Changes In Patient Status Research Articles

Coding for Noncritical Inpatient and Observation Services: The Dilemma

Coding for Noncritical Inpatient and Observation Services: The Dilemma

Do all mechanically ventilated pediatric patients require continuous capnography?

With most patients in modern ICUs requiring mechanical ventilation, any technology that may lead to more optimal ventilatory strategies would be invaluable in the management of critically ill patients. The focus of most ventilator strategies is protecting the lung from the deleterious effects of mechanical ventilation. Every effort is made to minimize the duration of mechanical ventilation while optimizing the potential for successful extubation. A concise organized plan based on objective criteria that is adjusted to meet changes in patient status is clearly recommended. Continuous capnographic monitoring provides clinicians with clear, precise, objective data that may prove beneficial in the design and implementation of mechanical ventilatory strategies. There are no clear-cut methods for achieving the optimal ventilator strategy for a specific patient. Although guidelines and management theories exist throughout the medical literature, in practice, they often merely serve as loose guidelines. The dynamic properties of an acutely ill patient make the management of mechanical ventilation an ongoing process requiring clinical assessment and planning by multidisciplinary members of the patient care team. Comprehensive evaluation of ventilatory management strategies and patient responses must be made by a collaborative effort of physicians, respiratory care practitioners, and nurses. An objective, consistent approach to the overall management is essential. Although still controversial, it is the authors' opinion that volumetric capnograph provides the data necessary to establish adequate gas delivery, optimal PEEP, and effective ventilation with the least amount of mechanical assistance, regardless of clinician or institutional preferences.

Die klinische Untersuchung des kritisch kranken Patienten auf der Intensivpflegestation

Various circumstances hinder the clinical examination of a patient in an intensive care unit (ICU). Nevertheless, the clinical assessment is crucial for the formulation of a diagnostic and therapeutic plan. History and clinical examination need to be performed timely and efficiently. They are best done in a structured manner, so that no important details are missed. The doctor should follow the concept of "A B C", in which "A" stands for airways, "B" for breathing and "C" for circulation. It is essential that some pathological findings in the clinical examination prompt immediate therapeutic interventions to avoid further deterioration. Thorough clinical assessment is normally performed at the time of patient's admission to the ICU. However, parts of history and clinical examinations may still be missed. It is therefore crucial that this information is obtained as soon as possible as it may help with the management of the patient. Clinical examination is repeated at the daily ward rounds as well as at any time that the patient's condition changes. Results of tests and data collected from monitoring equipment should be viewed as an addition to the patient's clinical assessment and must not distract the clinician from the patient's clinical condition. Precise documentation of the findings is vital to allow comparison of the patient's progress on a daily basis and to provide continuity of care.

Nonconvulsive status epilepticus in metastatic CNS disease

The authors describe the clinical and diagnostic characteristics of four patients with metastatic CNS disease presenting in de novo nonconvulsive status epilepticus (NCSE). Treatment with anticonvulsants resulted in resolution of NCSE in two patients and a brief improvement in mental status in the other two patients. NCSE should be considered in the differential diagnosis of acute mental status change in patients with metastatic CNS disease.

Diacetylated Derivatives of Spermine and Spermidine as Novel Promising Tumor Markers

N1,N12-diacetylspermine (DiAcSpm) and N1,N8-diacetylspermidine (DiAcSpd) are minor components of human urinary polyamine to which little attention has been paid until recently. HPLC analysis of urinary polyamines has revealed that the excretion of these diacetylpolyamines, in particular, into urine was frequently and markedly increased in association with every type of cancer so far examined. Remission was usually accompanied by recovery of urinary diacetylpolyamines to the normal level. DiAcSpm was more sensitive than CEA for detecting colorectal cancer patients, while DiAcSpd was highly specific for malignant conditions in that the excretion of the latter was scarcely elevated in cases of benign urogenital diseases. An ELISA procedure for rapid determination of DiAcSpm was developed to promote the clinical application of these new tumor markers, and subsequent studies indicated that DiAcSpm was elevated in 60% of colorectal cancer patients at early stages (stage 0 + I), whereas only 10% of these patients were CEA-positive. DiAcSpm may also be useful as a follow-up marker that is efficient for detecting recurrence and sensitive to changes in the clinical condition of patients. The evidence accumulated so far indicates that DiAcSpm and DiAcSpd are promising novel tumor markers. They deserve more intensive studies, including studies of their biochemistry and metabolism.

Generic versus Disease-specific Instruments in Quality-of-life Assessment of Chronic Obstructive Pulmonary Disease

Chronic respiratory diseases may alter a patient's social life and well-being. Measures of health-related quality of life have been proven to bring complementary information to functional assessments. The aim of the study was to describe the questionnaires that are most frequently used to measure this subjective construct in patients with chronic obstructive pulmonary disease (COPD) and to compare the responses obtained via administering one generic (SF-36) and one disease-specific questionnaire (St. George's Respiratory Questionnaire; SGRQ) to patients with COPD. One group of patients (46 individuals) was used to evaluate the questionnaire's performance in repeated administrations under unchanged conditions (reproducibility) and to study the correlations of corresponding domains of respective questionnaires. Responsiveness of both questionnaires was tested on another group of 129 patients measured before and after the therapeutic stay at the spa. Methods of correlational analysis (Spearman, intraclass, and canonical correlation coefficients) as well as the Wilcoxon rank test were used for statistical analysis. Both questionnaires seem to be comprehensive outcome measures for patients with COPD, but some particular areas may not be covered with the same intensity (e.g. emotional problems). Reproducibility of both questionnaires was good and only small non-significant shifts were seen, particularly in physical and social functioning domains. In repeated measurement, the SGRQ seemed to be slightly more responsive to change than the SF-36. The idea of using generic and disease-specific questionnaires together probably represents the best approach to this topic. It may improve our knowledge and explain better the relationship between disease-specific changes in patient status and both disease-specific treatment and general functional status.

A dynamic model for estimating changes in health status and costs

We develop an innovative method to assess total treatment costs over a finite period of time while incorporating the dynamics of change in the health status of patients. Costs are incurred through medical care use while patients sojourn in health states. Because complete ascertainment of costs and observation of events are not always feasible, some patient utilization will be incomplete and events will also be censored. A Markov model is used to estimate the transition probabilities between health states and the impact of patient variables on transition intensities. A mixed-effects model is used for sojourn costs with transition times as random effects and patient variables as fixed effects. The models are combined to estimate net present values (NPVs) of expenditures over a finite time interval as a function of patient characteristics. The method is applied to a data set of 624 incident cases of cancer. Physical functioning after cancer diagnosis was assessed periodically through structured interviews. The outcomes of interest are normal physical function, impaired physical function, or the terminal state, dead. Charges were obtained from Medicare claim files for 2 years following cancer diagnosis. For demonstration purposes, we estimate NPVs for charges incurred over 2 years by cancer site and cancer stage. Our method, a joint regression model, provides a flexible approach to assessing the influence of patient characteristics on both cost and health outcomes while accommodating heteroscedasticity, skewness and censoring in the data.

Homeostasis in patients with ovarian benign tumors and reproductive function disorders

Objective: the elicitation of immune status changes in patients with benign ovarian tumors and reproductive function disorders.

Evaluation of the Pediatric Crohn Disease Activity Index: A Prospective Multicenter Experience

Longitudinal assessment of disease activity is necessary for studies of therapeutic intervention in children with Crohn disease. The Pediatric Crohn Disease Activity Index (PCDAI) was developed a decade ago for such a purpose, but it function has only been examined in a small number of studies with a limited number of patients. The primary objectives of the present study were to develop cut scores reflecting disease activity as determined by physician global assessment (PGA) and to evaluate the responsiveness of the PCDAI to changes in patient condition after therapeutic interventions. Data were derived from a prospective database of newly diagnosed children with inflammatory bowel disease established in 2002 at 18 pediatric gastroenterology centers in the United States and Canada. At diagnosis, at 30 days and 3 months after diagnosis, and quarterly thereafter, children (<16 years of age) with Crohn disease had disease assessment performed by PGA and PCDAI. Disease management was provided according to the dictates of the attending gastroenterologist and not by predetermined protocol. 181 patients had concomitant PGA and PCDAI performed at diagnosis, and 95 of these had similar assessment at short-term follow up. Mean +/- SD PCDAI scores for mild, moderate, and severe disease by PGA at diagnosis were 19.5 +/- 10.4, 32.2 +/- 12.7, and 47.8 +/- 14.9, respectively (P < 0.001 for all comparisons). Mean +/- SD PCDAI for inactive disease after treatment was 5.2 +/- 5.4. Receiver operating characteristic (ROC) curve analysis suggested that: 1) activity of moderate/severe disease was best reflected by a PCDAI of > or = 30 points, 2) clinical response (moderate/severe disease improving to mild/inactive) was best reflected by a decrease in PCDAI of > or = 12.5 points, and 3) a PCDAI < 10 best reflected inactive disease. PCDAI scores accurately reflect disease activity as assessed by physician global assessment. A PCDAI score of > or = 30 has acceptable sensitivity and specificity to indicate disease of moderate/severe activity. A PCDAI decrease of 12.5 points or greater following therapeutic intervention accurately reflects a clinically significant response. The PCDAI is an appropriate tool for intervention trials in Crohn disease in children.

Visual analogue scale, numeric pain rating scale and the McGill pain Questionnaire: an overview of psychometric properties

It is essential for physical therapists to use outcome measures that identify and measure a change in patient status; however, pain is a multidimensional experience that is often difficult to measure. A variety of instruments have been developed in an attempt to obtain an accurate measure of patients' perceived level of pain. Three of the most common outcome measures utilised by physical therapists include the visual analogue scale, the numeric pain rating scale and the McGill Pain Questionnaire. The purpose of this review is to describe the psychometric properties, including reliability and responsiveness, of these outcome measures.

The Yield of Flexible Fiberoptic Bronchoscopy in Pediatric Intensive Care Patients

To evaluate the contribution of flexible fiberoptic bronchoscopy (FFB) and BAL to the clinical management of patients in a pediatric ICU (PICU). A retrospective study based on medical records in a six-bed pediatric ICU of a tertiary care children's hospital serving as a referral center for airway surgery. One hundred consecutive infants and children hospitalized in a PICU, who underwent FFB with or without BAL. One hundred fifty-five procedures were performed, for the following causes: search for airways anatomic pathologies (114 of 155 procedures, 74%), including 55 procedures during the perioperative period of airway surgery; treatment of atelectasis (35 of 155 procedures, 22.5%); and BAL (30 of 155 procedures, 19%). Thirty-five percent of procedures had more than one cause. Airway pathology was observed in 79 of 114 procedures (69%). Management changed from conservative to surgical in 44 of 114 procedures (39%). In airway surgery cases, reoperation subsequent to postoperative FFB took place in 35%. BAL results changed antimicrobial treatment in 15 of 30 cases, with clinical improvement in 10 of 30 cases (33%). Treatment of atelectasis was successful in 26 of 35 cases (74.3%). No procedure-related mortality, life-threatening complications, or significant changes in patient status occurred. FFB is an important and safe procedure in very sick infants and children with a variety of respiratory diseases, and significantly contributes to their management. FFB should be considered to be a PICU staff expertise.

A neuro-fuzzy inference system for modeling and prediction of heart rate variability in the neuro-intensive care unit

In the neurological intensive care unit (NICU), prediction of impending changes in patient condition would be highly beneficial. In this paper, we employ a neuro-fuzzy inference system (NFIS) for short-term prediction of heart rate variability in the NICU. An NFIS was selected because it allows for a “gray-box” approach through which a system identification procedure is used in conjunction with fuzzy modeling. The NFIS is described in detail and is compared to an auto-regressive moving average (ARMA) model for its ability to model both simulated and measured data from NICU patients. We found that the NFIS is capable of predicting changes in heart rate to a reasonable extent, and that the NFIS has both advantages and limitations over the ARMA model. The NFIS may therefore be a reasonable technique to consider for more extensive prediction purposes in ICU settings.

Decisions in chest pain: how often do they change after the initial evaluation?

Study objectives: We determine to what extent decisions in chest pain change from initial emergency department (ED) patient encounter to final ED diagnosis, disposition, and treatment. Methods: We designed a prospective, observational study of a convenience sample of chest pain patients triaged to the critical care area of an urban ED. Patients were excluded if they were diagnosed with ST-segment elevation myocardial in farction. Physician decisions about these patients were studied. The physicians involved in the study were attending emergency physicians and upper-level emergency medicine residents who staff 100% of cases with an attending emergency physician. Physicians were surveyed after initial patient evaluation. This initial evaluation was defined as initial medical history and physical examination and reading of the ECG. The survey elicited initial working diagnosis, treatment, and disposition. The treating physician was again surveyed after final ED decisions and disposition were made. The second survey elicited the same information as the first survey about decisions. The second survey also asked the treating physicians to cite the factors that led to changes in their decisions. The surveys were then compared, and decision changes were noted as upgrades or downgrades. Changes in decisions were correlated with cardiac marker results and physician-cited factors that led to those decision changes. Results: Of 83 physician/patient interactions studied, 20 (24%) had an upgrade in management, 24 (29%) a downgrade, and 39 (47%) had no change. Seventy-six patients had negative cardiac markers. Of the patients with negative markers, 14 (18%) had an upgrade, 24(32%) had a downgrade, and 37 (49%) had no change in decisions. The most common factor cited by the treating physician as affecting decisions was change in patient status (N=34, 41%). The second most common factor cited was cardiac marker results (N=30, 36%). From these 30 interactions, 4 had positive markers, all of which had an upgrade in management; 26 had negative markers. Of these 26, 6 were upgraded and 8 were downgraded; 12 had no change in management, even though the physician stated that the marker results affected their decisions. Finally, from these 30 interactions in which cardiac markers were cited as affecting decisions, 9 patients had negative markers and duration less than 6 hours. Follow-up was available for 81 of the 83 patients. No significant correlation between changes in decision and outcomes was found. Conclusion: Nearly 50% of chest pain management decisions did not change after the initial evaluation. Physicians may inappropriately rely on initial cardiac marker results in determining the etiology of a patient's chest pain.

Quantification of Muscle Spasticity Using MRI and Resistance to Passive Movement

2298 Evaluation of muscle spasticity is based on subjective assessment of limb resistance to passive movement. Such assessment lacks the reliability and sensitivity to detect small or moderate changes in patient status. It would be useful to have an objective quantitative indicator of muscle spasticity, especially for the evaluation of efficacy of experimental treatments. PURPOSE: To perform a preliminary evaluation of magnetic resonance imaging (MRI) and resistance to passive movement for the evaluation of spastic muscle. METHODS: Six hemipeligic stroke survivors with muscle spasticity in the elbow flexors and extensors participated (56.2 ± 1.9 yrs). T2 weighted MRI scans of the upper arm were obtained at rest and following performance of 3 sets of 10 concentric repetitions of arm flexion/extension at 30% of maximal voluntary isometric contraction. Resistance to passive movement was measured subjectively (Ashworth) by a clinician and objectively by an isokinetic dynamometer where the lower arm was moved about the elbow at speeds of 5, 60, 90, and 120 degrees/sec. RESULTS: The affected muscle groups were weaker than the unaffected muscle groups (flexors- affected: 20.1 ± 5.1 N-M, unaffected: 58.1 ± 3.9 N-M; extensors- affected: 22.0 ± 1.7 N-M, unaffected: 56.5 ± N-M; p<0.001). The unaffected cross-sectional area (CSA) of the triceps muscle group was significantly larger than the affected side (6.04 ± 0.72 cm2 vs 4.55 ± 0.43 cm2; p=0.01), whereas no differences in the biceps muscle group was observed (5.27 ± 0.78 cm2 vs 5.02 ± 0.57 cm2). There was a tendency (p=0.07) for resting T2 to be higher in affected vs. unaffected biceps (30 ± 3 vs. 27 ± 3 msec) but triceps values were similar. In both biceps and triceps the unaffected side showed a significant (∼30%) increase in T2 after exercise and no exercise-induced change in T2 for the affected muscles. For the elbow flexors, a greater passive resistance to movement was observed for the affected side as speed of movement increased. At 90 degrees/sec, the exerted passive torque ranged from 0.33-3.57 N-M, despite all subjects receiving an Ashworth score of 1. The elbow extensors also displayed an increased passive resistance to movement with increasing speed, with a larger range of exerted torque values and Ashworth scores measured on the affected side (Passive torque range: 2.7-19.9 Newton-Meters, Ashworth score range: 0-3). CONCLUSION Both MRI and quantitative resistance to passive movement may be useful in the evaluation of spastic muscle.

輸血採血業務に携わる輸血部門看護師の現状と問題点‐認定輸血看護師（仮称）に向けて‐

Nurses play an important role in managing patients and donors at the time of transfusion blood collection, and are required to have advanced knowledge of transfusion medicine and technology. To identify the present conditions and problems in blood collection, particularly at the time of aphereis procedure in hospitals, we performed a questionnaire survey of nurses working at Japanese Transfusion Society-certified transfusion institutions. We also asked the nurses for opinions on the certified transfusion nurse system. The recovery rate of the questionnaire was 55%. The ratio of responses of nurses belonging to transfusion sections was 36%. The proportion of hospitals performing 10 or more of apheresis procedures per month was 10%, 6-10 times, 9%; 3-5 times, 30%; and 1-2 times, 51%. About 40% of nurses were uneasy about managing donors or patients during the apheresis procedure, mainly related to sudden change in patient condition or mechanical trouble. Inadequate management and knowledge were considered to be the causes of the unease. About 70% of nurses approved of the establishment of a certified transfusion nurse system. From these questionnaire findings, the nursing system in transfusion sections was judged inadequate, and improvement is required. We also detected the necessity for better education of nurses regarding the technology of blood transfusion medicine. For this purpose, an authorization system led by a society is considered to be the most effective. The Japan Society of Blood Transfusion and The Japanese Society for Apheresis are expected to take the lead towards realization of these goals.

Evaluating changes in health status: sensitivity to change of the modified Arabic health assessment questionnaire in patients with rheumatoid arthritis

Objective. – To test the correlation between clinical improvements in patients with rheumatoid arthritis (RA) as defined by the American College of Rheumatology (ACR) response criteria and functional improvements as assessed by functional measures in the modified Arabic version of the Health Assessment Questionnaire (Arabic-HAQ) and to estimate the sensitivity to change of the Arabic-HAQ, in a prospective study. Methods. – Eighty-two patients with active RA were given methotrexate and followed up prospectively for 12 months. ACR response rates and score improvements on the modified Arabic-HAQ were compared. Results. – The Arabic-HAQ scores showed significant sensitivity to change after 6 and 12 months and were significantly correlated with the ACR response. Percentages of agreement with ACR response levels were high after 6 months and higher still after 12 months. Standardized effect sizes were 2.34 and 2.84 after 6 and 12 months, respectively. Relative efficiency of the total Arabic-HAQ score in relation to the tender joint count was greater than 1. Conclusion. – The Arabic-HAQ is valid and sensitive to functional status changes in patients with RA. The results are comparable to those of the original HAQ. Thus, the Arabic-HAQ can be used to evaluate treatments and to identify changes that are important to RA patients.

Standardizing DSM-IV Diagnoses: The Clinical Applications of Structured Interviews

Psychological assessments of Axis I and Axis II diagnoses are strongly enhanced by the use of structured interviews. Structured interviews standardize the clinical inquiries, sequencing of diagnostic issues, and criterion-based ratings. For a broad range of clinical settings, structured interviews can systematically assess changes in patient status, corroborative data from multiple sources, interrater and test-retest reliability, and diagnostic validity. This article outlines the potential uses of different diagnostic interviews that are tailored for or adapted to specific clinical purposes.

Évaluation des variations de l’état de santé : sensibilité au changement de la version arabisée de l’indice fonctionnel HAQ au cours de la polyarthrite rhumatoïde

Objective. – To test the correlation between clinical improvements in patients with rheumatoid arthritis (RA) as defined by the American College of Rheumatology (ACR) response criteria and functional improvements as assessed by functional measures in the modified Arabic version of the health assessment questionnaire (Arabic-HAQ) and to estimate the sensitivity to change of the Arabic-HAQ, in a prospective study. Methods. – Eighty-two patients with active RA were given methotrexate and followed up prospectively for 12 months. ACR response rates and score improvements on the modified Arabic-HAQ were compared. Results. – The Arabic-HAQ scores showed significant sensitivity to change after 6 and 12 months and were significantly correlated with the ACR response. Percentages of agreement with ACR response levels were high after 6 months and higher still after 12 months. Standardized effect sizes were 2.34 and 2.84 after 6 and 12 months, respectively. Relative efficiency of the total Arabic-HAQ score in relation to the tender joint count was greater than 1. Conclusion. – The Arabic-HAQ is valid and sensitive to functional status changes in patients with RA. The results are comparable to those of the original HAQ. Thus, the Arabic-HAQ can be used to evaluate treatments and to identify changes that are important to RA patients.

Etiology of Mental Status Changes in Patients After Total Hip Arthroplasty

Etiology of Mental Status Changes in Patients After Total Hip Arthroplasty

Current issues related to home monitoring.

Physiologic monitoring is no longer confined to the critical care unit. Home monitors connect patients with clinics, physician offices, disease management programs, and home care agencies for the purpose of streamlining care delivery, maintaining a close patient connection, and promoting early identification of patient status changes. The advent of telehealth technologies offers a wide range of options for home monitoring. The goal of home monitoring is to promote patient comfort and avoid disruption of daily activities. To accomplish this, however, nurses must address issues such as, technology compatibility with patient capabilities, compatibility with nurses' practice beliefs, cost of home monitoring of overall care, and the physiologic parameters that will measure early decompensation.