[Proposal of Admission Criteria for Psychiatric Hospitalization]

N/a.

[Reduction of reconciliation errors in chronic pediatric patients through an educational strategy]

BACKGROUND

Medication reconciliation errors, also known as unintentional discrepancies, are frequent during admission, especially in chronic patients, and have an impact on safety. Educational interventions can be a reduction strategy.

MATERIAL AND METHODS

Quasi-experimental study, before-after design. Participants were chronic patients admitted into hospitalization services. Medication reconciliation was conducted at admission. The intervention consisted of a training to each prescribing physician with study contents and printed educational material. To study the association between intervention and change of frequency of unintentional discrepancies was made a logistic regression model, adjusting for selected variables.

RESULTS

A sample of 54 patients was studied in each stage. In the first stage it was observed that 42.6% of patients had at least one unintentional discrepancy. After intervention the proportion of patients with at least one unintentional discrepancy decreased to 24.1% (p = 0.041). In both stages, omission was the main category of unintentional discrepancy. The significant reduction after the intervention is maintained by controlling for variables such as emergency admission and pre-admission service.

CONCLUSIONS

Incidence of unintentional discrepancies in admission is high in chronic hospitalized patients and can be reduced through an educative strategy.

Impact of Ramadan on Emergency Department Patients Flow; a Cross-Sectional Study in UAE

Introduction:

Ramadan, the ninth month of the Islamic lunar calendar, is, to Muslims, the holiest month of the year. During this month, young, able-bodied Muslims are commanded to abstain from food and drink from dawn to dusk.

Objective:

The objective of the study is to analyze emergency department (ED) patients flow during the holy month of Ramadan and compare it to non-Ramadan days. We hypothesized that Ramadan would affect ED attendance by altering peak hours, and expected a dip in attendance around evening time (after sunset).

Methods:

In Abu Dhabi, United Arab Emirates, a retrospective study was conducted at a tertiary hospital (2014–2016). The data was strategically separated and patient presence was analyzed year-wise, weekday basis and based on the hourly presence of the patients in the ED of the chosen hospital.

Results:

A total of 45,116 ED’s patient visits were analyzed over the mentioned study period. There was a difference in the total volume of Ramadan and non-Ramadan patient between the years 2014–2016. In all of the years, the highest percentage of visits was during the non-Ramadan days and this had a small fluctuation from 53% in 2014 to 52% in 2016 (p=0.001). It was observed from the collected data that 53% of the patients were present in the hospital during the fasting hours whereas 47% were present during the non-fasting hours (p<0.001).

Conclusion:

We were successfully able to derive a pattern from the data of 3 years in relation to the patient flow in the ED of the hospital. Moreover, we observed the difference in the patient arrival pattern between the Ramadan and non-Ramadan days in the hospital along with the predominant categorization of patient chief complaints. Our study identified a unique pattern of ED hourly visits during Ramadan.

[Availability and Readiness Assessment of Facilities with Hospital Admission Capacity in Two Regions of Guinea-Bissau]

INTRODUCTION

The weaknesses of Guinea-Bissau's health system have long been highlighted. The purpose of this study is to contribute with evidence for decision-making on the reform of the country's healthcare map, by analyzing the availability and readiness of services at the facilities that may become part of a Hospital Complex in Bissau, proposed in the National Health Development Plan.

MATERIAL AND METHODS

We analyzed 13 public and private facilities with inpatient capacity, located in Bissau and Biombo. Service Availability and Readiness Assessment (SARA) tools were used for data collection, treatment and analysis.

RESULTS

A comprehensive overview of these facilities has been provided, describing their general capacity to provide care and their readiness to implement it, along with the availability and readiness of specific services: diagnosis, family planning, mother and child health, obstetrics, communicable and non communicable diseases, blood transfusion and surgery. We observed a greater concentration of beds and professionals in the facilities of public sector, the only that provides all the specific services analyzed. Private sector services with agreements to supply the public sector have higher readiness levels and the private sector has the lowest operating capacity.

DISCUSSION

Findings reflect the lack of equipment, infrastructure and resources, the predominance of the public sector and the growth of the private for-profit and non-profit sectors, as well as inadequacies in planning and regulation. Similarities and differences between our findings and those described in the literature for other African countries are identified.

CONCLUSION

This study reinforces the relevance of developing integrated and rational responses of health services and provides evidence for this.

Facilitators and barriers in implementing medication safety practices across hospitals within 11 European Union countries

Background:

The study was carried out as part of the European Network for Patient Safety (EUNetPas) project in 2008-2010.

Objective:

To investigate facilitators and barriers in implementation process of selected medication safety practices across hospitals within European Union countries.

Methods:

This was an implementation study of seven selected medication safety practices in 55 volunteering hospitals of 11 European Union (EU) member states. The selected practices were two different versions of medicine bed dispensation; safety vest; discharge medication list for patients; medication reconciliation at patient discharge; medication reconciliation at patient admission and patient discharge, and sleep card. The participating hospitals submitted an evaluation report describing the implementation process of a chosen practice in their organisation. The reports were analysed with inductive content analysis to identify general and practice-specific facilitators and barriers to the practice implementation.

Results:

Altogether 75 evaluation reports were submitted from 55 hospitals in 11 EU member states. Implementation of the medication safety practices was challenging and more time consuming than expected. The major reported challenge was to change the work process because of the new practice. General facilitators for successful implementation were existence of safety culture, national guidelines and projects, expert support, sufficient resources, electronic patient records, interdisciplinary cooperation and clinical pharmacy services supporting the practice implementation.

Conclusions:

The key for the successful implementation of a medication safety practice is to select the right practice for the right problem, in the right setting and with sufficient resources in an organization with a safety culture.

Implementing a guideline for acute tonsillitis using an ambulatory medical unit

OBJECTIVE

Acute tonsillitis represents a significant proportion of admissions to ENT departments nationally. Given current hospital pressures, it is vital to look for safe alternatives to admission. This study explores the safe management of patients in an ambulatory medical unit, without the need for admission.

METHODS

A retrospective review of 48 patients' notes was carried out. Following the development and implementation of a guideline for acute tonsillitis, a prospective re-audit of 41 patients was carried out, measuring length of stay, overnight admissions and re-admissions.

RESULTS

The rate of overnight admission following implementation of the guideline fell from 0.75 to 0.29, and average length of stay dropped from 19.2 to 9.5 hours. There were two re-admissions in each cycle of the audit, which represents a non-significant increase.

CONCLUSION

The tonsillitis guideline has significantly reduced admissions and length of stay. Re-admissions remain low, demonstrating that this is a safe and cost-effective intervention.

Rate of Correction of Hypernatremia and Health Outcomes in Critically Ill Patients

BACKGROUND AND OBJECTIVES

Hypernatremia is common in hospitalized, critically ill patients. Although there are no clear guidelines on sodium correction rate for hypernatremia, some studies suggest a reduction rate not to exceed 0.5 mmol/L per hour. However, the data supporting this recommendation and the optimal rate of hypernatremia correction in hospitalized adults are unclear.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We assessed the association of hypernatremia correction rates with neurologic outcomes and mortality in critically ill patients with hypernatremia at admission and those that developed hypernatremia during hospitalization. We used data from the Medical Information Mart for Intensive Care-III and identified patients with hypernatremia (serum sodium level >155 mmol/L) on admission (n=122) and hospital-acquired (n=327). We calculated different ranges of rapid correction rates (>0.5 mmol/L per hour overall and >8, >10, and >12 mmol/L per 24 hours) and utilized logistic regression to generate adjusted odds ratios (aOR) with 95% confidence intervals (95% CIs) to examine association with outcomes.

RESULTS

We had complete data on 122 patients with severe hypernatremia on admission and 327 patients who developed hospital-acquired hypernatremia. The difference in in-hospital 30-day mortality proportion between rapid (>0.5 mmol/L per hour) and slower (≤0.5 mmol/L per hour) correction rates were not significant either in patients with hypernatremia at admission with rapid versus slow correction (25% versus 28%; P=0.80) or in patients with hospital-acquired hypernatremia with rapid versus slow correction (44% versus 40%; P=0.50). There was no difference in aOR of mortality for rapid versus slow correction in either admission (aOR, 1.3; 95% CI, 0.5 to 3.7) or hospital-acquired hypernatremia (aOR, 1.3; 95% CI, 0.8 to 2.3). Manual chart review of all suspected chronic hypernatremia patients, which included all 122 with hypernatremia at admission, 128 of the 327 hospital-acquired hypernatremia, and an additional 28 patients with ICD-9 codes for cerebral edema, seizures and/or alteration of consciousness, did not reveal a single case of cerebral edema attributable to rapid hyprnatremia correction.

CONCLUSIONS

We did not find any evidence that rapid correction of hypernatremia is associated with a higher risk for mortality, seizure, alteration of consciousness, and/or cerebral edema in critically ill adult patients with either admission or hospital-acquired hypernatremia.

Frequency of occurrence of medication discrepancies and associated risk factors in cases of acute hospital admission

Background

Medication discrepancies are a common occurrence following hospital admission and carry the potential for causing harm. However, little is known about the potential risk factors involved in medication discrepancies.

Objective

The objective of this study was to determine how frequently medication discrepancies occur and their associated risk factors, in patients hospitalized via the emergency department of the Spaarne Gasthuis Hospital, located in The Netherlands.

Methods

This retrospective observational study examines 832 hospital admissions which took place between April 1st and June 30th, 2015. Medication reconciliation was performed within 24 hours of admission and medication discrepancies were registered. The primary outcome recorded in the study was the proportion of patients experiencing one or more medication discrepancies, as verified by the physician. As a secondary outcome, the association between these discrepancies and pre-specified variables was analyzed using univariate and multivariate logistic regression.

Results

At least one medication discrepancy was found to have occurred with 97 of the 832 patients (11.7%), the most common discrepancies involving incorrect drug dose (44.9%) and omission of medication (36.4%). In the univariate analysis, age (OR=1.03 [95% CI 1.02:1.04] p<0.001) and number of pre-admission medications taken (OR=1.13 [95%CI 1.09:1.17] p<0.001) were revealed to be significantly associated with the risk of medication discrepancies. Sex, type of medical specialty, and surgical versus non-surgical specialty were found not to be significantly associated with discrepancies. In the multivariate analysis, both the number of pre-admission medications (OR=1.10 [95%CI 1.06:1.15] p<0.001) and age (OR=1.02 [95%CI 1.01:1.03] p=0.004) were independently associated with the risk of medication discrepancy.

Conclusions

Of the total number of patients, 11.7% experienced one or more medication discrepancies following admission to the hospital. Elderly patients taking multiple drugs were found to be particularly at risk.

Characteristics of Critically-Ill Patients at Two Tertiary Care Hospitals in Sudan

Objectives

Knowledge of intensive care unit (ICU) admission patterns and characteristics is necessary for the development of critical care services, particularly in low-resource settings. This study aimed to describe the characteristics of critically-ill patients admitted to ICUs in Sudan.

Methods

This prospective observational study was conducted between February and May 2017 in the ICUs of two government tertiary care hospitals in Khartoum, Sudan. A total of 100 consecutive adult patients admitted to the ICUs were included in the study. The patients' demographic and clinical characteristics and Acute Physiologic Assessment and Chronic Health Evaluation (APACHE II) scores upon admission were recorded, as well as the reason for admission, presence of any underlying comorbidities, interventional requirements like mechanical ventilation or haemodialysis, length of stay in the ICU and patient outcome.

Results

Of the sample, 58% were female and 42% were male. The mean age was 47.4 ± 18.3 years old. Upon admission, the mean APACHE II score was 14.2 ± 9.6. In total, 54% of the patients had no known underlying comorbidities. The most common reasons for ICU admission were neurological diseases (27%), sepsis or infectious diseases (19%) and postoperative management (12%). Mechanical ventilation and haemodialysis were required by 35% and 11% of the patients, respectively. The average length of stay was 10.0 ± 7.2 days and the mortality rate was 24%.

Conclusion

Most of the patients admitted to the ICUs were middle-aged females with no known underlying comorbidities. Larger studies are necessary to provide a comprehensive understanding of the critical care needs of Sudanese hospitals.

Patterns of Inpatient Admissions during Hajj: Clinical conditions, length of stay and patient outcomes at an advanced care centre in Makkah, Saudi Arabia

Objectives:

This study aimed to describe inpatient clinical conditions at an advanced care facility in Saudi Arabia during the annual Hajj pilgrimage and to determine factors correlating with length of stay (LOS).

Methods:

This retrospective study was conducted at the King Abdullah Medical City (KAMC), Makkah, Saudi Arabia, and included all inpatients admitted during the annual Hajj pilgrimage between August and October 2015. Demographic, administrative and clinical data were collected from patient charts and analysed.

Results:

A total of 296 inpatients were included in the study, of which the majority were male (73.6%) and ≥55 years old (77%). Walk-in admissions occurred less frequently than referrals (38.9% versus 61.1%). Most patients (41.6%) were admitted during the peak Hajj period (the 8-13^th days of Dhu al-Hijjah). Acute coronary syndrome was the most prevalent provisional diagnosis (65.2%). In terms of outcomes, 89.2% of the inpatients were discharged in a stable condition, with 37.5% discharged within ≤24 hours of admission. However, 39.9% required admission to the Intensive Care Unit (ICU). Overall, LOS was significantly associated with various factors, including the mode of admission, admission period, admitting department, number of comorbidities and ICU admission (P <0.050 each).

Conclusion:

Most of admissions were referrals, and the main Hajj period witnessed the majority of admissions. The vast majority of inpatients eventually discharged in a stable condition. Determinants of the length of hospital stay were the mode of admission, admission period, admitting department, number of comorbidities and ICU admission.

Association Between Weekend and Holiday Admission with Pneumonia and Mortality in a Tertiary Center in Portugal: A Cross-Sectional Study

INTRODUCTION

Acute bacterial pneumonia is a common and potentially fatal disease where early recognition and treatment are crucial. Increasing medical literature suggests worse outcomes in patients admitted for medical and surgical conditions during the weekend. Little is known about this effect in patients with acute bacterial pneumonia. Obective: The aim of this study was to evaluate the impact of weekend and holiday hospital admission on the outcomes of acute bacterial pneumonia.

MATERIAL AND METHODS

Retrospective analysis of adult patients (> 18 years) with acute bacterial pneumonia collected from a tertiary referral center database. Length of stay, total cost, admission to intensive care unit, development of sepsis and organ failure, and mortality were compared between patients admitted on a weekday and patients admitted during a weekend or holiday.

RESULTS

We analyzed 53 854 hospital admissions from 42 512 patients (median age 84.0 years, range 18 - 118 years), corresponding to 30 554 admissions during weekdays, 21 222 at weekends and 2078 during public holidays. Weekend and holiday admission was not associated with increased costs, length of stay, intensive care unit admission, development of sepsis, organ failure, and mortality.

CONCLUSION

A weekend/holiday effect in acute bacterial pneumonia was not evident in our series.

Differences in the Clinical Characteristics of Rapid Response System Activation in Patients Admitted to Medical or Surgical Services

Variability in rapid response system (RRS) characteristics based on the admitted wards is unknown. We aimed to compare differences in the clinical characteristics of RRS activation between patients admitted to medical versus surgical services. We reviewed patients admitted to the hospital who were detected by the RRS from October 2012 to February 2014 at a tertiary care academic hospital. We compared the triggers for RRS activation, interventions performed, and outcomes of the 2 patient groups. The RRS was activated for 460 patients, and the activation rate was almost 2.3 times higher for surgical services than that for medical services (70% vs. 30%). The triggers for RRS activation significantly differed between patient groups (P = 0.001). They included abnormal values for the respiratory rate (23.2%) and blood gas analysis (20.3%), and low blood pressure (18.8%) in the medical group; and low blood pressure (32.0%), low oxygen saturation (20.8%), and an abnormal heart rate (17.7%) in the surgical group. Patients were more likely classified as do not resuscitate or required intensive care unit admission in the medical group compared to those in the surgical group (65.3% vs. 54.7%, P = 0.045). In multivariate analysis, whether the patient belongs to medical services was found to be an independent predictor of mortality after adjusting for the modified early warning score, Charlson comorbidity index, and intervention performed by the RRS team. Our data suggest that RRS triggers, interventions, and outcomes greatly differ between patient groups. Further research is needed to evaluate the efficacy of an RRS approach tailored to specific patient groups.

Impact of pharmacy-led medication reconciliation on medication errors during transition in the hospital setting

Objective:

To assess if the pharmacy department should be more involved in the medication reconciliation process to assist in the reduction of medication errors that occur during transition of care points in the hospital setting.

Methods:

This was an observational prospective cohort study at a 531-bed hospital in Pensacola, FL from June 1, 2014 to August 31, 2014. Patients were included in the study if they had health insurance and were taking five or more medications. Patients with congestive heart failure were excluded from the study. Student pharmacists collected and evaluated medication histories obtained from patients’ community pharmacies, and directed patient interviews. Primary care providers were only contacted on an as needed basis. The information collected was presented to the clinical pharmacist, where interventions were made utilizing clinical judgment.

Results:

During the three month study, 1045 home medications were reviewed by student pharmacist. Of these, 290 discrepancies were discovered (27.8%; p=0.02). The most common medication discrepancy found was dose optimization (45.5%). The remaining discrepancies included: added therapy (27.6%), other (15.2%), and discontinued therapy (11.7%). Pharmacists made 143 interventions based on clinical judgment (49.3%; p=0.04).

Conclusion:

Involvement of pharmacy personnel during the medication reconciliation process can be an essential component in reducing medical errors. With the addition of the pharmacy department during the admission process, accuracy, cost savings, and patient safety across all phases and transition points of care were achieved.

The Efficacy of Written Information Intervention in Reduction of Hospital Re-admission Cost in Patients With Heart Failure; A Systematic Review and Meta-Analysis

Objective: To assess the efficacy of written information versus non written information intervention in reducing hospital readmission cost, if prescribed or presented to the patients with HF.

Methods: The study was a systematic review and meta-analysis. We searched Medline (Ovid) and Cochrane library during the past 20 years from 1993 to 2013. We also conducted a manual search through Google Scholar and a direct search in the group of related journals in Black Well and Science Direct trough their websites. Two reviewers appraised the identified studies, and meta-analysis was done to estimate the mean saving cost of patient readmission. All the included studies must have been done by randomization to be eligible for study.

Result: We assessed the full-texts 3 out of 65 studies with 754 patients and average age of 74.33. The mean of estimated saving readmission cost in intervention group versus control group was US $2751 (95% CI: 2708 – 2794) and the mean of total saving cost in intervention group versus control group was US $2047 (base year 2010) with (95% CI: 2004 – 2089). No publication bias was found by testing the heterogeneity of studies.

Conclusion: One of the effective factors in minimizing the healthcare cost and preventing from hospital re-admission is providing the patients with information prescription in a written format. It is suggested that hospital management, Medicare organizations, policy makers and individual physicians consider the prescription of appropriate medical information as the indispensable part of patient’s care process.

Predictors of prehospital delay in patients with acute myocardial infarction in kashan city

Background:

The prehospital delay might result in death in patients with acute myocardial infarction (AMI).

Objectives:

This study aimed to investigate the prehospital delay and its related factors in patients with AMI admitted to Kashan’s Shahid Beheshti Hospital.

Patients and Methods:

This cross-sectional study was conducted on 117 patients with AMI in the second half of 2013. The interval between the onset of symptoms and arrival at the hospital was noted and in cases of delay, the factors leading to the delay were investigated using a questionnaire. The content validity of the questionnaire was confirmed through content validity method and its internal consistency was confirmed using Cronbach's alpha coefficient. Chi-square test, odds ratio, and logistic regression analysis were used in data analysis.

Results:

The median delay was 129 minutes (mean ± SD, 240.44 ± 295.30). Overall, 32.5% of patients were admitted within 90 minutes of symptom onset. The long distance between living locations to the hospital was the most common cause of delay to hospital admission (31.7%). Significant associations were observed between the delay time and location of residency (P = 0.00) and type of transportation vehicle (P = 0.003). Multivariate logistic regression analysis showed that the location of residency and type of transportation vehicle could significantly predict the delay time in patients with AMI (P = 0.039 and 0.036, respectively).

Conclusions:

The delay time from symptom onset to hospital admission was high in patients with AMI. It is necessary to create emergency medical system (EMS) stations in suburbs and train the public on the importance of quick contact with the EMS when the symptoms of an AMI are observed.

Protocol for an exploration of knowledge sharing for improved discharge from a mental health ward

INTRODUCTION

Strategies to reduce hospital admissions for mental health service users have received vast amounts of attention, yet the transfer of care from hospital to the community has been ignored. The discharge process is complex, messy, disjointed and inefficient, relying on cross-agency and organisational working. Focusing on one acute mental health admission ward, we will investigate whether the discharge process for people with severe mental health problems can be enhanced through the creation, implementation and utilisation of a knowledge sharing proforma that is used on their admission to the ward.

METHODS AND ANALYSIS

The project uses qualitative interviews to understand the complex processes associated with being admitted and discharged from inpatient mental health wards. Practitioners will be asked to identify and map the relevant stakeholders involved in admission and discharge, and discuss any problems with the process. The study team will work with clinicians to develop a knowledge collection proforma, which will be piloted for 2 months. Qualitative interviews will be carried out to collect reflections on the experiences of using the tool, with data used for further refinement of the intervention. Baseline and repeat quantitative measures will be taken to illustrate any changes to length of stay and readmission rates achieved as a result of the study.

ETHICS AND DISSEMINATION

A key issue is that participants are able to comment frankly on something that is a core part of their work, without fear or reprise. It is equally important that all participants are offered the opportunity to develop and coproduce the knowledge collection proforma, in order that the intervention produced is fit for purpose and usable in the real world, away from a research environment. The study has received ethical approval from Nottingham University Business School ethics committee, and has all appropriate National Health Service research governance clearances.

Pharmacists implementing transitions of care in inpatient, ambulatory and community practice settings

OBJECTIVE

To introduce pharmacists to the process, challenges, and opportunities of creating transitions of care (TOC) models in the inpatient, ambulatory, and community practice settings.

METHODS

TOC literature and resources were obtained through searching PubMed, Ovid, and GoogleScholar. The pharmacist clinicians, who are the authors in this manuscript are reporting their experiences in the development, implementation of, and practice within the TOC models.

RESULTS

Pharmacists are an essential part of the multidisciplinary team and play a key role in providing care to patients as they move between health care settings or from a health care setting to home. Pharmacists can participate in many aspects of the inpatient, ambulatory care, and community pharmacy practice settings to implement and ensure optimal TOC processes. This article describes establishing the pharmacist's TOC role and practicing within multiple health care settings. In these models, pharmacists focus on medication reconciliation, discharge counseling, and optimization of medications [corrected].

CONCLUSION

Optimizing the TOC process, reducing medication errors, and preventing adverse events are important focus areas in the current health care system, as emphasized by The Joint Commission and other health care organizations. Pharmacists have the unique opportunity and skillset to develop and participate in TOC processes that will enhance medication safety and improve patient care.

Sterile pyuria in patients admitted to the hospital with infections outside of the urinary tract

OBJECTIVES

The objective of this study was to determine the incidence, associations, evaluation, and management of pyuria in patients admitted to the hospital with nonurinary infections.

METHODS

This study abstracted inpatient records of consecutive patients hospitalized for pneumonia, intra-abdominal infections, female genital tract infections (GYN infections), bacterial septicemia, and enteritis in the pediatric and adult medical and surgical units at an academic medical center.

RESULTS

The study population included 210 patients (66 children; 144 adults). Nearly one-third had ≥5 white blood cells (WBCs) per high-power field (pyuria). Pyuria was more common in women (P < .001) and in patients with GYN infections (P = .001) and less common in patients with pneumonia (P < .001). Cultures were performed on 18 of 19 children (94.7%) and 26 of 43 adults (60.5%) with pyuria. Of those, 11.1% of children and 42.1% of adults had a positive culture, and all but one of those met criteria for a urinary tract infection. Excluding patients with GYN infections, only 18.8% of patients with pyuria had a positive culture. Of the 44 patients with pyuria who were cultured, a positive culture was associated with having a GYN infection (P = .01), moderate or large amounts of bacteria in the urine (P = .005), and a positive urine nitrite (P = .004). The absolute number of WBCs or red blood cells in the urine and the presence of casts, proteinuria, and leukocyte esterase were not associated with positive culture or urinary tract infection. Neither pyuria nor a positive culture was related to temperature, systemic WBC count, or serum albumin, blood urea nitrogen, or creatinine.

CONCLUSIONS

Sterile pyuria of uncertain cause is common in patients admitted to the hospital with acute nonurinary infections.