Patient discharge Research Papers - Academia.edu (original) (raw)

This study evaluates the effectiveness of a performance-focused methodology for engaging multidisciplinary, frontline healthcare teams in making behavioural changes that improve patient care and health system efficiency. Results include significant declines in average length of stay in hospital and waiting time for surgery, and a dramatic increase in early patient ambulation. Performance-focused methodology using key performance indicators, targets, measurement, and ongoing feedback, supported by non-monetary incentives, can quickly improve healthcare outcomes.

- by
- •
- Medicine, Motivation, Healthcare Management, Length of Stay
- by H. Johnson and +1
- •
- Engineering, Physics, Chemistry, Biology

This study examined risk and determinants of rehospitalization of children and adolescents (n = 186) following a first psychiatric hospitalization. It specifically examined the role of postdischarge services. Data were collected for a 30-month follow-up period through structured telephone interviews with caregivers and case record abstractions. 43% of youth experienced readmissions during the follow-up period. Risk of rehospitalization was highest during the first 30 days following discharge and remained elevated for 3 months. 72% of youth received 284 postdischarge services during the follow-up period, which significantly reduced the risk of rehospitalization. Longer first hospitalizations and a higher risk score at admission increased risk.

- by RL Smith
- •
- Psychology, Risk, Mental Health Policy, Adolescent

The prevalence and short-term outcomes of hypertensive urgency (systolic blood pressure ≥180 mm Hg and/or diastolic blood pressure ≥110 mm Hg) are unknown. Guidelines recommend achieving blood pressure control within 24 to 48 hours. However, some patients are referred to the emergency department (ED) or directly admitted to the hospital, and whether hospital management is associated with better outcomes is unknown. To describe the prevalence of hypertensive urgency and the characteristics and short-term outcomes of these patients, and to determine whether referral to the hospital is associated with better outcomes than outpatient management. This retrospective cohort study with propensity matching included all patients presenting with hypertensive urgency to an office in the Cleveland Clinic Healthcare system from January 1, 2008, to December 31, 2013. Pregnant women and patients referred to the hospital for symptoms or treatment of other conditions were excluded. Final follow-up wa...

- by Krishna Patel
- •
- Emergency Medical Services, Hypertension, Hospitalization, United States

The effects of implementation WHO/UNICEF Breastfeeding Hospital Initiative (BFHI) and community postnatal support on breastfeeding rates were examined during and after the breastfeeding promotion campaign in one county of Croatia. Comparison with a control group indicated increase of breastfeeding prevalence in a period of BFHI implementation (1994-1998) - 68% vs. 87% at infant age 1 mo., 30% vs. 54% at 3 mo., 11.5% vs. 28% at 6 mo., and 2% vs. 3.5% at infant age 11-12 mo. (chi-square test, p < 0.05). More considerable increase has been noticed in period 1999-2000 which is characterized by breastfeeding support groups activity: 68% vs. 87% at infant age 1 mo., 30% vs. 66% at 3 mo., 11.5% vs. 49% at 6 mo., and 2% vs. 23% at infant age 11-12 mo. (chi-square test, p < 0.05). Our conclusion is that activities aiming to promote breastfeeding in maternity hospitals have had limited success. They have resulted in satisfactory increase of breastfeeding prevalence in early infant's...

- by Jadranka Bozikov
- •
- Anthropology, Health Promotion, Social Support, Self Help Groups
- by Norman Dy
- •
- Research Design, Medicine, Software, Internal Medicine
- by Bernard Ewigman
- •
- Family Medicine, United States, Logistic Models, Patient discharge

Objective: To determine whether infants with chronic lung disease (CLD), ready for neonatal unit discharge, maintain cardiorespiratory stability while sleeping supine. Methods: Subjects were 15 infants born <32 weeks gestational age (GA) and ready for discharge from the regional tertiary neonatal intensive care unit. Polysomnography recordings of sleep state, heart rate, arterial oxygen saturation, respiratory effort and nasal/oral airflow were taken prone and supine for up to 3 h post feed with the first position randomly allocated. The main outcome measures were oxygen saturation and apnoea hypopnoea index (AHI). Results: Seven infants (median GA 27 weeks, birthweight 945 g) had CLD and eight infants (median GA 29 weeks, birthweight 1160 g) did not. CLD infants were more mature at study than non-CLD infants (median 39 vs 36 weeks, P = 0.019). Neither oxygen saturation nor AHI were position dependent and no group differences were noted with respect to CLD status. There was a significant interaction of GA and sleep position with less-mature infants spending less time in quiet sleep (QS) in supine position (P = 0.006). These less-mature infants also had a higher AHI (P = 0.033). As expected, the AHI and arousal index (AI) were higher in active sleep (P ≤ 0.001, P = 0.013, respectively) and mean oxygen saturation was lower (P = 0.001). Conclusions: The supine position appears appropriate for very preterm infants with CLD going home from the neonatal unit. Respiratory instability on neonatal discharge is more likely to be associated with immaturity than CLD.

- by Dorota Doherty
- •
- Paediatrics, Chronic Disease, Lung Diseases, Sleep

This paper presents an in-depth, idiographic study examining the lived experience of chronic pain following spinal cord injury (SCI). Neuropathic pain (NP) occurs in a large majority of the SCI population and is particularly intractable to treatment. It can be both psychologically and physically debilitating. This study examines how the experience of NP is mediated by its meaning to the sufferer. Method: Semi-structured interviews were conducted with eight people with SCI and chronic NP, attending outpatient clinics at a specialist SCI Centre in the UK. Verbatim transcripts were subjected to interpretative phenomenological analysis in order to further understand the experience. Results: Analysis suggested that NP has powerful consequences upon the sufferer's physical, psychological, and social well-being, in line with a biopsychosocial understanding of pain. Three super-ordinate themes were identified: a perceived gap between treatments received and participants' views of what they wanted and needed; a fight for life control and acceptance; and feeling understood by others with SCI, but isolated from the non-understanding able-bodied. Conclusions: The results are discussed in terms of the possible application of acceptance-based therapy to NP and the potential for the alleviation of the debilitating consequences of NP.

- by Philip Fine
- •
- Qualitative methodology, Chronic Pain, Quality of life, Qualitative Research

Transitions of care pose significant risks for patients with complex medical histories. There are few experiential medical education curricula targeting this important aspect of care. We designed and tested an internal medicine transitions of care experience integrated into interns' ambulatory curriculum. The program included 1-hour group didactics, a posthospitalization discharge visit in pairs with a home care nurse (cohort 1: 2011-2012; cohort 2: 2012-2013), and a half-day small-group visit to a skilled nursing facility led by a faculty member in geriatrics (cohort 2 only). Both visits had structured debriefings by faculty in geriatrics. For cohort 1, a quantitative follow-up survey was administered 18 to 20 months after the experience. For cohort 2, reflections were analyzed. Thirty-three of 42 second-year residents (79%) in cohort 1 who participated in didactics and a home visit completed the survey. Seventy-six percent (25 of 33) reported increased knowledge of interprofes...

- by Christina Whitehouse
- •
- Geriatrics, Patient Safety, Problem Based Learning, Medicine

Background Health records are essential for good health care. Their quality depends on accurate and prompt documentation of the care provided and regular analysis of content. This study assessed the quantitative properties of inpatient health records at the Federal Medical Centre, Bida, Nigeria. Method A retrospective study was carried out to assess the documentation of 780 paper-based health records of inpatients discharged in 2009. Results 732 patient records were reviewed from the departments of obstetrics (45.90%), pediatrics (24.32%), and other specialties (29.78%). Documentation performance was very good (98.49%) for promptness recording care within the first 24 h of admission, fair (58.80%) for proper entry of patient unit number (unique identifier), and very poor (12.84%) for utilization of discharge summary forms. Overall, surgery records were nearly always (100%) prompt regarding care documentation, obstetrics records were consistent (80.65%) in entering patients' names in notes, and the principal diagnosis was properly documented in all (100%) completed discharge summary forms in medicine. 454 (62.02%) folders were chronologically arranged, 456 (62.29%) were properly held together with file tags, and most (80.60%) discharged folders reviewed, analyzed and appropriate code numbers were assigned. Conclusions Inadequacies were found in clinical documentation, especially gross underutilization of discharge summary forms. However, some forms were properly documented, suggesting that hospital healthcare providers possess the necessary skills for quality clinical documentation but lack the will. There is a need to institute a clinical documentation improvement program and promote quality clinical documentation among staff.

- by abdullahi jibril
- •
- Engineering, Medical Informatics, Documentation, Nigeria

Objective To test a theoretical model examining processes through which a parent-focused educationalbehavioral intervention [Creating Opportunities for Parent Empowerment (COPE)] relates to children's posthospital adjustment problems. Methods Mothers (n ¼ 143) and their 2-7-year-old children, unexpectedly hospitalized in two pediatric intensive care units, were randomized to COPE or control conditions. Maternal measures included parental beliefs, anxiety, negative mood, and child adjustment 3 months post discharge. Observers rated maternal support of their children during hospitalization. Results Structural equation modeling suggested that the model tested provided a reasonable fit to the data [w 2 (97 df) ¼ 129.43; p ¼ .016; root mean square error of approximatio n ¼ .048; comparative fit index ¼ .95]. COPE effects on children's post-hospital externalizing behaviors were indirect, via associations with parental beliefs and maternal negative mood state. Furthermore, COPE participation was associated with more maternal support of their children, which was also associated with less internalizing and externalizing behaviors 3 months post discharge. Conclusion Implementing COPE may help avert future mental health problems in this high risk population. Understanding the processes by which an already empirically validated program relates to child outcomes is likely to aid clinicians and administrators in the widespread uptake of the COPE program.

- by Linda Alpert-Gillis
- •
- Program Evaluation, Mental Health, Pediatric Psychology, Child
- by Odhrán Murray
- •
- Quality Improvement, Morale, Orthopedics, Clinical Sciences

BACKGROUND: The pediatric hospital discharge process presents significant challenges, and medication discrepancies remain an unsolved problem. The purpose of this study was to determine the discrepancy rates at the time of discharge when multiple sources of medication documentation exist, and to characterize the medication discrepancies into error type, medication category, and discharge summary authorship.

- by Kerry Mychaliska
- •
- Pharmacy, Documentation, Electronic Health Records, Prospective studies

There is fragmented information about the different needs following a spinal cord injury (SCI). Expressed SCI needs can be met or unmet, they change along the rehabilitation continuum (eg, acute, rehabilitation and reintegration into the community) and can be different for traumatic and non traumatic SCI. The general objective of this scoping study is to evaluate and integrate the needs of individuals with traumatic and non-traumatic SCI, their family caregivers and those reported by rehabilitation professionals from the time of rehabilitation admission to community reintegration. The specific objectives are to: (A) synthesise the needs of individuals with SCI as perceived by themselves, their family caregivers and rehabilitation professionals using two theoretical models, (B) classify needs as met and unmet, (C) explore the evolution of met/unmet needs from the time of rehabilitation admission to community reintegration and (D) provide recommendations to improve SCI care. METHODS A...

- by Diana Zidarov
- •
- Research Design, Psychometrics, Family, Quality of life

Background: Congestive cardiac failure (CCF) has emerged as a major public health problem worldwide and imposes an escalating burden on the health care system. Objective: To determine the causes and mortality rate of CCF in the University of Port Harcourt Teaching Hospital (UPTH), south Nigeria, over a five-year period from January 2001 to December 2005. Methods: A retrospective study of CCF cases were identified from the admission and discharge register of the medical wards of UPTH and the case notes were retrieved from the medical records department and analyzed. Results: There were 423 patients: 242 males and 181 females. Their ages ranged from 18 to 100 years with a mean of 54.4 ± 17.3. The commonest causes of CCF were hypertension (56.3%) and cardiomyopathy (12.3%). Chronic renal failure, rheumatic heart disease, and ischemic heart disease accounted for 7.8%, 4.3%, and 0.2% of CCF, respectively. Peripartum heart disease was rare despite being commonly reported in northern Nigerian females. Eighteen patients died from various complications with a mortality rate of 4.3%. Conclusion: The burden of CCF in the Niger Delta is mainly attributed to hypertension. Efforts should be geared towards hypertension awareness, detection, treatment, and prevention in the region.

- by Arthur Onwuchekwa
- •
- Nigeria, Adolescent, Heart Failure, Pregnancy

Comprehensive rehabilitation services after acute stroke have been shown efficacious in European trials; however, their effectiveness in everyday practices in the United States is unknown. We compared outcomes of veteran patients provided with comprehensive rehabilitation with those provided with consultative rehabilitation services after acute stroke using propensity scores. Outcomes included change in patients' physical and cognitive independence after rehabilitation, discharge to home as opposed to other settings, and 1-yr after hospital discharge survival. Of the 2,963 patients in the study, 683 (23.1%) received comprehensive rehabilitation while the remaining patients received consultative services. We found, after propensity adjustment, that those who received comprehensive rehabilitation compared with consultative gained on average 12.8 (95% confidence interval [CI]: 9.1 to 16.5) more points of physical independence on a 78-point scale and gained 1.5 (95% CI: 0.8 to 2.2) more points of cognitive independence on a 30-point scale. The likelihoods of discharge to home from the hospital (odds ratio [OR] = 1.61, 95% CI: 1.07 to 2.44) and 1 yr posthospital discharge survival (OR = 1.79, 95% CI: 1.25 to 2.56) were significantly higher among those who received comprehensive rehabilitation. Among patients hospitalized for acute stroke, comprehensive rehabilitation services are associated with greater recovery of physical and cognitive independence, improved home discharge likelihood, and improved 1 yr survival.

- by Diane Cowper-Ripley
- •
- Cognition, Medicine, Stroke, Hospitalization

Rationale, aims and objectives The accuracy of health care professionals in reporting safety events determines their usefulness for both system improvement and research. The study objectives were to: (1) validate (assess the accuracy of) the reasons recorded by doctors and pharmacists for discontinuing medication orders at discharge in a hospital's electronic patient records (EPR); (2) investigate the causes of any detected recording inaccuracy; and (3) collect preliminary data on the frequency and types of medication discontinuation. Methods This was a validation study in one English hospital. The study comprised two steps: extraction of discontinued medication orders from the EPR followed by short structured interviews with doctors and pharmacists who made the discontinuation. A total of 104 discontinued orders were discussed during 15 face-to-face and six telephone interviews. The software package spss was used for data analysis. Results Duplication of therapy (27, 25.2%), omission of drug (23, 21.5%) and dosage regimen change (19, 17.8%) were the three most frequent reasons given for discontinuing medications. The majority of recorded discontinuation reasons were correct (100, 96.2%) and complete (101, 97.1%), and hence were judged accurate (97, 93.3%). The difference in accurate recording between doctors (15, 88.2%) and pharmacists (82, 94.3%) was not statistically significant. Potential causes of recording inaccuracy included: slip or lapse, lack of training, carelessness and electronic system rigidity. Conclusion This study showed that doctors and pharmacists recorded accurate reasons for the majority of the discontinued medication orders. It also showed that utilizing pharmacists' recorded reasons during clinical interventions using EPR was beneficial in understanding and characterizing prescribing errors. Although they require further research, the reasons identified present preliminary data about the most prevalent types of pharmacists' interventions during hospital discharge.

- by Husni Abdelqader
- •
- Medicine, Physicians, HUMAN ERROR, Accuracy

Inpatient discharge instructions provide critical information for patients to manage their own care. These instructions are typically free-text and not easy for patients to understand and remember. In this pilot study, we developed a set of pictographs through a participatory design process and used them to enhance two mock-up discharge instructions. Tested on 13 healthy volunteers, the pictograph enhancement resulted in statistically significant better recall rates (p<0.001). This suggests that patient comprehension and recall of discharge instructions could be improved by supplementing free texts with pictographs.

- by Qing Zeng-treitler
- •
- Multimedia, Comprehension, Patients, Boston

There is little research literature on patient flow in rehabilitation. Accepted definitions of barriers to discharge and agreed performance measures are needed to support research and understanding of this topic. The potential of improved patient flow in rehabilitation to assist relieving demand pressures in acute hospitals underscores its importance. This study develops a definition of barriers to discharge from postacute care and classifies their causes using a multiphased iterative consultation and feedback process involving physiatrists, aged-care physicians, and senior nursing and allied health clinicians. Key performance indicators (KPIs) for postacute patient flow are then proposed, the development of which were informed by the available literature and a survey (nZ101) of physiatrists, aged-care physicians, and hospital managers with responsibility for patient flow who were questioned about the use of relevant KPIs in this setting. Most (>70%) respondents believed that using KPIs (eg, waiting time from acceptance by postacute care and ready for transfer until admission, percentage of postacute bed days occupied by inpatients with a discharge barrier) to measure aspects of patient flow could improve processes, but few reported collecting this information (45% admission KPIs, 19% discharge KPIs). By using the definition and classification of discharge barriers prospectively to document and address barriers, in conjunction with appropriate KPIs, postacute patient flow and the efficiency of hospital resource utilization can potentially be improved. Our commentary aims to stimulate interest among others to develop a more robust evidence base for improved flow through postacute care.

- by John Olver
- •
- Operations Research, Medicine, ICF, Prospective studies

The arrest rates of nearly 2,000 psychiatric patients released from psychiatric centers in 1968 and those of nearly 2,000 patients released in 1975 were compared with the arrest rates of a group of 5,000 patients studied 25 years earlier. In general, arrest rates among the two recent samples were considerably higher than general population rates, primarily because of the large proportion of patients previously arrested. Other characteristics related to subsequent arrest were age and admitting diagnosis. One additional finding was that the number of patients with prior arrests had increased markedly over the years.

- by Mary Evans
- •
- Criminal Law, Violence, Criminal Psychology, Adolescent

BACKGROUND AND OBJECTIVES: Discharging patients from the NICU may be delayed for nonmedical reasons including the need for medical equipment, parental education, and children's services. We describe a method to predict which patients will be medically ready for discharge in the next 2 to 10 days, providing lead time to address nonmedical reasons for delayed discharge. METHODS: A retrospective study examined 26 features (17 extracted, 9 engineered) from daily progress notes of 4693 patients (103 206 patient-days) from the NICU of a large, academic children's hospital. These data were used to develop a supervised machine learning problem to predict days to discharge (DTD). Random forest classifiers were trained by using examined features and International Classification of Diseases, Ninth Revision-based subpopulations to determine the most important features. RESULTS: Three of the 4 subpopulations (premature, cardiac, gastrointestinal surgery) and all patients combined performed similarly at 2, 4, 7, and 10 DTD with area under the curve (AUC) ranging from 0.854 to 0.865 at 2 DTD and 0.723 to 0.729 at 10 DTD. Patients undergoing neurosurgery performed worse at every DTD measure, scoring 0.749 at 2 DTD and 0.614 at 10 DTD. This model was also able to identify important features and provide "rule-of-thumb" criteria for patients close to discharge. By using DTD equal to 4 and 2 features (oral percentage of feedings and weight), we constructed a model with an AUC of 0.843. CONCLUSIONS: Using clinical features from daily progress notes provides an accurate method to predict when patients in the NICU are nearing discharge.

- by Chris Lehmann
- •
- Pediatrics, Forecasting, Newborn Infant, Time Factors

To verify whether the use of the T-piece resuscitator compared with the self-inflating bag in preterm infants ventilated at birth modifies survival to hospital discharge without major morbidities. Pragmatic prospective cohort study. 20 Brazilian university hospitals of Brazilian Network on Neonatal Research. Patients were 1962 inborn infants in 2014-2015 ventilated at birth with 23-33' weeks gestation and birth weight 400-1499 g without malformations. Patients transferred until the 27th day after birth were excluded. Positive pressure ventilation at birth with T-piece resuscitator or self-inflating bag without positive end expiratory pressure valve. Intervention with ventilation followed the Brazilian Society of Pediatrics guidelines. The choice of the equipment was at the neonatologist's discretion in each delivery. The main outcome measures were survival to hospital discharge without bronchopulmonary dysplasia, severe peri-intraventricular haemorrhage and periventricular l...

- by Walusa Assad Gonçalves Ferri
- •
- Brazil, Survival Analysis, Medicine, Pregnancy

Background: Although emergency department (ED) discharge is often based on the presumption of continued care, the reported compliance rate with follow-up appointments is low. Study Objectives: The objectives of this study are to identify factors associated with missed follow-up appointments from the ED and to assess the ability of clinicians to predict which patients will follow-up. Methods: Patients without insurance or an outpatient primary care provider (PCP) were given a followup clinic appointment before discharge. Information identifying potential follow-up barriers was collected, and the physician's perception of the likelihood of follow-up was recorded. Patients who missed their appointment were contacted via telephone and were offered a questionnaire and a rescheduled clinic appointment. Results: A total of 125 patients with no PCP were enrolled. Sixty (48%; 95% confidence interval, 39-57) kept their scheduled appointment. Sex, distance from clinic, availability of transportation, or time since last nonemergent physician visit was associated with attendance to the follow-up visit. Clinicians were unable to predict which patients would follow-up. Contact by telephone was made in 48 (74%) of patients who failed to follow-up. Of the 14 patients willing to reschedule, none returned for follow-up. Conclusion: Among ED patients who lack a PCP and are given a clinic appointment from the ED, less than half keep the appointment. Moreover, clinicians are unable to predict which patients will follow up. This study highlights the difficulty in maintaining continuity of care in populations who are self-pay or have Medicaid and lack regular providers. This may have implications on discharge planning from the ED.

- by Kumar Alagappan
- •
- Emergency Medicine, Health insurance, Prospective studies, Continuity of Care

Children are not just 'small adults'. They have specific physical, psychological and social requirements that must be identified and addressed to optimise their well-being in the perioperative period. The healthcare practitioner should be trained to understand the needs of the paediatric patient in hospital, including the ever increasing need to take into account cultural differences. Hospital policy should include a preoperative preparation programme, specially aimed at the paediatric population, where parental involvement is encouraged throughout.

- by Emeka Oragui
- •
- Psychology, Nursing, Pain, Fear

Adolescent inpatient psychiatric treatment was evaluated from the multiple perspectives of clinicians, young people, and parents using standardised measures and goal-based outcomes (GBOs). The sample included cases (N = 128) discharged from a London adolescent unit between April 2009 and December 2015. Measures were completed at admission and discharge, and change in ratings analysed to assess treatment outcomes. Ratings of clinicians and young people on the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) were compared. Adolescents demonstrated significant improvement across all measures from admission to discharge. Correlation between clinicians' and adolescents' HoNOSCA ratings was weak at admission (r = .25) but stronger at discharge (r = .63). Standardised effect sizes were larger for GBOs (d = 1.73 and 3.16 for adolescent and clinician-rated goals respectively) compared to all standardised measures (d = 0.31-0.93). Improvement was observed across all measures of functioning and symptoms following inpatient treatment. Clinicians and young people developed better shared understanding of the problems from admission to discharge. GBOs are more sensitive to change compared to standardised measures and may be meaningfully adopted by inpatient units for routine outcome monitoring.

- by Pippa` Hembry
- •
- Adolescent, Multidisciplinary, Mental Disorders, Patient Admission

In the three decades since the definitive decisions regarding duty to warn and protect, several cases have shaped psychiatric practice. In this article we present a tragic case that we postulate may have a significant effect on psychiatric practice in Canada. A psychiatric patient murdered a relative some 50 days after the patient left the hospital. On the day before his release, the patient's status was changed from involuntary to voluntary. We argue that this case may result in a reversal of current mental health and social policy, whereby psychiatrists will be less willing to release difficult and potentially dangerous patients. To provide context to the case, we review some concepts of the literature and recent legal cases pertaining to the release of such patients.

- by Graham Glancy
- •
- Law, Psychiatry, Homicide, Expert testimony

Background: Decreased functional ability is common in older adults after hospitalisation. Lower levels of functional ability increase the risk of hospital readmission and nursing care facility admission. Discharge planning across the hospital and community interface is suggested to increase functional ability and decrease hospital length of stay and hospital readmission. However evidence is limited and the benefits of occupational therapists providing this service has not been investigated. This randomised trial will investigate the clinical effectiveness of a discharge planning program in reducing functional difficulties of older adults post-discharge. This trial will also examine the cost of the intervention and cost effectiveness when compared to in-hospital discharge planning. Methods/design: 400 participants admitted to participating hospitals will be recruited. Participants will be 70 years of age and over, have no significant cognitive impairment and be independently mobile at discharge. This study protocol was approved by the ethics committee of

- by Lindy Clemson
- •
- Occupational Therapy, Treatment Outcome, Clinical Sciences, Aged

Background Physical therapists and occupational therapists practicing in acute care hospitals play a crucial role in discharge planning. A standardized assessment of patients' function could be useful for discharge recommendations. Objectives The study objective was to determine the accuracy of “6-Clicks” basic mobility and daily activity measures for predicting discharge from an acute care hospital to a home or institutional setting. Design The study was retrospective and observational. Methods “6-Clicks” scores obtained at initial visits by physical therapists or occupational therapists and patients' discharge destinations were used to develop and validate receiver operating characteristic curves for predicting discharge destination. Positive predictive values (PPV), negative predictive values (NPV), and likelihood ratios were calculated. Results Areas under the receiver operating characteristic curves for basic mobility scores were 0.857 (95% confidence interval [CI]=0.85...

- by Alan Jette
- •
- Occupational Therapy, Adolescent, Physical Therapy, Activities of Daily Living

Learning from patient records may aid knowledge acquisition and decision making. Existing inductive machine learning (ML) systems such us Newld, CN2, C4.5 and AQl5 learn from past case histories using symbolic a&or numeric values. These systems learn symbolic rules (IF... THEN like) which link an antecedent set of clinical factors to a consequent class or decision. This paper compares the learning performance of alternative ML systems with each other and with respect to a novel approach using logic minimization. called LML, to learn from data. Patient cases were taken from the archives of the Paediatric Surgery Clinic of the University Hospital of Crete, Heraklion. Greece. Comparison of ML system performance is based both on classification accuracy and on informal expert assessment of learned knowledge.

- by Michalis Blazadonakis
- •
- Engineering, Algorithms, Artificial Intelligence, Expert Systems
- by Arkotong Longkumer
- •
- Business, Psychology, Computer Science, Nursing

Earn Up to 8.5 CE Hours. See page 596. D ischarge planning has become increasingly important, with current trends toward shorter hospital stays, increased health care costs, and more community-based health services. Effective discharge planning ensures the safety and ongoing care for patients, 1 and it also benefits health care providers and organizations. It results in shorter hospital stays, fewer readmissions, higher access rates to post-hospitalization services, greater patient satisfaction with the discharge, and improved quality of life and continuity of care. All acute care patients and their caregivers require some degree of preparation for discharge home-education about their health status, risks, and treatment; help setting health goals and maintaining a good level of self-care; information about community resources; and follow-up appointments and referrals to appropriate community health providers. Inadequate preparation exposes the patient to unnecessary risks of recurrence or complications of the acute complaint, neglect of nonacute comorbidities, mismanagement and side effects of medication, disruption of family and social life, emotional distress, and financial loss. The result may be re-presentation to the emergency department. It is noteworthy that up to 18% of ED presentations are revisits within 72 hours of the original visit 5 ; many of these are considered preventable. 6

- by Helen Chapman
- •
- Nursing, Emergency, Emergency Nursing, Clinical Sciences

Aim. This paper is a report of a study of the process of social rehabilitation, and the analysis of the main elements and influencing factors which are important in the process. Background. The process of social rehabilitation lacks conceptual and empirical understanding in Neurology because most rehabilitation programmes have focused on cognitive and physical recovery. Methods. An action research project was undertaken in two neurological wards of a highly specialized hospital in Spain, and was completed in 2006. A social rehabilitation programme based on the assessment of social needs and individualized social education was planned with health professionals, and implemented and evaluated with patients and carers. Several instruments were used to explore how patients and carers perceived the process of social rehabilitation before and after the programme: semi-structured interviews, socio-demographic forms, field notes, participant observations, and scales of activities of daily living, social impairment and adjustment. Comparative content and statistical analyses were undertaken. Findings. Social rehabilitation was identified as a dynamic process in which the environment, activities, social interaction, self-recognition and awareness of social problems, coping and satisfaction played an essential role. Some defining criteria for social rehabilitation related to patients' and carers' attitudes, behaviour and the external implications that the socialization process had for them. Conclusion. This study shows the advantages of multidisciplinary work, and user and family involvement in social rehabilitation and provides in-depth knowledge about how patients and carers experience and could face barriers to develop a role in their family environment, social groups and society.

- by Sarah Cowley
- •
- Nursing, Long Term Care, Health Services Research, Activities of Daily Living

BACKGROUND: Tracheostomy practice in patients with acute respiratory failure (ARF) varies greatly among institutions. This variability has the potential to be reflected in the resources expended providing care. In various healthcare environments, increased resource expenditure has been associated with a favorable effect on outcome. OBJECTIVE: To examine the association between institutional resource expenditure and mortality in ARF patients managed with tracheostomy. METHODS: We developed analytic models employing the University Health Systems Consortium (Oakbrook, Illinois) database. Administrative coding data were used to identify patients with the principal diagnosis of ARF, procedures, complications, post-discharge destination, and survival. Mean resource intensity of participating academic medical centers was determined using risk-adjusted estimates of costs. Mortality risk was determined using a multivariable approach that incorporated patient-level demographic and clinical variables and institution-level resource intensity. RESULTS: We analyzed data from 44,124 ARF subjects, 4,776 (10.8%) of whom underwent tracheostomy. Compared to low-resource-intensity settings, treatment in high-resource-intensity academic medical centers was associated with increased risk of mortality (odds ratio 1.11, 95% CI 1.05-1.76), including those managed with tracheostomy (odds ratio high-resource-intensity academic medical center with tracheostomy 1.10, 95% CI 1.04-1.17). We examined the relationship between complication development and outcome. While neither the profile nor number of complications accumulated differed comparing treatment environments (P > .05 for both), mortality for tracheostomy patients experiencing complications was greater in high-resource-intensity (95/313, 30.3%) versus low-resource-intensity (552/2,587, 21.3%) academic medical centers (P < .001). CONCLUSIONS: We were unable to demonstrate a positive relationship between resource expenditure and outcome in ARF patients managed with tracheostomy.

- by Steven Kymes
- •
- United States, Length of Stay, Clinical Sciences, Health Expenditures

The primary aim of this study was to determine which objectively-measured patient demographics, emergency department (ED) operational characteristics, and healthcare utilization frequencies (care factors) were associated with patient satisfaction ratings obtained from phone surveys conducted by a third-party vendor for patients discharged from our ED. This is a retrospective, observational analysis of data obtained between September 2011 and August 2012 from all English- and Spanish-speaking patients discharged from our ED who were contacted by a third-party patient satisfaction vendor to complete a standardized nine-item telephone survey by a trained phone surveyor. We linked data from completed surveys to the patient's electronic medical record to abstract additional demographic, ED operational, and healthcare utilization data. We used univariate ordinal logistic regression, followed by two multivariate models, to identify significant predictors of patient satisfaction. We inc...

- by Avis Thomas
- •
- Demography, Multivariate Analysis, United States, Patient Satisfaction

Depression among hospitalized patients is often unrecognized, undiagnosed, and therefore untreated. Little is known about the feasibility of screening for depression during hospitalization, or whether depression is associated with poorer outcomes, longer hospital stays, and higher readmission rates. We searched PubMed and PsycINFO for published, peer-reviewed articles in English (1990-2016) using search terms designed to capture studies that tested the performance of depression screening tools in inpatient settings and studies that examined associations between depression detected during hospitalization and clinical or utilization outcomes. Two investigators reviewed each full-text article and extracted data. The prevalence of depression ranged from 5% to 60%, with a median of 33%, among hospitalized patients. Several screening tools identified showed high sensitivity and specificity, even when self-administered by patients or when abbreviated versions were administered by individua...

- by Itai Danovitch
- •
- Depression, Medicine, Hospitals, Hospitalization

For the most part, discharge from hospital is routine and uneventful. However, for a percentage of people, discharge from acute care requires careful planning to ensure continuity of care. This is particularly the case with older patients who have complex medical needs. This literature review reveals that the essential elements for discharge planning are: communication, coordination, education, patient participation and collaboration between medical personnel. Outcomes measures of successful discharge planning include patient satisfaction and quality of life. Smooth and efficient coordination of this process reduces stress and anxiety for the patient, family, nurse, doctor, hospital and community services.

- by Aine Carroll
- •
- Nursing, Communication, Quality of life, Anxiety

Objective: To evaluate the predictive validity of the Mobility Scale for Acute Stroke (MSAS) in determining discharge destination (home or not home) after an acute stroke. Design: Cohort study. Subjects: Two-hundred and twenty-three patients with acute ischemic or intraparenchymal hemorrhagic, unilateral stroke Methods: The MSAS was administered as part of the initial physical therapy examination. The Receiver Operating Characteristic determined the optimal MSAS cutoff score associated with discharge home. A multiple logistic regression equation with discharge destination as the criterion variable (home or not home) was conducted with age, length of stay and optimal MSAS cutoff score as covariates. Results: Subjects were discharged home 35.9% (n = 80) and not home 64.1% (n = 143) of the time. Mean age was 68.5 years (standard deviation 1.8). The ROC determined 26 to be the optimal cutoff score for the MSAS. Results of the multiple logistic regression equation indicated that controlling for age and length of stay, only the MSAS cutoff score of 26 reliably predicted discharge to home with an adjusted odds ratio of 57.79 with a 95% confidence interval of 20.09-166.21. Conclusion: The MSAS may be useful for predicting discharge destination from the acute hospital after stroke.

- by Marianne Beninato
- •
- Rehabilitation Medicine, Adolescent, Comorbidity, Activities of Daily Living

BACKGROUND: An estimated 1.1 million people sustain a mild traumatic brain injury (MTBI) annually in the United States. The natural history of MTBI remains poorly characterized, and its optimal clinical management is unclear. The Eastern Association for the Surgery of Trauma had previously published a set of practice management guidelines for MTBI in 2001. The purpose of this review was to update these guidelines to reflect the literature published since that time. METHODS: The PubMed and Cochrane Library databases were searched for articles related to MTBI published between 1998 and 2011. Selected older references were also examined. RESULTS: A total of 112 articles were reviewed and used to construct a series of recommendations. CONCLUSION: The previous recommendation that brain computed tomographic (CT) should be performed on patients that present acutely with suspected brain trauma remains unchanged. A number of additional recommendations were added. Standardized criteria that may be used to determine which patients receive a brain CT in resource-limited environments are described. Patients with an MTBI and negative brain CT result may be discharged from the emergency department if they have no other injuries or issues requiring admission. Patients taking warfarin who present with an MTBI should have their international normalized ratio (INR) level determined, and those with supratherapeutic INR values should be admitted for observation. Deficits in cognition and memory usually resolve within 1 month but may persist for longer periods in 20% to 40% of cases. Routine use of magnetic resonance imaging, positron emission tomography, nuclear magnetic resonance, or biochemical markers for the clinical management of MTBI is not supported at the present time.

- by Robert Barraco
- •
- Medicine, Brain, X ray Computed Tomography, Brain injuries
- by Jennifer Walthall
- •
- Qualitative Research, Child, Triage, Patient Admission

Medication reconciliation is recognized as an important tool for the prevention of medication discrepancies and subsequent patient harm at care transitions. However, there is inconclusive evidence as to the impact of medication reconciliation at hospital transitions overall, as well as pharmacy-led medication reconciliation services. This review sought to evaluate the impact of pharmacy-led medication reconciliation interventions on medication discrepancies at hospital transitions and to categorize these interventions as single transition interventions or multiple transitions interventions. PubMed, MEDLINE, EMBASE, IPA, CINHAL and PsycINFO databases, inclusive from inception to December 2014, were searched. Included studies were published studies in English that compared the effectiveness of pharmacy-led medication reconciliation interventions to usual care and that aimed to assess medication discrepancies at hospital transitions. 'Usual care' was defined as any care where t...

- by Andrew McLachlan
- •
- Hospitals, Patient Admission, Pharmacists, Medication Reconciliation

Objective: To analyze the frequency of use of potentially inappropriate medication prescribed to elderly at hospital discharge from a public hospital, considering the Brazilian Consensus on Potentially Inappropriate Medication for Elderly, and to identify the associated factors. Methods: Patients aged ≥60 years, admitted in clinical and geriatric units of a public hospital were invited to participate in the study. The information about the use of medicines was collected from the patient’s electronic record and through telephone contact. The Brazilian Consensus on Potentially Inappropriate Medication for Elderly was used to classify the medication, regardless of the clinical condition. Results: A total of 255 elders were included in this study. The frequency of use of potentially inappropriate medication by elderly was 58.4%. The potentially inappropriate medication use in elderly was positively associated with the presence of depression (odds ratio of 2.208) and polypharmacy (odds ratio of 2.495). The hospitalization in a geriatric unit showed an inverse association with the potentially inappropriate medication use in elderly (odds ratio of 0.513). Conclusion: The frequency of potentially inappropriate medication prescription to elderly upon hospital discharge was high. The presence of depression and polypharmacy were directly associated with use of potentially inappropriate medication in the elderly. Admission to the geriatric clinic has become a protection factor for the use of potentially inappropriate medication in elderly. Strategies to improve the elderly pharmacotherapy should implemented aiming at healthcare quality and safety in the transition of care.

- by Journal einstein (São Paulo)
- •
- Elderly, Age, Drug Therapy, Inappropriate Prescribing
- by Elizabeth Rasch
- •
- Medicine, Stroke, Hospitalization, Clinical Sciences
- by Peter Blair
- •
- Anoxia, United States, Risk factors, Sudden Infant Death Syndrome

Objectives: To review the first 50 patients to receive extracorporeal membrane oxygenation (ECMO) for respiratoryfailure at Glenfield Hospital,and to compare them with published series of patients receiving positive pressure ventilation.... more

- by Darryl Abrams
- •
- Forecasting, Medicine, Dopamine, Anoxia

As extremely preterm infant mortality rates have decreased, concerns regarding resource utilization have intensified. Accurate models to predict time to hospital discharge could aid in resource planning, family counseling, and perhaps stimulate quality improvement initiatives. Objectives-For infants <27 weeks estimated gestational age (EGA), to develop, validate and compare several models to predict time to hospital discharge based on time-dependent covariates, and based on the presence of 5 key risk factors as predictors. Patients and Methods-This was a retrospective analysis of infants <27 weeks EGA, born 7/2002-12/2005 and surviving to discharge from a NICHD Neonatal Research Network site. Time to discharge was modeled as continuous (postmenstrual age at discharge, PMAD), and categorical variables ("Early" and "Late" discharge). Three linear and logistic regression models with timedependent covariate inclusion were developed (perinatal factors only, perinatal+early neonatal factors, perinatal+early+later factors). Models for Early and Late discharge using the cumulative presence of 5 key risk factors as predictors were also evaluated. Predictive capabilities were compared using coefficient of determination (R 2) for linear models, and AUC of ROC curve for logistic models. Results-Data from 2254 infants were included. Prediction of PMAD was poor, with only 38% of variation explained by linear models. However, models incorporating later clinical characteristics were more accurate in predicting "Early" or "Late" discharge (full models: AUC 0.76-0.83 vs. perinatal factor models: AUC 0.56-0.69). In simplified key risk factors models, predicted probabilities for Early and Late discharge compared favorably with observed rates. Furthermore, the AUC (0.75-0.77) were similar to those of models including the full factor set. Conclusions-Prediction of Early or Late discharge is poor if only perinatal factors are considered, but improves substantially with knowledge of later-occurring morbidities. Prediction using a few key risk factors is comparable to full models, and may offer a clinically applicable strategy.

- by Michael Cotten
- •
- Pediatrics, Survival Analysis, Risk assessment, Linear models

Professional societies have called for increased geriatrics training for all medical students and physicians. A Geriatrics Standardized Patient Instructor (GSPI) was developed in which learners assess the functional status of a patient preparing for hospital discharge. Standardized patients (SPs) rate learners on functional assessment and communication skills, and provide feedback. Seventeen SPs were trained. Correlations of ratings by SPs with ratings by three geriatricians of videotaped encounters indicated good reliability (correlation coefficient 5 0.69 and 0.70 for functional assessment and communication skills, respectively). Results from two learner groups illustrated the utility and feasibility of the GSPI. First, 138 house officers in nine specialties experienced the GSPI as a formative evaluation during implementation of new geriatrics curricula. Mean scores AE standard deviation (on a 100-point scale) for functional assessment and communication skills were 78 AE 16 and 86 AE 11, respectively. House officers rated the overall experience positively (mean rating (1 5 poor, 5 5 excellent) 3.9 AE 0.8). Second, 171 first-year medical students (M1 s) encountered the GSPI as part of an intense, multimodal educational intervention. Mean scores on functional assessment and communication skills were 93 AE 10 and 93 AE 7, respectively. Mean overall rating of the experience by M1 s was 4.1 AE 0.8. After demonstrated success as a teaching tool in these two groups of learners, the GSPI has been successfully used with second-and third-year (M3) medical students and house officers from a total of 12 specialties and incorporated into multistation Objective Standardized Clinical Examination exercises for incoming house officers and M3 s. Unlike existing diagnosis-oriented SPs, the GSPI can be used to assess and teach geriatrics skills to physician learners across disciplines and levels of training.

- by Brent Williams
- •
- Geriatrics, Communication, Medical Students, Undergraduate medical education