided as he died of multiple cerebral metastases diagnosed shortly after his deterioration. The authors recommend that patients with sino-orbital fungal disease preferably be treated conservatively, without orbital exenteration.