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Kinds of Medical Patients Selected AbstractsVenous thromboembolism in the medically ill patient: a call to actionINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 5 2005J.-F. Bergmann Summary The risk of venous thromboembolism (VTE) in medical patients is generally underestimated. However, recent studies including two large double-blind placebo-controlled trials, the Prospective Evaluation of Dalteparin Efficacy for Prevention of VTE in Immobilised Patients trial (PREVENT) and prophylaxis in MEDical patients with ENOXaparin, study show that low-molecular-weight heparins (LMWHs) provide effective thromboprophylaxis for medical patients at risk from VTE without increasing the risk of bleeding. In PREVENT the significant 45%, reduction in VTE among patients receiving dalteparin 5000 IU once daily for 14 days was attributed entirely to a reduction in clinically relevant VTE. The recently published guidelines for the prevention and treatment of VTE, issued by the American College of Chest Physicians, recommend prophylaxis with LMWHs (or low-dose unfractionated heparin) in acutely ill medical patients with risk factors for VTE (grade 1A). Current evidence should encourage the more widespread adoption of thromboprophylaxis in at-risk medical patients, and thus reduce the number of preventable deaths and complications due to VTE. [source] The Relationship of Indwelling Urinary Catheters to Death, Length of Hospital Stay, Functional Decline, and Nursing Home Admission in Hospitalized Older Medical PatientsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2007Jayna M. Holroyd-Leduc MD OBJECTIVES: To determine the association between indwelling urinary catheterization without a specific medical indication and adverse outcomes. DESIGN: Prospective cohort. SETTING: General medical inpatient services at a teaching hospital. PARTICIPANTS: Five hundred thirty-five patients aged 70 and older admitted without a specific medical indication for urinary catheterization. INTERVENTION: Indwelling urinary catheterization within 48 hours of admission. MEASUREMENTS: Death, length of hospital stay, decline in ability to perform activities of daily living (ADLs), and new admission to a nursing home. RESULTS: Indwelling urinary catheters were placed in 76 of the 535 (14%) patients without a specific medical indication. Catheterized patients were more likely to die in the hospital (6.6% vs 1.5% of those not catheterized, P=.006) and within 90 days of hospital discharge (25% vs 10.5%, P<.001); the greater risk of death with catheterization persisted in a propensity-matched analysis (hazard ratio (HR)=2.42, 95% confidence interval (CI)=1.04,5.65). Catheterized patients also had longer lengths of hospital stay (median, 6 days vs 4 days; P=.001); this association persisted in a propensity-matched analysis (HR=1.46, 95% CI=1.03,2.08). Catheterization was not associated (P>.05) with decline in ADL function or with admission to a nursing home. CONCLUSION: In this cohort of older patients, urinary catheterization without a specific medical indication was associated with greater risk of death and longer hospital stay. [source] Low Muscle Mass of the Thigh is Significantly Correlated with Delirium and Worse Functional Outcome in Older Medical PatientsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2002Wolfram Weinrebe MD No abstract is available for this article. [source] Variations on the CAGE Alcohol Screening Questionnaire: Strengths and Limitations in VA General Medical PatientsALCOHOLISM, Issue 10 2001Katharine A. Bradley Background: Several variations on the CAGE alcohol screening questionnaire have been recommended. This report evaluates modifications and additions to the CAGE. Methods: Alcohol screening questionnaires were evaluated in male VA general medicine patients (n= 227; mean age, 65.8). Mailed questionnaires included two scoring options for the CAGE (standard and last-year time frames), questions about quantity and frequency of drinking, two questions about episodic heavy drinking, and the question "Have you ever had a drinking problem?" Main analyses compared alcohol screening questions, at various cut-points, to a gold standard of hazardous drinking during the past year (,14 drinks/week or ,5 drinks on an occasion) and/or DSM-III-R alcohol abuse or dependence, based on standardized interviews. Results: The CAGE questionnaire with a past-year time frame was much less sensitive (0.57 vs. 0.77) but more specific (0.82 vs. 0.59) than the standard CAGE for detecting hazardous drinking during the past year and/or DSM-III-R alcohol abuse or dependence. An eight-item questionnaire that included the standard CAGE was most sensitive (0.92) but had low specificity (0.50). A single question about the frequency of drinking ,6 drinks on an occasion, included in the eight-item questionnaire, was both relatively sensitive (0.77) and specific (0.83). Conclusion: The CAGE questionnaire with a past-year time frame was an insensitive alcohol-screening test. An eight-item augmented version of the standard CAGE was the most sensitive. A question about the frequency of drinking ,6 drinks on an occasion performed better than the standard CAGE, which made it the optimal brief screening test for at-risk drinking. [source] Subthreshold depression as a risk indicator for major depressive disorder: a systematic review of prospective studiesACTA PSYCHIATRICA SCANDINAVICA, Issue 5 2004P. Cuijpers Objective:, In order to examine whether the incidence of major depressive disorder (MDD) is increased in subjects with subthreshold depression, or sD (clinically relevant depressive symptoms, without meeting criteria for a full-blown MDD), we conducted a review of prospective studies examining the incidence of MDD in subjects with sD. Method:, A systematic literature search was conducted. For all studies, the relative risk of developing MDD was calculated, based on person-years. Results:, Twenty studies (23 comparisons) were found, based on community samples, general medical patients and high-risk subjects. Most comparisons showed that subjects with sD had a consistently larger chance of developing MDD. The studies differed considerably in the definition of sD, the recency (occurrence of the last sD) and the in-/exclusion of lifetime MDD. Conclusion:, The incidence of MDD in subjects with sD is larger than in subjects without sD. Otherwise, the concept of sD is too broad to be used. In future studies, some consensus should be reached regarding the definition of sD. [source] Emergency Physician,Verified Out-of-hospital Intubation: Miss Rates by ParamedicsACADEMIC EMERGENCY MEDICINE, Issue 6 2004James H. Jones MD Abstract Objectives: To prospectively quantify the number of unrecognized missed out-of-hospital intubations by ground paramedics using emergency physician verification as the criterion standard for verification of endotracheal tube placement. Methods:The authors performed an observational, prospective study of consecutive intubated patients arriving by ground emergency medical services to two urban teaching hospitals. Endotracheal tube placement was verified by emergency physicians and evaluated by using a combination of direct visualization, esophageal detector device (EDD), colorimetric end-tidal carbon dioxide (ETCO2), and physical examination. Results: During the six-month study period, 208 out-of-hospital intubations by ground paramedics were enrolled, which included 160 (76.9%) medical patients and 48 (23.1%) trauma patients. A total of 12 (5.8%) endotracheal tubes were incorrectly placed outside the trachea. This comprised ten (6.3%) medical patients and two (4.2%) trauma patients. Of the 12 misplaced endotracheal tubes, a verification device (ETCO2 or EDD) was used in three cases (25%) and not used in nine cases (75%). Conclusions: The rate of unrecognized, misplaced out-of-hospital intubations in this urban, midwestern setting was 5.8%. This is more consistent with results of prior out-of-hospital studies that used field verification and is discordant with the only other study to exclusively use emergency physician verification performed on arrival to the emergency department. [source] Incidence of Deep Venous Thrombosis Associated with Femoral Venous CatheterizationACADEMIC EMERGENCY MEDICINE, Issue 5 2000Nabeela Z. Mian MD ABSTRACT Objective: To determine in adult medical patients the incidence of deep venous thrombosis (DVT) resulting from femora] venous catheterization (FVC). Methods: A prospective, observational study was performed at a 420-bed community teaching hospital. Hep-arin-coated 7-Fr 20-cm femoral venous catheters were inserted unilaterally into a femoral vein. Each contra-lateral leg served as a control site. Age, gender, number of FVC days. DVT risk factors, administration of DVT prophylaxis, and DVT formation and site were tabulated for each patient. Venous duplex sonography was performed bilaterally on each patient within 7 days of femoral venous catheter removal. Results: Catheters were placed in 29 men and 13 women. Femoral DVT was identified by venous duplex sonography in 11 (26.2%) of the FVC legs and none (0%) in the control legs. Posterior tibial and popliteal DVT was identified in both the FVC and control legs of 1 patient. DVT formation at the site of FVC insertion was highly significant (p = 0.005). There were no statistically significant associations with age (p = 0.42), gender (p = 0.73), number of DVT risk factors (p = 0.17), number of FVC days (p = 0.89), or DVT prophylaxis (p , 099). Conclusion: Placement of femoral catheters for central venous access is associated with a significant incidence of femoral DVT as detected by venous duplex sonography criteria at the site of femoral venous catheter placement. Physicians must be aware of this risk when choosing this vascular access route for adult medical patients. Further studies to assess the relative risk for DVT and its clinical sequelae when using the femoral vs other central venous catheter routes are indicated. Key words: deep venous thrombosis; femoral vein; catheterization; pulmonary embolism. [source] The Relationship of Post-acute Home Care Use to Medicaid Utilization and ExpendituresHEALTH SERVICES RESEARCH, Issue 3 2002Susan M. C. Payne Research Objectives: To describe the use of post-acute home care (PAHC) and total Medicaid expenditures among hospitalized nonelderly adult Medicaid eligibles and to test whether health services utilization rates or total Medicaid expenditures were lower among Medicaid eligibles who used PAHC compared to those who did not. Study Population: 5,299 Medicaid patients aged 18,64 discharged in 1992,1996 from 29 hospitals in the Cleveland Health Quality Choice (CHQC) project. Data Sources: Linked Ohio Medicaid claims and CHQC medical record abstract data. Data Extraction: One stay per patient was randomly selected. Design: Observational study. To control for treatment selection bias, we developed a model predicting the probability (propensity) a patient would be referred to PAHC, as a proxy for the patient's need for PAHC. We matched 430 patients who used Medicaid-covered PAHC ("USE") to patients who did not ("NO USE") by their propensity scores. Study outcomes were inpatient re-admission rates and days of stay (DOS), nursing home admission rates and DOS, and mean total Medicaid expenditures 90 and 180 days after discharge. Principal Findings: Of 3,788 medical patients, 12.1 percent were referred to PAHC; 64 percent of those referred used PAHC. Of 1,511 surgical patients, 10.9 percent were referred; 99 percent of those referred used PAHC. In 430 pairs of patients matched by propensity score, mean total Medicaid expenditures within 90 days after discharge were $7,649 in the USE group and $5,761 in the NO USE group. Total Medicaid expenditures were significantly higher in the USE group compared to the NO USE group for medical patients after 180 days (p<.05) and surgical patients after 90 and 180 days (p<.001). There were no significant differences for any other outcome. Sensitivity analysis indicates the results may be influenced by unmeasured variables, most likely functional status and/or care-giver support. Conclusions: Thirty-six percent of the medical patients referred to PAHC did not receive Medicaid-covered services. This suggests potential underuse among medical patients. The high post-discharge expenditures suggest opportunities for reducing costs through coordinating utilization or diverting it to lower-cost settings. Controlling for patients' need for services, PAHC utilization was not associated with lower utilization rates or lower total Medicaid expenditures. Medicaid programs are advised to proceed cautiously before expanding PAHC utilization and to monitor its use carefully. Further study, incorporating non-economic outcomes and additional factors influencing PAHC use, is warranted. [source] A need for a simplified approach to venous thromboembolism prophylaxis in acute medical inpatientsINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 2 2007D. P. J. Howard Summary Venous thromboembolism (VTE) is a major cause of morbidity and mortality in the UK. Studies have shown that pulmonary embolism causes or contributes to approximately 1 in 10 hospital deaths of medical patients admitted to general hospitals in the UK (Lindblad B, Sternby NH, Bergqvist D. BMJ 1991; 302: 709,11), with pulmonary embolus being the most common preventable cause of hospital death. Thromboprophylaxis is safe, highly effective and cost effective, but despite various current clinical guidelines, physicians fail to prescribe prophylaxis for the majority of medical inpatients at risk of VTE. This article outlines the current evidence for VTE prophylaxis in medical patients and discusses the reasons behind the insufficient use of prophylaxis in the acute medical setting. [source] Venous thromboembolism in the medically ill patient: a call to actionINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 5 2005J.-F. Bergmann Summary The risk of venous thromboembolism (VTE) in medical patients is generally underestimated. However, recent studies including two large double-blind placebo-controlled trials, the Prospective Evaluation of Dalteparin Efficacy for Prevention of VTE in Immobilised Patients trial (PREVENT) and prophylaxis in MEDical patients with ENOXaparin, study show that low-molecular-weight heparins (LMWHs) provide effective thromboprophylaxis for medical patients at risk from VTE without increasing the risk of bleeding. In PREVENT the significant 45%, reduction in VTE among patients receiving dalteparin 5000 IU once daily for 14 days was attributed entirely to a reduction in clinically relevant VTE. The recently published guidelines for the prevention and treatment of VTE, issued by the American College of Chest Physicians, recommend prophylaxis with LMWHs (or low-dose unfractionated heparin) in acutely ill medical patients with risk factors for VTE (grade 1A). Current evidence should encourage the more widespread adoption of thromboprophylaxis in at-risk medical patients, and thus reduce the number of preventable deaths and complications due to VTE. [source] The use of thrombelastography to determine coagulation status in severe anorexia nervosa: A case seriesINTERNATIONAL JOURNAL OF EATING DISORDERS, Issue 4 2010Jennifer L. Gaudiani MD Abstract Objective: Hospitalized patients with severe anorexia nervosa (AN) frequently have a complex coagulation profile, with elements of hypocoagulability-thrombocytopenia and elevated international normalized ratio (INR) and elements of hypercoagulability-usually manifested as immobility, which is either due to their marked weakness or from enforced degrees of bed rest to minimize energy expenditure. Hospitalized medical patients have been shown to have appropriate prophylaxis for venous thromboembolic (VTE) disease in only 40% of cases. Method: A simple test that could evaluate the overall coagulation profile of these patients would help guide appropriate VTE prophylaxis. The thrombelastogram is a blood test that evaluates the full dynamic process of hemostasis. Results: The study of patients did not reveal evidence of being hypocoagulable and thus should be considered for VTE prophylaxis. Discussion: We report on three cases of young women with severe AN and weakness, hospitalized for closely monitored refeeding, in whom the thromboelastogram was used to evaluate the coagulation status of the patient and assist in guiding therapy. © 2009 by Wiley Periodicals, Inc. Int J Eat Disord 2010 [source] Serum S100B in elderly patients with and without deliriumINTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, Issue 3 2010Barbara C. van Munster Abstract Objective Elevation of S100B has been shown after various neurologic diseases with cognitive dysfunction. The aim of this study was to compare the serum level of S100B of patients with and without delirium and investigate the possible associations with different subtypes of delirium. Methods Acutely admitted medical patients aged 65 years or more were included from 2005 through 2008. Delirium was diagnosed by Confusion Assessment Method, delirium subtype by Delirium Symptom Interview and preexistent global cognitive function by the ,Informant Questionnaire on Cognitive Decline-short form'. S100B levels were determined in serum by electrochemiluminescence immunoassay. Results Samples of 412 patients were included, 91 during delirium, 35 after delirium and 286 of patients without delirium. Patients with delirium (31%) were significantly older, 81.5 versus 76.6 years (p,<,0.001) and experienced significantly more often preexistent cognitive and functional impairment (p,<,0.001). S100B level differed significantly (p,=,0.004) between the three groups: median 0.07,,g/L (inter-quartile ranges: 0.05,0.14,,g/L) during delirium, 0.12,,g/L (0.05,0.29,,g/L) after delirium and 0.06,,g/L (0.03,0.10,,g/L) in patients without delirium. Combining the impact of cognitive impairment, infection and age on S100B, highest S100B was observed in the oldest patients after delirium with preexistent cognitive impaired and infection. Delirium subtype and S100B level were not significantly correlated. Conclusion Higher S100B levels were found in patients with delirium than in patients without delirium, with highest levels of S100B in samples taken after delirium. Future studies are needed to elucidate the mechanism responsible for the increase of S100B and the possible association with long term cognitive impairment. Copyright © 2009 John Wiley & Sons, Ltd. [source] Maximizing Clinical Research Participation in Vulnerable Older Persons: Identification of Barriers and MotivatorsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2008Edward R. Marcantonio MD OBJECTIVES: To identify barriers and motivators to participation in long-term clinical research by high-risk elderly people and to develop procedures to maximize recruitment and retention. DESIGN: Quantitative and qualitative survey. SETTING: Academic primary care medicine and pre-anesthesia testing clinics. PARTICIPANTS: Fifty patients aged 70 and older, including 25 medical patients at high risk of hospitalization and 25 patients with planned major surgery. MEASUREMENTS: Fifteen- to 20-minute interviews involved open- and closed-ended questions guided by an in-depth script. Two planned study protocols were presented to each participant. Both involved serial neuropsychological assessments, blood testing, and magnetic resonance brain imaging (MRI); one added lumbar puncture (LP). Participants were asked whether they would be willing to participate in these protocols, rated barriers and incentives to participation, and were probed with open-ended questions. RESULTS: Of 50 participants (average age 78, 44% male, 40% nonwhite), 32 (64%) expressed willingness to participate in the LP-containing protocol, with LP cited as the strongest disincentive. Thirty-eight (76%) expressed willingness to participate in the protocol without LP, with phlebotomy and long interviews cited as the strongest disincentives. Altruism was a strong motivator for participation, whereas transportation was a major barrier. Study visits at home, flexible appointment times, assessments shorter than 75 minutes, and providing transportation and free parking were strategies developed to maximize study participation. CONCLUSION: Vulnerable elderly people expressed a high rate of willingness to participate in an 18-month prospective study. Participants identified incentives and barriers that enabled investigators to develop procedures to maximize recruitment and retention. [source] Hyperglycemia as a Predictor of In-Hospital Mortality in Elderly Patients without Diabetes Mellitus Admitted to a Sub-Intensive Care UnitJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 6 2008Intissar Sleiman MD OBJECTIVES: To investigate the association between hyperglycemia and in-hospital and 45-day mortality in acutely ill elderly patients. DESIGN: Retrospective cohort. SETTING: Hospital medical patients admitted to a sub-intensive care unit (sub-ICU) for elderly patients, which is a level of care between ordinary wards and intensive care. PARTICIPANTS: One thousand two hundred twenty-nine patients (mean age 79.6±8.4) admitted to the sub-ICU from January 2003 to January 2006. Forty patients with acute myocardial infarction and 34 patients with extreme fasting glucose values (<60 or >500 mg/dL) were excluded. Eight hundred twenty-two patients without a history of diabetes mellitus (DM) and 333 patients with a diagnosis of DM were selected and subdivided into three categories according to serum fasting blood glucose: 60 to 126 mg/dL (Group A), 127 to 180 mg/dL (Group B), and 181 to 500 mg/dL (Group C). MEASUREMENTS: Age, sex, mental and functional status, Acute Physiology Score, comorbid conditions, serum albumin, serum cholesterol, fasting serum glucose, and length of stay. In-hospital mortality was the primary outcome, and 45-day mortality was the secondary outcome. RESULTS: Total in-hospital mortality was 14.5%. In patients with and without DM, mortality was 8.8% and 11.3%, respectively, in Group A; 13.6% and 17.3% in Group B, and 12.6% and 34.3% in Group C. After controlling for confounders, newly recognized hyperglycemia (>181 mg/dL) was independently associated with in-hospital mortality (adjusted odds ratio=2.7, 95% confidence interval=1.6,4.8). Forty-five-day mortality in newly recognized hyperglycemic patients was 17.5%, 25.7%, and 42% in Groups A, B, and C, respectively, whereas it was 21.2% in patients with DM. CONCLUSION: In elderly patients, newly recognized hyperglycemia was associated with a higher mortality rate than in those with a prior history of DM. These data suggest that further randomized clinical trials are needed to assess the efficacy and the risk of a target glucose of greater than 180 mg/dL. [source] SCL-90-R profiles in a sample of severely violent psychiatric inpatientsAGGRESSIVE BEHAVIOR, Issue 6 2002Stål Bjørkly Abstract A sample of 39 patients who had committed serious violent acts toward others were assessed with the revised Symptom Checklist (SCL-90-R). The SCL-90-R is a self-report symptom inventory for the measurement of psychopathology in psychiatric and medical patients. In addition to the patients' self-report, an observer-rated SCL-90-R was obtained. This was accomplished by letting one pair of nurses complete SCL-90-R ratings for each patient. The first aim of the study was to compare the SCL-90-R self-report scores of the patient sample with the psychiatric inpatient norms [Derogatis LR (1992): Clinical Psychometric Research Inc]. Another purpose of this study was to explore possible trends of discordance between the observer ratings and the self-reports of the study group. Always considering the limitations of the small sample, it was nevertheless also of interest to look for possible sex differences and differences between violent subgroups and between diagnostic groups in the self-reported scores as well as in the observer ratings. The most striking findings of the present study were that the self-reported scores were lower than the inpatient norms for SCL-90-R and that the patients' self-reported levels of distress were significantly lower than those found in the observer ratings. Underreporting of psychopathology as a marker of violence risk is discussed in light of these findings. In this study, women reported higher distress levels than men in the Interpersonal Sensitivity symptom dimension. There were no significant differences concerning SCL-90-R ratings between patients who had committed homicide, attempted homicide, or physically assaulted another person in a serious but not life-threatening way. Aggr. Behav. 28:446,457, 2002. © 2002 Wiley-Liss, Inc. [source] Stress ulcer prophylaxis for non-critically ill patients on a teaching serviceJOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 5 2007Kevin O. Hwang MD Abstract Rationale, Doctors frequently give non-critically ill patients unjustified stress ulcer prophylaxis (SUP). It is unknown if this practice also occurs during residency training. Objective, To evaluate the pattern of SUP given to non-critically ill medical patients on the teaching service of an internal medicine residency programme. Methods, This was a retrospective cohort study of non-critically ill adults admitted to the internal medicine teaching service of a community hospital from August 2003 to July 2004. We assessed receipt of SUP, association of SUP with risk factors for stress ulcer bleeding; appropriateness of SUP according to evidence-based criteria; and incidence of stress ulcer bleeding. Results, Of the 774 patient records reviewed, 545 were included in the study. The average age was 55.4 years. Patients were more likely to receive SUP if they had more risk factors for stress ulcer bleeding (P < 0.001). Overall, 54.9% (299 of 545) of patients received SUP. Of these 299 patients, at least 58.5% did not warrant SUP, depending on the criteria used. Of the entire cohort of 545 non-critically ill patients, 32.1% to 54.9% received unjustified SUP, depending on the criteria applied. There were no cases of stress ulcer bleeding. Conclusions, Many non-critically ill patients on the teaching service received unjustified SUP, suggesting the need for institutional protocols and educational interventions to promote evidence-based practice during residency training. [source] Coding diagnoses and procedures using a high-quality clinical database instead of a medical record reviewJOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 3 2001Carl van Walraven MSc MD FRCPC Abstract A discharge abstract must be completed for each hospitalization. The most time-consuming component of this task is a complete review of the doctors' progress notes to identify and code all diagnoses and procedures. We have developed a clinical database that creates hospital discharge summaries. To compare diagnostic and procedural coding from a clinical database vs. the standard chart review by health records analysts (HRA). All patients admitted and discharged from general medical and surgical services at a teaching hospital in Ontario, Canada. Diagnostic and procedural codes were identified by reviewing discharge summaries generated from a clinical database. Independently, codes were identified by hospital health records analysts using chart review alone. Codes were compared with a gold standard case review conducted by a health records analyst and a doctor. Coding accuracy (percentage of codes in gold standard review) and completeness (percentage of gold standard codes identified). The study included 124 patients (mean length of stay 5.5 days; 66.4% medical patients). The accuracy of the most responsible diagnosis was 68.5% and 62.9% for the database (D) and chart review (C), respectively (P = 0.18). Overall, the database significantly improved the accuracy (D = 78.9% vs. C = 74.5%; P = 0.02) and completeness (D = 63.9% vs. C = 36.7%; P < 0.0001) of diagnostic coding. Although completeness of procedural coding was similar (D = 5.4% vs. C = 64.2%; P = NS), accuracy decreased with the database (D = 70.3% vs. C = 92.2%; P < 0.0001). Mean resource intensity weightings calculated from the codes (D = 1.3 vs. C = 1.4; P = NS) were similar. Coding from a clinical database may circumvent the need for HRAs to review doctors' progress notes, while maintaining the quality of coding in the discharge abstract. [source] Outcomes-based trial of an inpatient nurse practitioner service for general medical patientsJOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 1 2001Mathilde H. Pioro MD Abstract Although teaching hospitals are increasingly using nurse practitioners (NPs) to provide inpatient care, few studies have compared care delivered by NPs and housestaff or the ability of NPs to admit and manage unselected general medical patients. In a Midwest academic teaching hospital 381 patients were randomized to general medical wards staffed either by NPs and a medical director or medical housestaff. Data were obtained from medical records, interviews and hospital databases. Outcomes were compared on both an intention to treat (i.e. wards to which patients were randomized) and actual treatment (i.e. wards to which patients were admitted) basis. At admission, patients assigned randomly to NP-based care (n = 193) and housestaff care (n = 188) were similar with respect to demographics, comorbidity, severity of illness and functional parameters. Outcomes at discharge and at 6 weeks after discharge were similar (P > 0.10) in the two groups, including: length of stay; charges; costs; consultations; complications; transfers to intensive care; 30-day mortality; patient assessments of care; and changes in activities of daily living, SF-36 scores and symptom severity. However, after randomization, 90 of 193 patients (47%) assigned to the NP ward were actually admitted to housestaff wards, largely because of attending physicians and NP requests. None the less, outcomes of patients admitted to NP and housestaff wards were similar (P > 0.1). NP-based care can be implemented successfully in teaching hospitals and, compared to housestaff care, may be associated with similar costs and clinical and functional outcomes. However, there may be important obstacles to increasing the number of patients cared for by NPs, including physician concerns about NPs' capabilities and NPs' limited flexibility in managing varying numbers of patients and accepting off-hours admissions. [source] Thromboprophylaxis for hospitalized medical patients: A Multicenter Qualitative study,,JOURNAL OF HOSPITAL MEDICINE, Issue 5 2009Deborah Cook MD Abstract BACKGROUND: Observational studies have documented that medical patients infrequently receive venous thromboembolism (VTE) prevention. OBJECTIVE: To understand the barriers to, and facilitators of, optimal thromboprophylaxis. PATIENTS: Hospitalized medical patients. DESIGN: We conducted in-depth interviews with 15 nurses, 6 pharmacists, 12 physicians with both clinical and managerial experience, and 3 hospital administrators. SETTING: One university-affiliated and 2 community hospitals. INTERVENTION: Interviews were audiotaped and transcribed verbatim. Transcripts were reviewed and interpreted independently in duplicate. MEASUREMENT: Analysis was conducted using grounded theory. RESULTS: Physicians and pharmacists affirmed that evidence supporting heparin is strong and understood. Clinicians, particularly nurses, reported that mobilization was important, but were uncertain about how much mobilization was enough. Participants believed that depending on individual physicians for VTE prevention is insufficient. The central finding was that multidisciplinary care was also perceived as a barrier to effective VTE prevention because it can lead to unclear accountability by role confusion. Participants believed that a comprehensive, systems approach was necessary. Suggestions included screening and risk-stratifying all patients, preprinted orders at hospital admission that are regularly reevaluated, and audit and feedback programs. Patient or family-mediated reminders, and administrative interventions, such as hiring more physiotherapists and profiling thromboprophylaxis in hospital accreditation, were also endorsed. CONCLUSIONS: Universal consideration of thromboprophylaxis finds common ground in multidisciplinary care. However, results of this qualitative study challenge the conviction that either individual physician efforts or multidisciplinary care are sufficient for optimal prevention. To ensure exemplary medical thromboprophylaxis, clinicians regarded coordinated, systemwide processes, aimed at patients, providers, and administrators as essential. Journal of Hospital Medicine 2009;4:269,275. © 2009 Society of Hospital Medicine. [source] Emergency department attendances associated with drug-related problems in paediatricsJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 2 2003KL Easton-Carter Objectives: To determine the frequency and characteristics of paediatric emergency department attendances associated with drug-related problems (DRP) at three Victorian hospitals. Methods: All paediatric medical patients attending the emergency department of the Royal Children's Hospital, Geelong Hospital or Box Hill Hospital were considered for inclusion. The investigator and attending medical practitioners screened eligible patients. A multidisciplinary panel reviewed collated data. Causality, preventability and clinical significance classifications were established by the panel. Results: Combining data from the three hospitals, over 18 weeks of data collection, a total of 8601 patients met the eligibility criteria. Of these, 280 (3.3%, 95% CI 2.9,3.7%) were determined to have emergency department attendances associated with DRP. Of the 187 cases assessed for preventability, 51.3% were judged to be preventable. Conclusions: Emergency department attendances are associated with DRP in paediatrics. Given that the need to prevent DRP in adults is recognized, it is now time to act to reduce the consequences of DRP in paediatrics. [source] Physician compliance with advanced electronic alerts for preventing venous thromboembolism among hospitalized medical patientsJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 8 2009N. KUCHER Summary.,Background: Worldwide, more than half of the hospitalized medical patients at high risk do not receive venous thromboembolism (VTE) prophylaxis. Although VTE among hospitalized patients at risk is reduced with electronic alerts (eAlerts), the majority of eAlerts are being ignored by the responsible physician. Methods: We investigated physician compliance with an advanced eAlert system in 1027 (age 59 ± 17 years) hospitalized medical patients. A continuously flashing non-interruptive eAlert, visible to all healthcare professionals, was issued in the electronic patient chart 6 h after admission if the physician did not order prophylaxis. Results: The rate of appropriate prophylaxis increased from 44% before to 76% after the implementation of the eAlert system. Although the patients whose physicians cared for , 20 patients during the study period had a more frequent physician response to the eAlert than patients whose physicians cared for fewer patients (69% vs. 40%, P < 0.001), they received appropriate prophylaxis less often (72% vs. 81%, P = 0.016). After adjustment for significant patient predictors of appropriate prophylaxis, including cancer, age, duration of hospital stay, and thrombocytopenia, patients whose physicians cared for , 20 patients during the study period were less likely to receive appropriate prophylaxis (odds ratio 0.65, 95% confidence interval 0.44,0.96; P = 0.032) than patients whose physicians cared for fewer patients. Conclusions: The introduction of an advanced eAlert system accompanied by continuing medical education for the prevention of VTE resulted in a substantial increase in the rate of appropriate prophylaxis among hospitalized medical patients. However, many eAlerts may cause decreased physician compliance owing to ,alert fatigue'. [source] The costs of heparin-induced thrombocytopenia: a patient-based cost of illness analysisJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 5 2009T. WILKE Summary.,Background and objectives:,Due to the complexity of heparin-induced thrombocytopenia (HIT), currently available cost analyses are rough estimates. The objectives of this study were quantification of costs involved in HIT and identification of main cost drivers based on a patient-oriented approach. Methods:,Patients diagnosed with HIT (1995,2004, University-hospital Greifswald, Germany) based on a positive functional assay (HIPA test) were retrieved from the laboratory records and scored (4T-score) by two medical experts using the patient file. For cost of illness analysis, predefined HIT-relevant cost parameters (medication costs, prolonged in-hospital stay, diagnostic and therapeutic interventions, laboratory tests, blood transfusions) were retrieved from the patient files. The data were analysed by linear regression estimates with the log of costs and a gamma regression model. Mean length of stay data of non-HIT patients were obtained from the German Federal Statistical Office, adjusted for patient characteristics, comorbidities and year of treatment. Hospital costs were provided by the controlling department. Results and conclusions:,One hundred and thirty HIT cases with a 4T-score ,4 and a positive HIPA test were analyzed. Mean additional costs of a HIT case were 9008 ,. The main cost drivers were prolonged in-hospital stay (70.3%) and costs of alternative anticoagulants (19.7%). HIT was more costly in surgical patients compared with medical patients and in patients with thrombosis. Early start of alternative anticoagulation did not increase HIT costs despite the high medication costs indicating prevention of costly complications. An HIT cost calculator is provided, allowing online calculation of HIT costs based on local cost structures and different currencies. [source] Thromboprophylaxis rates in US medical centers: success or failure?JOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 8 2007A. AMIN Summary.,Background:,As hospitalized medical patients may be at risk of venous thromboembolism (VTE), evidence-based guidelines are available to help physicians assess patients' risk for VTE, and to recommend prophylaxis options. The rate of appropriate thromboprophylaxis use in at-risk medical inpatients was assessed in accordance with the 6th American College of Chest Physicians (ACCP) guidelines.Methods:,Hospital discharge information from the Premier PerspectiveÔ inpatient data base from January 2002 to September 2005 was used. Included patients were 40 years old or more, with a length of hospital stay of 6 days or more, and had no contraindications for anticoagulation. The appropriateness of VTE thromboprophylaxis was determined in seven groups with acute medical conditions by comparing the daily thromboprophylaxis usage, including type of thromboprophylaxis, dosage of anticoagulant and duration of thromboprophylaxis, with the ACCP recommendations.Results:,A total of 196 104 discharges from 227 hospitals met the inclusion criteria. The overall VTE thromboprophylaxis rate was 61.8%, although the appropriate thromboprophylaxis rate was only 33.9%. Of the 66.1% discharged patients who did not receive appropriate thromboprophylaxis, 38.4% received no prophylaxis, 4.7% received mechanical prophylaxis only, 6.3% received an inappropriate dosage, and 16.7% received an inappropriate prophylaxis duration based on ACCP recommendations.Conclusions:,This study highlights the low rates of appropriate thromboprophylaxis in US acute-care hospitals, with two-thirds of discharged patients not receiving prophylaxis in accordance with the 6th ACCP guidelines. More effort is required to improve the use of appropriate thromboprophylaxis in accordance with the ACCP recommendations. [source] Risk factors for venous thrombosis in medical inpatients: validation of a thrombosis risk scoreJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 12 2004N. A. Zakai Summary.,Background/objectives:,The occurrence of and risk factors for venous thrombosis (VT) complicating hospital admission in unselected medical inpatients have not been widely studied. Patients and methods:,In a 400-bed teaching hospital we identified all cases of VT complicating hospital admission between September 2000 and September 2002 using discharge codes and chart review. Controls were randomly selected adult inpatients frequency matched to cases for medical service. Results:,The incidence of VT complicating hospital admission was 7.6 per 1000 admissions. On average, VT was diagnosed on the fifth hospital day. The median age of the 65 cases and 123 controls was 68 years and 45% were men. Cases had a 4-fold higher death rate than controls [95% confidence interval (CI) 1.9, 8.8]. At admission, trauma within 3 months, leg edema, pneumonia, platelet count > 350 × 103 mm,3 and certain cancers were associated with risk of VT. Age, body mass index, and acute myocardial infarction were not associated with VT risk. One of three published VT risk models was able to risk stratify patients and was associated with a 2.6-fold increased risk of VT (95% CI 1.3, 5.5). Use of VT prophylaxis did not differ in cases and controls; prophylaxis was used <,1/3 of hospital days in 52% of patients. Conclusions:,VT was common among medical inpatients. Of the risk factors identified, elevated platelet count has not been previously reported. Only one of three published risk scores was associated with risk of inpatient VT. Future study should improve upon risk prediction models for in-hospital VT among medical patients. [source] Review article: the abdominal compartment syndromeALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 4 2008S. M. LERNER Summary Background, The term abdominal compartment syndrome refers to hypoperfusion and ischaemia of intra-abdominal viscera and structures caused by raised intra-abdominal pressure. It occurs most commonly following major trauma and complex surgical procedures, but can also occur in their absence. Definitive treatment is decompression at laparotomy. Prevention and recognition of abdominal compartment syndrome are crucial to avoid additional morbidity and mortality. Postinjury abdominal compartment syndrome continues to complicate current resuscitation methods and new strategies for resuscitating critically ill patients need to be explored in addition to more accurate monitoring of intra-abdominal pressure. Aim, To examine the published literature regarding the pathogenesis, diagnosis and management of the abdominal compartment syndrome. Methods, A comprehensive review of the literature was undertaken. Results, This syndrome is an important complication of major trauma and surgery as well as being recognized in critically-ill medical patients. It requires prompt recognition with a view to decompression at laparotomy. Conclusions, The abdominal compartment syndrome is an important complication of trauma, surgery and resuscitation. Key to its management are its prompt recognition and abdominal decompression. [source] A Review of Sympathetically Maintained Pain Syndromes in the Cancer Pain Population:PAIN PRACTICE, Issue 4 2001The spectrum of ambiguous entities of RSD, other pain states related to the sympathetic nervous system Abstract: Accepted wisdom contends that sympathetically maintained pain is rare in cancer pain syndromes. But this may be more of an artifact of how we diagnose this condition than a reflection of its true prevalence. One area in which one might suspect this to be true is in postsurgical states. While there are case reports of sympathetically maintained pain occurring after radical neck dissection, orbital and maxillary exenteration, it has not been reported in the more common areas of postsurgical pain. For instance, although one should suspect that the nerve damage that accompanies post-thoracotomy and postmastectomy pain syndromes would bring into being a certain incidence of sympathetically maintained pain, it is difficult to find collaborative reports. This may have more to do with the difficulty inherent in diagnosing sympathetically maintained pain than its actual contribution to these persistent cancer pain syndromes. The reason that it is more commonly reported in limb amputation is less comprehensible since blocking the sympathetic fibers that travel to an extremity is easier than those going to the thoracic cavity. In addition to surgically induced sympathetically maintained pain, medical patients with lymphoma and leukemia may have an element of sympathetically maintained pain when they develop postherpetic neuralgia. While the contribution of sympathetically maintained pain in these cases is not totally ignored, its involvement, as in the surgical patients mentioned above, is worthy of another analysis. This paper will discuss the topics introduced above and suggest diagnostic and therapeutic options available for this condition. [source] Combat Stress Casualties in Iraq.PERSPECTIVES IN PSYCHIATRIC CARE, Issue 3 2008Part 1: Behavioral Health Consultation at an Expeditionary Medical Group PURPOSE.,We review the role of military mental health professionals in consulting with inpatient medical patients and staff at a combat hospital and aeromedical evacuation staging facility in Iraq. CONCLUSIONS.,Behavioral health consultation with medical and surgical patients during hospitalization and prior to aeromedical evacuation can help identify patients with combat stress exposure that may require future mental health follow-up. PRACTICE IMPLICATIONS.,Extensive use of civilian mental health practitioners including nurse psychotherapists and psychiatric nurse practitioners will be needed to provide psychiatric care for the large number of U.S. veterans who return from deployment with combat stress related disorders. [source] Venous thromboembolism risk among hospitalized patients: Magnitude of the risk is staggeringAMERICAN JOURNAL OF HEMATOLOGY, Issue 9 2007Samuel Z. Goldhaber Quality assessment focuses on areas where measurement is easy and unequivocal. To determine whether high quality hospital medicine is being practiced, a natural target is assessment of the frequency of orders to implement preventive strategies against venous thromboembolism. Patient risk can be readily ascertained, and rigorous clinical trials have vetted effective strategies to prevent deep vein thrombosis and pulmonary embolism. Concentrating on reducing the risk of venous thromboembolism is worthwhile because more than 4 million surgical patients and almost 8 million medical patients warrant specific prophylaxis orders each year in the United States alone. For those who do not receive preventive measures, the result may not be apparent during the index hospitalization. More likely, such patients will tend to develop deep vein thrombosis or pulmonary embolism within the ensuing 90 days, either in a skilled nursing facility or at home in the community. It is now time for us to broaden our approach. What happens in the hospital (such as lapses in good hospital practice) does not necessarily stay in the hospital. Failure to prophylax against venous thromboembolism may have potentially devastating implications for months after hospital discharge. Am. J. Hematol., 2007. © 2007 Wiley-Liss, Inc. [source] The management of heparin-induced thrombocytopeniaBRITISH JOURNAL OF HAEMATOLOGY, Issue 3 2006David Keeling Abstract The Haemostasis and Thrombosis Task Force of the British Committee for Standards in Haematology has produced a concise practical guideline to highlight the key issues in the management of heparin-induced thrombocytopenia (HIT) for the practicing physician in the UK. The guideline is evidence-based and levels of evidence are included in the body of the article. All patients who are to receive heparin of any sort should have a platelet count on the day of starting treatment. For patients who have been exposed to heparin in the last 100 d, a baseline platelet count and a platelet count 24 h after starting heparin should be obtained. For all patients receiving unfractionated heparin (UFH), alternate day platelet counts should be performed from days 4 to 14. For surgical and medical patients receiving low-molecular-weight heparin (LMWH) platelet counts should be performed every 2,4 d from days 4 to 14. Obstetric patients receiving treatment doses of LMWH should have platelet counts performed every 2,4 d from days 4 to 14. Obstetric patients receiving prophylactic LMWH are at low risk and do not need routine platelet monitoring. If the platelet count falls by 50% or more, or falls below the laboratory normal range and/or the patient develops new thrombosis or skin allergy between days 4 and 14 of heparin administration HIT should be considered and a clinical assessment made. If the pretest probability of HIT is high, heparin should be stopped and an alternative anticoagulant started at full dosage unless there are significant contraindications while laboratory tests are performed. Platelet activation assays using washed platelets have a higher sensitivity than platelet aggregation assays but are technically demanding and their use should be restricted to laboratories experienced in the technique. Non-expert laboratories should use an antigen-based assay of high sensitivity. Only IgG class antibodies need to be measured. Useful information is gained by reporting the actual optical density, inhibition by high concentrations of heparin, and the cut-off value for a positive test rather than simply reporting the test as positive or negative. In making a diagnosis of HIT the clinician's estimate of the pretest probability of HIT together with the type of assay used and its quantitative result (enzyme-linked immunosorbent assay, ELISA, only) should be used to determine the overall probability of HIT. Clinical decisions should be made following consideration of the risks and benefits of treatment with an alternative anticoagulant. For patients with strongly suspected or confirmed HIT, heparin should be stopped and full-dose anticoagulation with an alternative, such as lepirudin or danaparoid, commenced (in the absence of a significant contraindication). Warfarin should not be used until the platelet count has recovered. When introduced in combination with warfarin, an alternative anticoagulant must be continued until the International Normalised Ratio (INR) is therapeutic for two consecutive days. Platelets should not be given for prophylaxis. Lepirudin, at doses adjusted to achieve an activated partial thromboplastin time (APTT) ratio of 1·5,2·5, reduces the risk of reaching the composite endpoint of limb amputation, death or new thrombosis in patients with HIT and HIT with thrombosis (HITT). The risk of major haemorrhage is directly related to the APTT ratio, lepirudin levels and serum creatinine levels. The patient's renal function needs to be taken into careful consideration before treatment with lepirudin is commenced. Severe anaphylaxis occurs rarely in recipients of lepirudin and is more common in previously exposed patients. Danaparoid in a high-dose regimen is equivalent to lepirudin in the treatment of HIT and HITT. Danaparoid at prophylactic doses is not recommended for the treatment of HIT or HITT. Patients with previous HIT who are antibody negative (usually so after >100 d) who require cardiac surgery should receive intraoperative UFH in preference to other anticoagulants that are less validated for this purpose. Pre- and postoperative anticoagulation should be with an anticoagulant other than UFH or LMWH. Patients with recent or active HIT should have the need for surgery reviewed and delayed until the patient is antibody negative if possible. They should then proceed as above. If deemed appropriate early surgery should be carried out with an alternative anticoagulant. We recommend discussion of these complex cases requiring surgery with an experienced centre. The diagnosis must be clearly recorded in the patient's medical record. [source] | |||||||||||||||||||||||||||||||