Patients In General Medical Wards Research Articles

Mental healthcare services in Kenyan counties: a descriptive survey of four counties in Western Kenya

BackgroundThe government of Kenya has made progressive efforts towards improving mental health services in the country. However there is little documentation of mental health services in the counties that would support actualization of the legislative frameworks in the context of a devolved healthcare system. This study sought to document existing mental health services within 4 counties in Western Kenya.MethodsWe conducted a cross sectional descriptive survey of four counties using the World Health Organization, Assessment Instrument for Mental Health Systems (WHO-AIMS). Data was collected in 2021, with 2020 being the year of reference. We collected data from the facilities offering mental healthcare within the counties as well as from County health policy makers and leaders.ResultsMental healthcare was provided at higher level facilities within the counties, with minimal structures at primary care facilities. No county had a stand-alone policy on mental health services or dedicated budget for mental healthcare. The national referral hospital, within Uasin-Gishu county, had a clear mental health budget for mental health. The national facility in the region had a dedicated inpatient unit while the other three counties admitted patients in general medical wards but had mental health outpatient clinics. The national hospital had a variety of medication for mental health care while the rest of the counties had very few options with antipsychotics being the most available. All the four counties reported submitting data on mental health to Kenya health information system (KHIS). There were no clearly defined mental healthcare structures in the primary care level except for funded projects under the National referral hospital and the referral mechanism was not well defined. There was no established mental health research in the counties except that which was affiliated to the national referral hospital.ConclusionIn the four counties in Western Kenya, the mental health systems are limited and not well structured, are faced with limited human and financial resources and there is lack of county specific legistrative frameworks to support mental healthcare. We recommend that counties invest in structures to support provision of quality mental healthcare to the people they serve.

Early activation for acutely ill elderly patients

In order to describe both the process and the impact of introducing a program of early activation for acutely admitted elderly patients in medical wards, two populations, one before and the other after the intervention of the program, were followed up. The program was implemented in cooperation with the nursing staff, who were integrated in the rehabilitation work. Population I (219 admissions) was collected in 1981 and Population II (272 admissions) during a corresponding period in 1983. Survival, type of residence and ADL status 5 months after hospital admission were recorded as outcome measures. There were no differences between 1981 and 1983. In 1983 the mean length of stay was 4.7 days shorter than in 1981. The program cannot be shown to have caused the difference in length of stay. The study shows that such a program of early activation was easy to apply in clinical practice for aged and disabled patients in general medical wards.

Validation of two nurse-based screening tools for delirium in elderly patients in general medical wards

BackgroundDelirium is an acute disturbance characterized by fluctuating symptoms related to attention, awareness and recognition. Especially for elderly patients, delirium is frequently associated with high hospital costs and resource consumption, worse functional deterioration and increased mortality rates. Early recognition of risk factors and delirium symptoms enables medical staff to prevent or treat negative effects. Most studies examining screening instruments for delirium were conducted in intensive care units and surgical wards, and rarely in general medical wards. The aim of the study is to validate the Nursing Delirium Screening Scale (Nu-DESC) and the Delirium Observation Screening Scale (DOS) in general medical wards in a German tertiary care hospital, considering predisposing delirium risk factors in patients aged 65 and older.MethodsThe prospective observational study including 698 patients was conducted between May and August 2018 in two neurological and one cardiology ward. During their shifts, trained nurses assessed all patients aged 65 or older for delirium symptoms using the Nu-DESC and the DOS. Delirium was diagnosed according to the DSM-5 criteria by neurologists. Patient characteristics and predisposing risk factors were obtained from the digital patient management system. Descriptive and bivariate statistics were computed.ResultsThe study determined an overall delirium occurrence rate of 9.0%. Regarding the DOS, sensitivity was 0.94, specificity 0.86, PPV 0.40 NPV 0.99 and regarding the Nu-DESC, sensitivity was 0.98, specificity 0.87, PPV 0.43, NPV 1.00. Several predisposing risk factors increased the probability of delirium: pressure ulcer risk OR: 17.3; falls risk OR: 14.0; immobility OR: 12.7; dementia OR: 5.38.ConclusionsBoth screening instruments provided high accuracy for delirium detection in general medical wards. The Nu-DESC proved to be an efficient delirium screening tool that can be integrated into routine patient care. According to the study results, pressure ulcer risk, falls risk, and immobility were risk factors triggering delirium in most cases. Impaired mobility, as common risk factor of the before mentioned risks, is well known to be preventable through physical activity programmes.

Orthostatic Tolerance Training of Stroke Patients in General Medical Wards. An Experimental Study

In order to initiate early activation and counteract the negative effects of bed rest, 71 patients acutely admitted to hospital with a confirmed stroke were randomized to either training or control wards. Sixty-three persons participated in a first orthostatic tolerance test on days 5-7 after admission, which was replicated on days 10-12. A third test was performed three months later. Regular stand-ups were initiated on days 1-2 after admission to hospital and were continued for 1-2 weeks. The trained group had a lower increase in heart rate during tilting and a lower proportion of severely disabled patients on days 5-7 compared with the control group. This difference was statistically significant but cannot be proved to be a result from the regular stand-ups. Still, this minimum type of early activation can be recommended for acute stroke patients, mainly those with a cerebral infarction, who are able to cooperate with the nursing staff.

Benzodiazepines for treatment of patients with delirium excluding those who are cared for in an intensive care unit.

Delirium is a very common condition associated with significant morbidity, mortality, and costs. Current critical care guidelines recommend first and foremost the use of nonpharmacological strategies in both the prevention and treatment of delirium. Pharmacological interventions may augment these approaches and they are currently used widely in clinical practice to manage the symptoms of delirium. Benzodiazepines are currently used in clinical practice to treat behavioural disturbances associated with delirium but current guidelines do not recommend their use for this indication. The use of these medicines is controversial because there is uncertainty about whether they are effective for patients or have the potential to harm them. To assess the effectiveness and safety of benzodiazepines in the treatment of delirium (excluding delirium related to withdrawal from alcohol or benzodiazepines) in any healthcare settings other than intensive care units (ICU). We searched ALOIS: the Cochrane Dementia and Cognitive Improvement Group's Specialized Register up to 10 April 2019. ALOIS contains records of clinical trials identified from monthly searches of a number of major healthcare databases (including MEDLINE, Embase, PsycINFO, CINAHL, LILACS), numerous trial registries (including national, international and pharmaceutical registries), and grey literature sources. We included randomised controlled trials (RCTs) conducted in healthcare settings that ranged from nursing homes and long-term care facilities to any hospital setting except for ICUs, involving adult patients with delirium excluding those with delirium related to alcohol or benzodiazepine withdrawal. Included RCTs had to assess the effect of benzodiazepines, at any dose and given by any route, compared with placebo or another drug intended to treat delirium. Two review authors independently assessed study eligibility, extracted data, and assessed the risk of bias of included studies. We decided whether or not to pool data on the basis of clinical heterogeneity between studies. We used GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods to assess the quality of evidence. We identified only two trials that satisfied the selection criteria. We did not pool the data because of the substantial clinical differences between the trials. In one trial, participants (n = 58) were patients in an acute palliative care unit with advanced cancer who had a mean age of 64 years. All of the participants had delirium, were treated with haloperidol, and were randomised to receive either lorazepam or placebo in combination with it. Due to very serious imprecision, all evidence was of low certainty. We were unable to determine whether there were clinically important differences in the severity of delirium (mean difference (MD) 2.10, 95% CI -0.96 to 5.16; n = 50), length of hospital admission (MD 0.00, 95% CI -3.45 to 3.45; n = 58), mortality from all causes (risk ratio (RR) 0.33, 95% CI 0.04 to 3.02; participants = 58) or any of a number of adverse events. Important effects could not be confirmed or excluded. The study authors did not report the length of the delirium episode. In the other trial, participants (n = 30) were patients in general medical wards with acquired immune deficiency syndrome (AIDS) who had a mean age of 39.2 years. Investigators compared three drug treatments: all participants had delirium, and were randomised to receive lorazepam, chlorpromazine, or haloperidol. Very low-certainty evidence was identified, and we could not determine whether lorazepam differed from either of the other treatments in the effect on severity of delirium, any adverse event, or mortality from all causes. The study authors did not report the length of the delirium episode or the length of hospital admission. There is no enough evidence to determine whether benzodiazepines are effective when used to treat patients with delirium who are cared for in non-ICU settings. The available evidence does not support their routine use for this indication. Because of the scarcity of data from randomised controlled trials, further research is required to determine whether or not there is a role for benzodiazepines in the treatment of delirium in non-ICU settings.

Frequent Prescription of Antibiotics and High Burden of Antibiotic Resistance among Deceased Patients in General Medical Wards of Acute Care Hospitals in Korea.

BackgroundAntibiotics are often administered to terminally ill patients until death, and antibiotic use contributes to the emergence of multidrug-resistant organisms (MDROs). We investigated antibiotic use and the isolation of MDROs among patients who died in general medical wards.MethodsAll adult patients who died in the general internal medicine wards at four acute care hospitals between January and June 2013 were enrolled. For comparison with these deceased patients, the same number of surviving, discharged patients was selected from the same divisions of internal medicine subspecialties during the same period.ResultsDuring the study period, 303 deceased patients were enrolled; among them, 265 (87.5%) had do-not-resuscitate (DNR) orders in their medical records. Antibiotic use was more common in patients who died than in those who survived (87.5% vs. 65.7%, P<0.001). Among deceased patients with DNR orders, antibiotic use was continued in 59.6% of patients after obtaining their DNR orders. Deceased patients received more antibiotic therapy courses (two [interquartile range (IQR) 1–3] vs. one [IQR 0–2], P<0.001). Antibiotics were used for longer durations in deceased patients than in surviving patients (13 [IQR 5–23] vs. seven days [IQR 0–18], P<0.001). MDROs were also more common in deceased patients than in surviving patients (25.7% vs. 10.6%, P<0.001).ConclusionsPatients who died in the general medical wards of acute care hospitals were exposed to more antibiotics than patients who survived. In particular, antibiotic prescription was common even after obtaining DNR orders in patients who died. The isolation of MDROs during the hospital stay was more common in these patients who died. Strategies for judicious antibiotic use and appropriate infection control should be applied to these patient populations.

A Comparative Study to Assess the Determinants and Outcomes of Sepsis Treated in Medical Wards and ICU in an Indian Teaching Hospital.

Sepsis is the primary cause of death from infection worldwide. In resource-limited countries, increasing number of sepsis is managed in non-ICU settings, in Medical Wards (MW). To compare the burden, aetiology and short term outcome of sepsis treated in MW with ICU. Prospective, observational, analytical study in sepsis patients in general MW and medical ICU in a tertiary care hospital. Two hundred forty five sepsis patients (MW=150, ICU=95), ≥18 years, selected randomly, were studied to compare aetiology, co-morbidities, clinical & microbiological profile and short-term outcome between MW and ICU sepsis. Sepsis following surgery, trauma, those transferred to/from ICU, those with other life threatening diseases were excluded. Chi-square test/Fisher's-exact test was used for comparing ratios. A 'p-value' <0.05 was considered statistically significant. Sepsis was more common in elderly males, both in MW and ICU (median age: 56.7, 59.2 years; male: female ratios = 1.34:1, 1.63:1 respectively). Frequency of presenting symptoms, co-morbidities and sources of sepsis were similar in both groups (p>0.05). Frequency of positive microbiological culture, pattern of microbial flora and antimicrobial resistance patterns were similar in both groups (p>0.05). Number of antibiotics used was significantly higher in ICU compared to MW (p<0.01); multi-organ dysfunction and mortality were significantly higher in ICU settings (55.8% vs. 38.7%, p=0.04; 48.4% vs. 32.6%, p=0.041 respectively). While sepsis and severe sepsis were significantly higher in MW (34.6% vs. 22.1 %, p=0.03; 47.3% vs. 26.3%, p<0.01 respectively), septic shock was significantly higher in ICU (51.6% vs. 18.0%, p<0.01). Mortality in both settings was highest in septic shock (55.5% and 61.2%, p>0.05) and multi-organ dysfunction (55.1% and 64.2%, p>0.05). Duration of hospital stay was significantly shorter in MW than ICU (7.3 vs. 11.0 days, p<0.01). Our study aimed to identify determinants and outcome of sepsis in MW and compare with ICU settings. Antibiotic usage in the two settings differed: concurrent use of ≥3 antibiotics, and carbapenems & linezolid usage were significantly higher in ICU compared to MW. Sepsis in MW had significantly lower incidence of multi-organ failure, lower mortality and shorter hospital stay compared to ICU.

Ceftaroline fosamil for the treatment of community-acquired bacterial pneumonia in the intensive care unit.

The Clinical Assessment Program and Teflaro® Utilization Registry (CAPTURE) is a multicenter study evaluating the clinical use of ceftaroline fosamil in patients with community-acquired bacterial pneumonia (CABP) or acute bacterial skin and skin structure infection. Data were collected between August 2011 and February 2013, from 398 evaluable patients receiving treatment at 33 sites in the USA. This manuscript presents data collected from patients with CABP who received care in an intensive care unit (ICU) or in general medical wards (35% and 64% of evaluable patients, respectively). The majority of ICU and general medical ward patients had underlying comorbidities (78% and 74%, respectively), with structural lung disease being the most common (42% in the ICU and 40% in general medical wards). Patients admitted to the ICU had a longer duration of stay, a longer duration of symptoms before treatment, and a longer duration of ceftaroline fosamil therapy than did general medical ward patients. Most patients treated in the ICU and in general medical wards were given ceftaroline fosamil as second-line therapy (87% and 80%, respectively). The overall rate of clinical success for patients treated with ceftaroline fosamil was 68% in the ICU and 85% in the general medical wards. Clinical success for patients receiving ceftaroline fosamil as a second-line agent was 84% in the ICU and 86% in general medical wards. These findings indicate that ceftaroline fosamil is a viable treatment option for CABP, both in the ICU and in general medical wards.

A trial of a real‐time Alert for clinical deterioration in Patients hospitalized on general medical wards

With limited numbers of intensive care unit (ICU) beds available, increasing patient acuity is expected to contribute to episodes of inpatient deterioration on general wards. To prospectively validate a predictive algorithm for clinical deterioration in general-medical ward patients, and to conduct a trial of real-time alerts based on this algorithm. Randomized, controlled crossover study. Academic center with patients hospitalized on 8 general wards between July 2007 and December 2011. Real-time alerts were generated by an algorithm designed to predict the need for ICU transfer using electronically available data. The alerts were sent by text page to the nurse manager on intervention wards. Intensive care unit transfer, hospital mortality, and hospital length of stay. Patients meeting the alert threshold were at nearly 5.3-fold greater risk of ICU transfer (95% confidence interval [CI]: 4.6-6.0) than those not satisfying the alert threshold (358 of 2353 [15.2%] vs 512 of 17678 [2.9%]). Patients with alerts were at 8.9-fold greater risk of death (95% CI: 7.4-10.7) than those without alerts (244 of 2353 [10.4%] vs 206 of 17678 [1.2%]). Among patients identified by the early warning system, there were no differences in the proportion of patients who were transferred to the ICU or who died in the intervention group as compared with the control group. Real-time alerts were highly specific for clinical deterioration resulting in ICU transfer and death, and were associated with longer hospital length of stay. However, an intervention notifying a nurse of the risk did not result in improvement in these outcomes.

Dietary salt intake and stroke

Dietary salt intake and stroke

EDITORIAL: Addiction medicine: a new medical specialty in a new age of medicine

EDITORIAL: Addiction medicine: a new medical specialty in a new age of medicine

Epidemiology, etiology, and diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia in Asian countries

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are significant public health issues in Asian countries, as they are worldwide. Mortality attributable to HAP and especially VAP can be very high. The present review aims to determine whether the incidence and prevalence of HAP and VAP are higher in Asian countries than in Western countries, whether the organisms causing these nosocomial infections differ etiologically, and whether they are more difficult to treat (ie, demonstrate greater resistance). The implementation of available guidelines can be best achieved through an understanding of local epidemiology, etiology, and resistance patterns, which can facilitate optimal treatment choices. The current review presents data on epidemiology, etiology, and diagnosis of HAP and VAP drawn from an expert panel of clinicians representing 10 Asian countries.

Energy and nutrient intake of patients in acute care.

There have been numerous reports that the nutritional intake of many hospitalized patients is sub-optimal, but there is little published information about patients' diets in Australian hospitals. In this study, the nutritional intake of patients in general medical wards of an Australian acute care hospital was assessed. Although the hospital diet can provide adequate energy and nutrients, many patients may not consume sufficient food to meet their needs. The estimated energy intake of about one-third of patients was very low, and vitamin C, calcium and zinc intakes were also of concern. The implications are discussed and recommendations for improved nutritional care are suggested.

Patients in the intensive care unit suffer from severe lack of sleep associated with loss of normal melatonin secretion pattern.

Patients hospitalized in the intensive care unit (ICU) tend to become agitated and confused, and many even develop temporary psychoses (the ICU syndrome). We wondered whether the regulation of sleep and the secretion of melatonin is abnormal in ICU patients. Therefore, we studied the association of sleep-wake pattern in patients hospitalized in the ICU, their melatonin secretion rates, and profile compared with a control group of patients in general medical wards. Sleep was assessed by actigraphy. Urine was collected every 3 hours for 24 hours. Melatonin secretion was assessed by measuring the melatonin metabolite 6-sulphatoxymelatonin by enzyme-linked immunosorbent assay. Actigraphy suggested that the ICU patients lacked normal sleep behavior for the entire study period, except for occasional short naps. Compared with controls, the nocturnal peak of melatonin secretion was absent, except in two patients in the nonventilated group, and showed a flat curve. Our results suggest that lack of sleep is indeed a severe problem in ICU patients and is accompanied by impairment of normal melatonin secretion. The possibility that melatonin administration may prove useful in improving sleep patterns in ICU patients deserves further study.

Incidence of nosocomial pneumonia in a medical intensive care unit and general medical ward patients in a public hospital in Bombay, India

We prospectively studied the incidence of hospital-acquired pneumonia in 1886 consecutive admissions to an 1800 bed hospital in Bombay; 991 of them to general medical wards and 895 to a 17-bed medical intensive care unit (ICU). The average bed occupancy in the general wards was 56 patients in a ward with 40 beds. Staffing in the general ward was two nurses for 56 patients, and in the ICU three nurses for 17 beds. One hundred and sixty-eight patients developed nosocomial pneumonia: 18 (1·8%) in general wards and 150 (16·7%) in the ICU. Common isolates included Pseudomonas spp (44%) and Klebsiella spp (34%). The most frequently used antibiotics were cefotaxime (34%), amikacin (25%), gentamicin (23%) and ofloxacin (13%). Crude mortality in general ward patients was 88·9 vs 14·6% in patients without pneumonia. The corresponding figures for ICU patients were 67·4 vs 37·1%; 40% of the crude mortality in ICU patients with pneumonia was attributable to the infection. Infected patients stayed an additional 5·8 days in the ICU and 6·7 days in the general ward. Costs of additional stay and antibiotics accounted for 18·6% of the ICU budget. The incidence of nosocomial pneumonia was lower than expected, despite occupancy exceeding bed capacity, low nurse:patient ratios, and extensive reuse of disposable respiratory therapy equipment. Nevertheless, nosocomial pneumonia imposes a significant financial burden on the already scarce resources available for intensive care in developing countries like India.

Feasibility of an acute stroke home care service for elderly patients

Since 1985, a home hospitalization service (HHS) has been operating in Turin. HHS allows to perform diagnostic and therapeutic interventions which are usually made in hospital, also at home. HHS has started a stroke care project since the beginning. This study was designed to assess the feasibility of home care for elderly patients, aged over 65 years, after an acute stroke and to identify the benefits of this care setting. The study was conducted on 40 randomized patients with ischemic stroke, admitted to the emergency department of our hospital; 20 of them were managed at home by HHS, and 20 in a general medical ward (GMW). Both groups were examined using the same protocol and received the same medical and rehabilitation therapy. Mortality and length of stay was not significantly different in either of the two care settings. Compared with the GMW patients, HHS patients presented a significant improvement of functional status assessed by functional independence measure (FIM).

General nurses’ attitudes to patients who self-harm

This article describes the prevalence of suicidal behaviour, both nationally and in relation to one inner city district general hospital. The authors discuss what is currently known about risk assessment for identifying those patients likely to repeat the act in the near future. They also examine the findings of a recent survey about nurses' perceptions and attitudes to patients who take deliberate drug overdoses. The survey found that nurses possessed some of the facts about risk factors relating to future parasuicidal intent and displayed generally professional attitudes to the treatment of these patients in general medical wards and A&E, but they appeared to show negative personal reactions after caring for patients who self-harm.

Screening and Referral of Alcoholic Patients in a General Hospital

A clinical trial investigating the evaluation and individualized referral of alcoholic patients in general medical wards, as compared to simple abstinence counselling, is reported. Individualized referral included a complete medical and psychosocial evaluation of the patient’s condition, followed by a multidisciplinary meeting aimed at defining individualized therapeutic proposals organized in a network of specific therapy and support. Screening (using the Michigan Alcoholism Screening Test) identified 107 patients. Eligible patients (n = 53), including those who refused to be randomized (n = 17) as well as those who were randomized (n = 36), were followed for 1 year. The study was limited by several problems arising from trial-related methods as well as from patient-related characteristics, such as a low rate of screening by residents, a high rate of exclusion (51 %), a high rate of randomization refusal (32%) as well as a high attrition rate after 1 year (42%). Among patients who were followed, we observed a high rate of abstinence (57%), which was longer in the intervention group, and was correlated with improved biological markers and scores in a quality-of-life questionnaire. This study emphasizes the need for other similar but larger trials; their design should take into consideration the methodological difficulties encountered in the present study, in order to limit the high exclusion and attrition rates.

Prediction of mortality in patients in acute medical wards using basic laboratory and anthropometric data.

The value of anthropometric and biochemical indices in predicting short-term mortality among patients in general medical wards was assessed in 294 patients admitted consecutively to a district hospital over a one month period. Using a stepwise logistic regression model and supported by the linear discriminant analysis method, mortality within 3 months could be predicted with sensitivity of 83% and specificity of 84% using the following variables: sex, functional ability, urea, total protein, alkaline phosphatase and albumin-adjusted calcium. Addition of anthropometric values and biochemical nutritional indices did little to improve the accuracy of the prediction, contrary to previous findings among surgical patients and elderly residents of long-term care institutions.

A reassessment of nurses' attitudes towards stroke patients in general medical wards

This paper summarizes a research study inquiring into the attitudes of qualified nursing staff and nursing auxiliaries towards stroke patients in general medical wards. The survey was undertaken on eight mixed-sex general medical wards in a large general hospital. All wards are used for clinical nursing experience for nurses in training. Each of the wards, despite having a particular interest in one or more medical specialities, regularly admit patients following stroke. All nurses were therefore familiar and in regular contact with this particular client group. A Likert scale with demonstrated reliability and validity was employed as the data collection instrument. Results indicated that nurses were largely ambivalent in their attitudes towards stroke rehabilitation. The patterns of responses indicate that the nurses who have the more positive attitudes about stroke patients consider that they have a role in stroke rehabilitation and that they value the nursing contribution. The nurses with less positive attitudes towards stroke patients see stroke patients as unco-operative and demanding. The findings suggest the need for specific education for the role of the nurse as a rehabilitator.