Multiple Hospital Admissions Research Articles

Acute care utilisation towards the end of life and the place of death for patients with serious mental disorders: a register-based cohort study in South London

ObjectivesThe aim of the study was to explore acute care utilisation towards end of life by and the place of death for patients with serious mental disorders and to demonstrate any inequalities in end-of-life care faced by this patient group. Study designThis is a retrospective cohort study using linked, routinely collected data. MethodsThis study used linked data extracted from mental health records, Hospital Episode Statistics and mortality data. Adult cases (≥18 years old) were included if they had a serious mental disorder and died between 2007 and 2015. Multiple imputation was used to manage missing data, and generalised linear models were used to assess multiple adjusted associations between sociodemographic and clinical explanatory variables and acute service use at the end of life and in-hospital deaths. ResultsA cohort of 1350 adults was analysed. More than half visited the accident and emergency (A&E) department in the last 90 days of life, and a third had a burdensome transition (multiple hospital admissions in the last 90 days of life or at least one in the last three days); the median number of days spent in the hospital was 4 (range: 0–86). Having more comorbidities was a strong correlate of more A&E visits (adjusted odds ratio [OR] = 1.03 [95% confidence interval = 1.02–1.04]), burdensome transitions (adjusted OR = 1.06 [1.04–1.08]) and days spent in the hospital (adjusted OR = 1.04 [1.03–1.05]). Having a diagnosis of schizophrenia spectrum disorder, compared with other serious mental disorder diagnoses, was associated with fewer A&E visits (adjusted OR = 0.78 [0.71–0.88]) and fewer days in the hospital (adjusted OR = 0.77 [0.66–0.89]). Younger age was associated with more A&E visits (adjusted OR = 1.28 [1.07–1.53]) and fewer days spent in the hospital (adjusted OR = 0.70 [0.52–0.95]). Hospital deaths were high (51%), and in a fully adjusted model, they were associated with having more comorbidities (adjusted OR = 1.02 [1.01–1.03]) and accessing acute care at the end of life (including more A&E visits; adjusted OR = 1.07 [1.05–1.10]), burdensome transitions (adjusted OR = 1.53 [1.37–1.71]) and days spent in the hospital (adjusted OR = 2.05 [1.70–247]). ConclusionPeople with comorbidities are more likely to use more burdensome acute health care at the end of life and are more likely to die in the hospital. Hospital deaths could be reduced, and end-of-life care could be improved by targeting patients with comorbidities and who are accessing more acute healthcare services.

P0366 / #1043: A POPULATION-BASED STUDY OF INFANTS AND CHILDREN ADMITTED TO INTENSIVE CARE IN AUSTRALIA

Aims & Objectives: The aim of this study was to examine rates, trends and characteristics of admissions and readmissions of children (age 28 days up to 16 years) admitted to intensive care (IC) in New South Wales (NSW), Australia. Methods: Data were sourced from the state-wide NSW Admitted Patients Data Collection and the state death registry for the years 2003-2013. These datasets were linked using probabilistic longitudinal linkage providing follow-up through multiple hospital admissions and/or death. Results: There were 21,200 IC admissions of 17,130 children with the majority (87.4%) admitted to a dedicated PICU. Annual incidence of IC admissions increased from 130.2 per 100,000 children in 2003 to 161.5 in 2013 (p<0.01). Overall, 3.2% of children died (555 during index admission, 332 late deaths). There were 3,882 (22.7%) readmissions to hospital within 28 days, 542 required IC and 67% of readmissions were classified as emergency admissions. Factors associated with readmission within 28 days were age <4 years, length of hospital stay ≥14 days and genitourinary, haematological or malignant conditions. Over half of children (n=10,104, 59.0%) were readmitted to hospital at some time after the index admission with 2,414 (14%) requiring ≥2 IC admissions. Conclusions: Identifying children at-risk of readmission to IC will ensure more targeted care and support to the youngest, most vulnerable children. This may inform strategies to reduce mortality and improve health following discharge.

Sidebar: North Carolina's Process for Developing Our COVID-19 Vaccine Plan.

### Background There are no national standards about the timing of initiating ACP discussions. It is suggested that ACP may be initiated following the diagnosis of a life-limiting condition, with a change in treatment focus, or following multiple hospital admissions. It was unknown how many patients dying at a specialist cancer centre had been involved in ACP prior to death, and at what stage in their illness this was commenced. ### Methods This was a baseline retrospective audit. The population sampled was all inpatient adult deaths over a two-month period in 2019 in a specialist cancer centre. Medical records and Co-ordinate My Care records (Electronic urgent care plan) were reviewed from six months prior to patient death for evidence and timing of ACP discussions. We anticipated that 70% of patients sampled would have ACP prior to death. ### Results There were 36 inpatient adult deaths. 89% of these patients had non-curative disease. 63% patients were involved in a DNAR discussion. Of these patients, 22% had a DNAR discussion prior to their final admission versus 78% who had a DNAR discussion during their final admission. 44% patients had a discussion about preferred place of care (PPC) and/or death (PPD). Of these patients, only 31% had these discussions prior to final admission compared to 69% who had these discussions during their final admission. ### Conclusions The most common form of ACP was a DNAR discussion, followed by PPC/PPD. The vast majority of ACP discussions occurred in the final inpatient admission as opposed to during outpatient clinics or previous hospital admissions. There is concern that by the time these conversations were being initiated, patients' options about future care and wishes were already restricted and had less chance of being achieved. This baseline audit will inform an education programme to encourage earlier and broader ACP discussions.

Trauma Recidivism in an Aging Population: Who Is Most at Risk?

Repeated episodes of trauma, particularly in older adults, result in increased morbidity and mortality. This study investigates trauma recidivism in our adult population to identify which patients in our region are more likely to become recidivists. This 4 year retrospective study (2013 to 2017) examines all patients 18 years of age or older with multiple hospital admissions for trauma, comparing patients ages 65 and older (older adults) to those ages 18 to 64 (younger adults). Exclusion criteria consisted of those younger than 18 and/or had a home zip code outside of the study region. Data included admission demographics, injury characteristics and other clinical metrics. There were 240 younger adult and 182 older adult trauma recidivists included. In total, 4% of all patients were recidivists with significantly higher rates of recidivism among older adults (OR: 1.94 [1.59-2.36], p <0.001). Older adult recidivists were more likely to be female (OR: 4.28 [2.82-6.51], p <0.001) and suffer blunt trauma secondary to a fall (OR: 5.36 [3.91-7.35], p <0.001). Trauma recidivism in older adults also correlated with a higher Injury Severity Score, longer length of stay and an increased proportion of patients requiring to be discharged home with organizational help or to a rehabilitation facility. Trauma can be recurrent and associated with poor health outcomes, particularly in older adults. Recidivists in the studied region were significantly older with the most at-risk population consisting of females suffering blunt injury secondary to a fall. Improved prevention strategies are needed for this population.

Drug-related bradycardia precipitating hospital admission in older adults: an ongoing problem

BackgroundDrug-related bradycardia (DRB) is a common clinical conundrum and can result in multiple hospital admissions as a result of the increased prescription of rate-limiting medications that can predispose to presyncopal...

Personalizing heart failure management in chronic kidney disease patients.

Chronic kidney disease (CKD) in heart failure (HF) patients is common, present in 49%, and is associated with a higher mortality hazard ratio [2.34 (95% confidence interval 2.20-2.50); P &lt; 0.001] and multiple hospital admissions. The management of HF in CKD can be challenging due to drug-induced electrolyte and creatinine changes, resistance to diuretics and infections related to device therapy. Evidence for improvement in mortality and HF hospitalizations exists in HF with reduced ejection fraction (HFrEF) in Stage 3 CKD patients from randomized controlled trials of angiotensin-converting enzyme inhibitor (ACEi) and mineralocorticoid receptor antagonist therapy but not in dialysis patients, where higher doses can cause hyperkalaemia. Evidence of improvement in cardiovascular death and HF hospitalizations has emerged with the angiotensin receptor neprilysin inhibitor ivabradine and more recently with sodium-glucose cotransporter inhibitors in HFrEF patients with CKD Stages 1-3. However, these studies have excluded CKD Stages 4 and 5 patients. Evidence for β-blocker therapy exists in CKD Stages 1-3 and separately in haemodialysis patients. Cardiac resynchronization therapy reduces HF hospitalizations and mortality in patients with CKD Stages 1-3 but has not been shown to do so in CKD Stages 4 and 5 or dialysis patients. Internal cardioverter and defibrillator therapy in HFrEF patients has been shown to be beneficial in CKD 3 patients but not in dialysis patients, where it is associated with high rates of infection. For HFpEF patients with CKD, therapy is symptomatic, as there is no proven therapy for improvement in survival or hospitalizations. HF patients with end-stage kidney disease with fluid overload may benefit from peritoneal dialysis. A multidisciplinary, personalized approach has been associated with better care and improved patient satisfaction.

Hemosuccus Pancreaticus: A systematic approach.

Hemosuccus pancreaticus is considered as one of the rare cause of upper gastrointestinal bleeding. Intermittent nature of bleeding and lack of standardized approach for diagnosis has resulted in significant delay in definitive management. We retrospectively analyzed prospectively maintained data of patients with suspected hemosuccus pancreaticus between January 2010 and December 2019. Out of 114 patients, 87 patients were diagnosed with hemosuccus pancreaticus. Mean age was 35.7±11.7years with 89.7% men. Median duration of bleeding before diagnosis was 10days, with 40.2%, 10.3%, and 5.7% patients had symptoms beyond 1, 6, and 12months, respectively. Visceral artery aneurysm was noted in 62% of cases with splenic artery aneurysm (37.9%) being the common source of bleed. Rarer causes noted were superior mesenteric artery aneurysm, pancreatic adenocarcinoma, gastrointestinal stromal tumor, and post-endoscopic retrograde cholangiopancreatography (2.3% each). Santorinirrhage was seen in 3.4% patients. Endoscopic diagnosis was possible in 64.4% of patients, and angiogram localization of bleeding source was noted in 94.2%. A 56.3% of patients underwent conventional angioembolization with 95.9% success and 28.7% underwent surgery, with overall rebleeding rate of 11.5%. Early diagnosis of hemosuccus pancreaticus avoids prolonged suffering, multiple hospital admissions, and multiple blood transfusions. It is not uncommon in the absence of aneurysm. In cases of high suspicion, repeating the endoscopy with proper technique and proper timing increases the yield. Angioembolization remains the most preferred first line therapeutic approach in majority of cases.

An early experience on the effect of solid organ transplant status on hospitalized COVID-19 patients.

We compared the outcome of COVID-19 in immunosuppressed solid organ transplant (SOT) patients to a transplant naïve population. In total, 10356 adult hospital admissions for COVID-19 from March 1, 2020 to April 27, 2020 were analyzed. Data were collected on demographics, baseline clinical conditions, medications, immunosuppression, and COVID-19 course. Primary outcome was combined death or mechanical ventilation. We assessed the association between primary outcome and prognostic variables using bivariate and multivariate regression models. We also compared the primary endpoint in SOT patients to an age, gender, and comorbidity-matched control group. Bivariate analysis found transplant status, age, gender, race/ethnicity, body mass index, diabetes, hypertension, cardiovascular disease, COPD, and GFR <60mL/min/1.73m2 to be significant predictors of combined death or mechanical ventilation. After multivariate logistic regression analysis, SOT status had a trend toward significance (odds ratio [OR] 1.29; 95% CI 0.99-1.69, p=.06). Compared to an age, gender, and comorbidity-matched control group, SOT patients had a higher combined risk of death or mechanical ventilation (OR 1.34; 95% CI 1.03-1.74, p=.027).

Diagnosing Urothelial Carcinoma from Delirium: A Near Miss

Urinary tract infection (UTI) is a common cause of delirium in the elderly. Although diagnosis of delirium secondary to UTI is relatively straightforward, a lack of thorough investigation could result in missing underlying factors and medical conditions that may require immediate clinical/surgical intervention. Case of a 77-year-old male with delirium diagnosis and multiple psychiatric hospital admissions is reported here. This patient with multiple medical disorders and anxiety was admitted to psychiatric facilities on three different occasions with multiple psychiatric diagnoses including delirium. After a month of hospital stay and thorough medical and radiological examinations, the cause of refractory delirium was identified as multifactorial including urothelial carcinoma. Although UTI and urinary retention are common in the elderly, this case shows the importance of multifactorial diagnoses in cases of prolonged or refractory delirium to avoid delays in appropriate treatment.

Prevalence and Antibiotics Resistance of Staphylococcus Aureus Among Hiv/Aids Patients on Highly Active Antiretroviral Therapy in Ekiti State

This study was carried out to determine the prevalence and antibiotics resistance of Staphylococcus aureus among HIV/AIDS patients on highly active antiretroviral therapy in Ekiti State, Nigeria. A total of 200 blood samples were collected from Federal teaching Hospital, Ido-Ekiti and University Teaching Hospital Ado-Ekiti. The blood samples were examined for bacteria using cultural and biochemical characteristics. Antibiogram was carried out by disc diffusion method. CD4+ T-cell count was done using flow cytometry method. The Socio-demographic data of the patients were obtained through questionnaire. A total of 26 Staphylococcus aureus were isolated from HIV/AIDS patients with overall prevalence rate of 13.0% which is statistically significant (p value 0.02). Results showed that female subjects 15(7.5%) with HIV/AIDS were more susceptible to S. aureus associated bacteraemia than males 11(5.5%). Age group 41-50 years were the most infected with S. aureus with median age of 35 years (p value 0.607, X2= 0.26, df=1) which is not statistically significant. The CD4+ T-cell of the HIV/AIDS patients with S. aureus were within the range of 20 to 400 cells/µl. However, low CD4-T cell and multiple previous hospital admission were the identified risk factors with 100% and 88.5% occurrence rate respectively. The bacterial isolates were tested for resistance to eight antibiotics commonly prescribed in hospitals. The resistance to the antibiotics ranged between 42.3% to 80.8% with ciprofloxacin having less resistance. This study strongly suggests that the isolation of the S. aureus from HIV/AIDS patients might be because it takes advantage of the weaken immune system provided by deficiency in β-cell and dysfunctional macrophage in HIV/AIDS patients

Distúrbios da deglutição e disfagia na infância

The role of the medical team in the evaluation of children with dysphagia goes way beyond the prescription of medical and nonmedical treatment and the evaluation of the possibility of oral feeding. Swallowing disorders in children may compromise growth and development with significant compromise to the child’s general health, sometimes leading to multiple hospital admissions and diagnostic exams that expose the child to unnecessary risks, when ordered outside the context of a multidisciplinary approach. Most times dysphagia is multifactorial. Several pathologies a part from neurologic impairments may be involved as the main cause or a co-factor for swallowing disorders. Treatment may be medical, surgical or both, and some interventions may be needed even during follow-up due to consequences of long-term dysphagia. Specialists central to all multidisciplinary programs are: the otolaryngologist, the pneumologist, the gastroenterologist and the speech and language pathologist to ensure that evaluation of structural and functional aspects of the respiratory and digestive systems and its repercussions on the child’s general health have been encountered and will be continuously accounted for. This letter hopes to bringing attention to the need of a detailed and specialized medical evaluation of these children before and continuously during diagnosis and rehabilitation of these children.

Ralstonia pickettii bacteremia: An emerging infection in a Tertiary care hospital setting

Background: Ralstonia species are Gram-negative bacilli that have increasingly been recognized as emerging nosocomial pathogens particularly in immunocompromised hosts. Ralstonia pickettii is the most clinically important pathogen from the Ralstonia genus. Nosocomial outbreaks of Ralstonia pickettii infections brought about by use of contaminated medical solutions including saline, sterile water as well as disinfectants have been reported. There have been case reports of invasive infections with variable presentations. Here we describe three cases of Ralstonia pickettii bacteremia during a period of one year in a tertiary care hospital in Karachi, Pakistan. Case description: Case1: A 76 year old male known case of Type 2 Diabetes Mellitus, Hypertension and Amyotrophic lateral sclerosis presented with complaints of burning micturition, hematuria and fever. Patient had history of multiple hospital admissions in the recent past. His blood culture was found to be positive for Ralstonia pickettii. CT KUB was suggestive of pyelonephritis. Patient improved on intravenous Meropenem. Case 2: A 47 year old gentleman with no prior co-morbids was admitted with gunshot injury to the neck resulting in complete cervical cord resection and mild hydrocephalus with intraventricular haemorrhage. Patient had a prolonged ICU stay which was complicated by ventilator associated pneumonia with Acinetobacter and central line associated bloodstream infection with Ralstonia pickettii. He was treated with Meropenem and colistin but continued to deteriorate and expired. Case 3: 46 year old lady, known case of end stage renal disease, admitted with prosthetic valve endocarditis, had prolonged hospital stay complicated by central line associated blood stream infection with Ralstonia pickettii, improved on Meropenem but later died due to fungemia. Discussion: Ralstonia pickettii is an emerging gram-negative opportunistic pathogen. Ralstonia pickettii has been rarely known to cause severe invasive infections, including pneumonia, endocarditis, osteomyelitis, meningitis, and septic arthritis. It is a waterborne organism of low virulence, with a propensity to cause severe infections in the immunocompromised. Among our cases, two of the patients had chronic debilitating illnesses, which could have predisposed them to infection with this organism. Conclusion: Ralstonia pickettii is an emerging cause of nosocomial infection in patients particularly those with prolonged hospital stay and can cause invasive and severe infections.

Hereditary Hemorrhagic Telangiectasia or Osler-Weber -Rendu Syndrome: Management of Epistaxis in 4 Cases

Hereditary Hemorrhagic Telangiectasia, also known as Osler-Weber-Rendu Syndrome is an autosomal dominant disorder causing systemic abnormalities of the vascular structure. There are multiple arteriovenous malformations present in the skin and mucosal surface of the nail beds, nose, gastrointestinal tract, lungs and brain. Epistaxis is the common presentation symptom, which may require multiple hospital admissions and blood transfusions. It is extremely rare disease in our population. We report 4 cases of HHT who presented to us with moderate to severe epistaxis and how we managed these patients.

Brain Damage in COVID-19. Case Reports and Summary of Data in Literature

Abstract SARS-CoV-2 (severe acute respiratory syndrome), rapidly escalated to a pandemic and has a significant impact on the quality of human life and activity, affecting millions of people. The presentation resumes data regarding the neurological impairment of patients affected by COVID-19; although the data was observational and limited, this examination would help us to broaden our understanding on the association between COVID-19 and the stroke. In order to support such observations I will present two cases of patients diagnosed with COVID-19 that have shown neurological damage, but with different altogether outcomes. The first case analysed, the age and comorbidities of the patient determined an unfavourable evolution, partly also due to tardiness in getting admitted. The apparition of the stroke after the serological negative bias SARS-CoV-2 denotes the complications recently emerged after the severe infection with COV-2, therefore while the viral infection remitted, the physical and pathological tumult determined the emergence of complications with unfavourable evolution. Although similar in certain ways to the first case, the second patient that also presented multiple unfavourable factors, such as old age, severe comorbidities and beyond that - multiple hospital admissions, recent neurosurgical intervention- clinical, immune-serum and biological evolutions have been favourable. Cerebrovascular events are somewhat common findings in COVID-19 infected patients and they could bare a multifactorial etiology. In order to better understand the impact of cerebrovascular events in COVID-19 infection, more precise and prospective data are needed.

Eosinopenia as predictor of infection in patients admitted to an internal medicine ward: a cross-sectional study.

The identification of infection in an internal medicine ward is crucial but not always straightforward. Eosinopenia has been proposed as a marker of infection, but specific cutoffs for prediction are not established yet. We aim to assess whether there is difference in eosinophil count between infected and noninfected patients and, if so, the best cutoffs to differentiate them. Cross-sectional, observational study with analysis of all patients admitted to an Internal Medicine Department during 2 consecutive months. Clinical, laboratory and imaging data were analyzed. Infection at hospital admission was defined in the presence of either a microbiological isolation or suggestive clinical, laboratory, and/or imaging findings. Use of antibiotics in the 8 days before hospital admission, presence of immunosuppression, hematologic neoplasms, parasite, or fungal infections were exclusion criteria. In case of multiple hospital admissions, only the first admission was considered.Sensitivity and specificity values for eosinophils, leukocytes, neutrophils, and C-reactive protein were determined by receiver operating characteristic curve. Statistical analysis was performed with IBM SPSS Statistics® v25 and MedCalc Statistical Software® v19.2.3. A total of 323 hospitalization episodes were evaluated, each corresponding to a different patient. One hundred fifteen patients were excluded. A total of 208 patients were included, 62.0% (n = 129) of them infected at admission. Ten patients had multiple infections.Infected patients had fewer eosinophils than uninfected patients (15.8 ± 42 vs 71.1 ± 159 cell/mm3; P < .001). An eosinophil count at admission ≤69 cell/mm3 had a sensitivity of 89.1% and specificity of 54.4% (area under the curve 0.752; 95% confidence interval 0.682-0.822) for the presence of infection. Eosinophil count of >77 cells/mm3 had a negative likelihood ratio of 0.16. Eosinophil count was significantly lower in infected than in uninfected patients. The cutoff 69 cells/mm3 was the most accurate in predicting infection. Eosinophil count >77 cells/mm3 was a good predictor of absence of infection.

Hemoglobin C/Korle-Bu Identified In A Patient With A Previous Diagnosis Of Hemoglobin S/C Disease

Abstract Casestudy Hemoglobin Korle-Bu (Hb-KB) is an uncommon Hb variant that can be mistaken for Hb-S on electrophoretic screening. While Hb-KB alone has no clinical manifestations, there are only limited case studies describing KB in combination with other Hb variants. Here we report a rare case of Hb-C/KB misdiagnosed and managed as Hb-S/C disease for over 20 years. Results A 21-year-old African American woman with presumed Hb-S/C disease presented with generalized abdominal pain, nausea, and vomiting. In 1999, Hb electrophoresis showed 59% of abnormal hemoglobin presumed to be HbS and 41% HbC+A2; agar/acetate gel analysis was not employed and the hemoglobinopathy remained incompletely characterized. She had a history of back, chest, abdomen, and extremity pains requiring multiple hospital admissions, with treatments including dilaudid, oxycontin, oxycodone, and hydroxyurea. Her vital signs were normal and her examination was only significant for abdominal tenderness. Imaging studies did not show any evidence vascular occlusion, avascular necrosis, or end-organ dysfunction. RBC indices were remarkable for mild borderline anemia, microcytosis, decreased MCH/elevated MCHC, and borderline elevated RDW. Peripheral smear showed microcytic red cells with anisocytosis, scattered target cells, and a notable absence of sickled cells and Hb-C-crystals. The diagnosis of Hb-S/C disease was then revisited. HPLC showed abnormal hemoglobins in the Hb-D window at 55.1% and in the Hb-C window at 40.6%, with 3.5% Hb-A2 and no normal Hb-A. Gel electrophoresis with cellulose acetate followed by citrate agar suggested Hb-C in combination with either D, G, or Korle-Bu. Definitive diagnosis was obtained by beta globin gene sequencing that demonstrated one copy Hb-C (19G&amp;gt;A, Glu7Lys) and one copy Hb- Korle-Bu (220G&amp;gt;A, Asp74Asn). Given the absence of Hb-S/C disease, her gastrointestinal distress and pain episodes were re-evaluated. Conclusion Hb-S and Hb-Korle-Bu migrate similarly in cellulose acetate electrophoresis but can be distinguished on citrate agar. Challenging beta chain variants can now be readily differentiated by complete gene sequencing. This case study emphasizes the importance of distinguishing Hb-KB from clinically-significant Hb-S.

The relationship of socio-environmental factors with hospital admissions and readmissions for Sickle Cell Disease

Background Though approximately 100,000 Americans have sickle cell disease (SCD), studies over long time periods and large geographic areas in the US are limited. Patients routinely have multiple hospital admissions per year. Identification of potential contributing socio-environmental factors is important to advance prevention efforts.Methods We conducted a descriptive study of SCD hospital encounters and readmissions by individual and area-level socio-environmental factors using representative encounter data from all hospitals in South Carolina. We obtained emergency department visit and hospital admission data from 2002 through 2013 for patients with a primary diagnosis related to SCD. We examined initial visits, total encounters, admission and readmission rates by individual and area-level socio-environmental factors.Results We identified 127,598 hospital encounters with complete data that were attributed to 6,631 individual patients. Average overall encounter rate was 19.2 (95% CI: 17.9, 20.6) and rate of readmissions within 30 days was 11.5 (95% CI: 10.2, 12.8). Encounter rates and readmission rates were lower among participants living in more affluent areas. Further, those who had Medicaid as their primary insurance had the highest rates of readmission.Conclusions We observed some suggestion of increased SCD-related hospital admission rates and readmissions among participants living in less affluent areas, thus prevention efforts may be warranted for these underserved communities.

Shared Reflection to Maximize Resources and Minimize Costs: The Reflecting Team Applied to a Hospital Environment.

Severe mental illness entails multiple hospital admissions and a large use of public resources. The Reflecting Team (RT), together with other dialogue strategies, place in a single therapeutic space, the patient, his family and a team of professionals to find together a solution to a situation of stagnation. The aim of this study was to evaluate feasibility and cost-effectiveness of a RT intervention in psychiatric inpatients in a public hospital. Six RT were performed, and clinical variables were collected retrospectively for six months pre-RT and post-RT. Both number of hospital admissions and total time spent in the psychiatric acute unit show a significant decrease. All computed cost showed statistically significant reduction. The results suggest RT might be a good strategy to introduce a positive change in the treatment of those psychiatric cases in which the patient and family find themselves caught in a system that seems to offer stale and ineffective help to problems that have become chronic.

Trust in the nurse: Findings from a survey of hospitalised children.

To measure hospitalised children's trust in the nurse. Trust is central to the therapeutic relationship between the nurse and the patient. There can be no trusting relationship between the nurse and child if the parents have no trust or block the relationship (Bricher [Journal of Clinical Nursing, 8: 452, 1999]). This study was a cross-sectional, correlational descriptive design using a self-complete questionnaire to measure children's trust in nurses, to examine the relationship between children's trust and their parents, and the correlations between trust and medication adherence, fear and interactions with the nurse. A modified version of the Children's Trust in General Nurses Scale designed by Rotenberg et al. (Journal for Specialists in Pediatric Nursing, 20: 298, 2015) was used. This Scale is a short self-report questionnaire designed to elicit information on children's beliefs in, and attitudes to, trust in nurses. The Strengthening the Reporting of Observational Studies in Epidemiology statement for observational studies was applied (von Elm [British Medical Journal, 335: 806, 2007]). The results indicated high levels of trust beliefs in the nurse. The children's and parents' trust beliefs were found to be correlated. Gender did not influence trust beliefs. Younger children had higher levels of trust than older children, particularly in relation to the perceived honesty of the nurse. Trust beliefs in the nurse lessened with previous exposure to the hospital setting. One-fifth of children reported fear of the nurse. Positive interaction with the nurse was shown to be positively related to adherence to care. Children's level of trust in the nurse can be measured. A trusting child is likely to be less fearful and experience clinical procedures as less threatening and is more likely to adhere to treatment. Children's nurses should recognise that trust can change with age and with multiple hospital admissions.

Cost analysis of 163 consecutive heart transplant operationsin an Indian setting.

Heart transplantation has become an established procedure in India with increasing numbers being done annually. The majority of these patients are very sick with a history of multiple hospital admissions. The economic burden of such therapy is substantial and the costs are borne by the patients with very little insurance coverage. The objective of this study was to estimate the following:The average cost of a heart transplant procedure in a "real-world setting" in a private healthcare facility in India, with varying patient risk profiles.Identify the factors contributing to the wide variations in cost seen in practice.Finally, based on data thus collected, can some kind of estimation be made about the expected cost in a given patient before the operation is done? The cost incurred by the hospital in doing 168 heart transplants during a 3-year period was analyzed. Costs were divided into direct and indirect costs. The direct costs consisted of medical consumables, laboratory investigations, radiology, costs involved in organ harvest and transport, and diet. Direct cost was 40 % of the total cost of the procedure and was used as a surrogate for total costing estimates. There was a wide variation in direct costs almost tenfold, ranging from INR 240,882 to 2403193 with a mean of 603755.The cost was affected by length of stay in the hospital, whether a patient survived or died and whether the patient died within 7 days of surgery or later. It was also affected by patient-specific factors like the INTERMACS status and preoperative creatinine levels. The average cost of the entire transplant procedure was INR 1459000. There is a wide variation in the cost incurred by the hospital in doing transplants dictated to a large extent by patient risk profiles. A "One package fits all model" is unrealistic. The data pertains to the cost to the hospital and not the hospital bill and is therefore relevant to any health care facility, public or private. This study provides a framework for Governmental and private insurance agencies to fix the reimbursement rates.