Number Of Inpatient Deaths Research Articles

179 Elimination of Routine Screening Labs for Psychiatric Admission

Previous research has shown that routine screening labs for patients with mental health complaints being admitted to psychiatry has low yield for finding unexpected pathology. Despite this, it is nearly universal practice for patients to undergo various routine screening labs tests prior to psychiatric admission. Eliminating a policy of routine lab ordering has potential to reduce costs without adversely affecting patient care. However, to our knowledge such a policy has not been adopted by any large hospital or care network. The objective of this study was to describe the effects of a hospital change in policy no longer requiring screening labs on cost of care and patient safety measures. This retrospective cohort study analyzed data from a cohort of patients admitted to a large tertiary care hospital four months before and four months after (allowing for a one-month washout period immediately after) the screening laboratory policy change. All patients who presented to the emergency department and were admitted to the inpatient psychiatry service were included. Data were obtained from an automated query of electronic health records. The primary outcome measure was the number of laboratory tests ordered both in the emergency department as well as during the inpatient stay before and after the policy change. Secondary measures included the number of hospital medicine or specialty consultations while admitted, the number of patient transfers to non-psychiatry services, and number of inpatient deaths. Statistical tests for differences between groups utilized chi square tests for categorical variables and Wilcoxon rank sum tests for continuous variables which were non-normally distributed. 1599 patients were included in the analysis (pre = 659; post = 900). Patient demographics and admitting diagnoses were similar between the groups. The total median number of lab tests ordered during the hospital stay decreased from 3 (IQR, 2) to 2 (IQR, 3) [P<0.0001]. Contributing to this overall decrease was a decrease in the number of tests ordered in the ED and a slight increase in the lab tests ordered on the psychiatry unit. The total median lab charges (ED arrival to hospital discharge) decreased from $399 (IQR, $299) to $304 (IQR, 423) [P<0.0001]. In addition, the number of patients with no labs ordered in the ED increased from 77 (11.7%) to 335 (35.7%) [p<0.0001]. The length of stay in the ED decreased from 529.0 minutes (IQR, 721.0) to 451.5 minutes (IQR, 560) [p<0.0001]. The length of stay in the hospital decreased from 102.65 hours to 97.00 hours (p=0.0465). There were no increases in consultations during the inpatient stay or transfers to hospital medicine after the change. No patients were transferred from psychiatry to an intensive care unit at any point, and no patients died. A policy that avoids routine lab orders for patients admitted to psychiatry can save money and improve ED throughput without increasing adverse outcomes. These data provide support for other hospitals to adopt similar policy changes, with the potential to decrease cost of care for this patient population.

An initiative to improve mortality index in gynecologic oncology.

256 Background: The mortality index (MI) is a quality metric that measures the ratio of actual mortality to expected mortality among inpatients. Expected mortality is a probability calculation based on patient risks and comorbidities. A MI of &lt; 1.0 represents that fewer patients die while admitted to the hospital than expected. Methods: We formed a multidisciplinary team that included Gynecologic Oncology (GO), Health Information Management, Clinical Informatics, Revenue Operations, Coding and Institutional Compliance experts. Our aim was to decrease the GO MI by 10% within a year. Quality Improvement Assessment Board approval was obtained. GO clinical providers were educated on proper documentation of patient comorbidities and severity of illness. Audits of the documentation were performed by the multidisciplinary team. GO patients perceived at high-risk of inpatient mortality were identified for additional review. All GO inpatient deaths were reviewed at the monthly GO Morbidity and Mortality conference and opportunities for avoidance of inpatient death were discussed. Plan-Do-Study-Act (PDSA) cycles were repeated with adjustments made to the review and education processes. Baseline (BL) 8/2017-7/2018 and interim post-intervention (PI) 11/2018-2/2019 outcomes were compared using the Mann Whitney U test. Results: The BL median number of inpatient deaths per month was 2 (range 0-7), with a median expected mortality of 2.96 (range 1.46-5.11), and a median MI of 0.84 (range 0-1.37). The PI median number of inpatient deaths per month was 2.5 (range 2-5), with a median expected mortality of 4.24 (range 3.77-5.06), and a median MI of 0.56 (range 0.53-1.27). The number of inpatient deaths per month was similar between groups (2 vs 2.5; p = 0.49) but the expected mortality increased from to 2.96 to 4.24 (p = 0.03). MI decreased by 33% between BL and PI (0.84 vs 0.56). Conclusions: Inpatient mortality is an important quality metric. Accurate measurement of expected mortality is critical and requires proper documentation. This can be improved through education, review and frequent assessment by PDSA cycles. Our preliminary results show improvement in accurate documentation and measurement of expected mortality resulting in a decrease in MI.

Surgery for CNS Tumors in the Brazilian National Health Care System.

PurposeResource limitations in low- and middle-income countries make the management of CNS tumors challenging, particularly in Brazil, a country with major disparities in socioeconomic status and access to health care. We aimed to evaluate cancer-related neurosurgical procedures in the public health care system.MethodsOn the basis of Brazil’s public health system database, we collected data for neurosurgical procedures related to CNS tumors performed between January 2008 and November 2013. Information about the number of procedures, costs, length of stay, and number of inpatient deaths were analyzed for each state and then correlated to the state-specific population, gross domestic product per capita, and number of procedures.ResultsIn all, 57,361 procedures were performed, the majority of them in the Southeast region. The mean length of hospital stay was 14.4 days, but longer hospital stay was reported for patients treated in the North. The inpatient mortality rate was 7.11%. Mortality rates decreased as the number of procedures (P < .001), gross domestic product per capita (P < .001), or state population increased (P < .001). On multivariate analysis, only the number of procedures (odds ratio, 0.93; 95% CI, 0.91 to 0.96; P < .001) and state population (odds ratio, 1.25; 95% CI, 1.13 to 1.38; P < .001) had an independent association with mortality.ConclusionTo the best of our knowledge, this is the first study to evaluate disparities in CNS tumor surgery in a middle-income country, confirming that regional disparities exist and that clinical and economic outcomes correlate with income level, number of procedures, and state population.

How do junior doctors in the UK learn to provide end of life care: a qualitative evaluation of postgraduate education.

BackgroundThe fundamental importance of good end of life care has been well documented however recent national publications have high-lighted inadequacies in training in this area. For many patients dying in the UK today care is provided in hospital and the number of inpatient deaths is forecast to climb significantly in future. The demands of providing medical care for these patients by junior doctors will continue to rise. However, there is currently only limited research on training for doctors in this setting.MethodsA qualitative study using semi-structured interviews of trainees working in general medicine analysed utilising a grounded theory approach.ResultsEleven medical trainees from nine different medical schools participated. They had worked in fifteen different UK hospitals in the course of their careers. All of the doctors interviewed felt generally confident in managing a dying patient. This had developed at postgraduate level and increased when working in certain key specialties. Emerging themes fell into five main categories: perceived ability in clinical management, different learning opportunities experienced, the impact of variations in approach to end of life care, the role of the specialist palliative care team and suggestions for improvements to training. All participants felt further teaching would be beneficial.ConclusionsThis study identified key areas where training could be improved. This included small changes in everyday practice to shift the emphasis for trainees to education. There also needs to be focus on end of life care in the curriculum, formal teaching programmes and assessment of junior doctors. The specialist palliative care team played a vital role in training as well as service provision. For those working in this specialty, every clinical encounter provides an opportunity for education. Specifically targeting junior doctors will not only improve patient care today but empower the consultants of the future.Electronic supplementary materialThe online version of this article (doi:10.1186/s12904-015-0039-6) contains supplementary material, which is available to authorized users.

OC-039 Improving Quality In A National Intestinal Failure Unit: Greater Efficiency, Improved Access, Reduced Mortality

IntroductionIn 2010, there was a significant waiting list for admission to the Intestinal Failure Unit (IFU) at Salford, one of two current nationally-accredited centres. There had also been a steady...

Rates and patterns of death after surgery in the United States, 1996 and 2006

Nationwide rates and patterns of death after surgery are unknown. Using the Nationwide Inpatient Sample, we compared deaths within 30 days of admission for patients undergoing surgery in 1996 and 2006. International Classification of Diseases codes were used to identify 2,520 procedures for analysis. We examined the inpatient 30-day death rate for all procedures, procedures with the most deaths, high-risk cardiovascular and cancer procedures, and patients who suffered a recorded complication. We used logistic regression modeling to adjust 1996 mortality rates to the age and gender distributions for patients undergoing surgery in 2006. In 1996, there were 12,573,331 admissions with a surgical procedure (95% confidence interval [CI], 12,560,171-12,586,491) and 224,111 inpatient deaths within 30 days of admission (95% CI, 221,912-226,310). In 2006, there were 14,333,993 admissions with a surgical procedure (95% CI, 14,320,983-14,347,002) and 189,690 deaths (95% CI, 187,802-191,578). Inpatient 30-day mortality declined from 1.68% in 1996 to 1.32% in 2006 (P < .001). Of the 21 procedures with the most deaths in 1996, 15 had significant declines in adjusted mortality in 2006. Among these 15 procedures, 8 had significant declines in operative volume. The inpatient 30-day mortality rate for patients who suffered a complication decreased from 12.10% to 9.84% (P < .001). Nationwide reporting on surgical mortality suggests that the number of inpatient deaths within 30 days of surgery has declined. Additional research to determine the underlying causes for decreased mortality is warranted.

Deaths in an Academic Medical Center

The number of inpatient deaths in a calendar year in an academic medical center was reviewed from a computerized database. The total number was 1222. The median length of hospital stay for those who died was 7 days (range, 1-190); 404 (33%) were 75 years or older. There were 678 (55%) males and 544 (45%) females. The pulmonary medicine service had the most deaths with 290 (24%) followed by hematology/oncology 230 (18%). The most common primary diagnoses in the decedents were subendocardial infarction 58 (5%), congestive heart failure 57 (5%), and pneumonia 45 (4%). The most common diagnostic-related groups (DRGs) were respiratory system disorders (475), 98 (8%); tracheostomy (483), 75 (6%); and heart surgery (110), 65 (5%). Frequent procedures done prior to death were mechanical ventilation (<96 hours) 101 (8%), and mechanical ventilation (>96 hours) 55 (5%), and tracheostomy 54 (4%). Invasive procedures were common. Forty-five percent of the predeath patient days were spent in intensive care units. Palliative medicine was involved in the care of 20% of all the decedents.

Suicide in psychiatric in-patients in England, 1997 to 2003

Psychiatric in-patients are at particularly high risk of suicide but few studies have investigated trends in in-patient suicide over time. We conducted a prospective study of all patients admitted to National Health Service (NHS) in-patient psychiatric care in England (1997-2003). The study was carried out as part of the National Confidential Inquiry into Suicide. The main outcome measure was death by suicide. Suicide rates were determined using Hospital Episode Statistics (HES) as the denominator. Between the first 2 years of the study (1997 and 1998) and the last 2 years of the study (2002 and 2003) the annual number of in-patient deaths from suicide fell from 187 to 156 (a 17% reduction). The rate of in-patient suicide fell by between 9% and 28% depending on which denominator was used. This fall was observed for both males and females, and was most marked for those aged 15-44 years. Reductions were also observed for the three most common methods of death (hanging, jumping, poisoning), but the trend for hanging did not reach statistical significance. Although the number of post-discharge suicides fell, the risk of post-discharge suicide (using admissions as a denominator) may have increased by as much as 10% during the study period. The rate of suicide among psychiatric in-patients appears to have fallen. The fall may reflect falling general population rates, changes in in-patient case mix, service improvements, or a transfer of risk to the post-discharge period. Services need to be aware of the importance of providing high quality aftercare following discharge from hospital.

Does the Availability of Hospital Beds Affect Utilization Patterns? The Case of End-of-Life Care

Hospital downsizing in Canada during the 1990s raised public concern over the availability of hospital care, in addition to heightening administrative interest in improving or maximizing hospital utilization. One ongoing concern about hospital utilization is that a disproportionately large share of hospital resources is used by terminally ill and dying people. A research study using 1992/1993–1996/1997 in-patient abstracts data for the province of Alberta, Canada, was undertaken to explore and describe hospital utilization by dying in-patients. This investigation found only 48.2% of all deaths in Alberta over the five years studied involved hospital in-patients. An 18.5% reduction in the number of in-patient deaths and an 83.3% reduction in length of final stay occurred when 50% of acute care beds were closed, which was followed by an increase when beds began reopening — in terms of both the number of in-patient deaths (4.8%) and the average length of stay (2.6%). The ratio of men to women, the average age of dying in-patients, and the intensity of hospital care changed relatively little over those five years. Most in-patients were admitted for nursing care; in 51.3% of all cases, no diagnostic or therapeutic procedures were performed prior to death. These findings indicate hospital bed availability influences admission to hospital and length of stay, but not treatment decisions affecting seriously ill and dying patients. In addition, reduced length of stay appears to have been a widespread response to hospital downsizing, with this change substantially preserving individual access to hospitals.

Does the availability of hospital beds affect utilization patterns? The case of end-of-life care.

Hospital downsizing in Canada during the 1990s raised public concern over the availability of hospital care, in addition to heightening administrative interest in improving or maximizing hospital utilization. One ongoing concern about hospital utilization is that a disproportionately large share of hospital resources is used by terminally ill and dying people. A research study using 1992/1993-1996/1997 in-patient abstracts data for the province of Alberta, Canada, was undertaken to explore and describe hospital utilization by dying in-patients. This investigation found only 48.2% of all deaths in Alberta over the five years studied involved hospital in-patients. An 18.5% reduction in the number of in-patient deaths and an 83.3% reduction in length of final stay occurred when 50% of acute care beds were closed, which was followed by an increase when beds began reopening--in terms of both the number of in-patient deaths (4.8%) and the average length of stay (2.6%). The ratio of men to women, the average age of dying in-patients, and the intensity of hospital care changed relatively little over those five years. Most in-patients were admitted for nursing care; in 51.3% of all cases, no diagnostic or therapeutic procedures were performed prior to death. These findings indicate hospital bed availability influences admission to hospital and length of stay, but not treatment decisions affecting seriously ill and dying patients. In addition, reduced length of stay appears to have been a widespread response to hospital downsizing, with this change substantially preserving individual access to hospitals.

Assessing Hospital-Associated Deaths-Reply

In Reply.— Dr Wagner argues that it would be more appropriate to observe hospital-associated mortality during a period from admission to 30 days after discharge rather than from admission to 30 days after admission. He observes that in states such as New York, with very long stays for certain patients with certain conditions (such as stroke), taking a period of 30 days after admission omits a substantial number of inpatient deaths; he also is concerned that physicians can delay inpatient deaths so that they fall after the 30-day observation period and artificially improve the performance of the hospital. The problem Dr Wagner identifies in data from New York is largely that New York hospitals are serving as skilled nursing facilities for a number of terminally ill patients, a situation that is much less frequent in other states. The statistic he proposes would charge New York hospitals with deaths that would