A Neurodisparity Index of Nationwide Access to Neurological Health Care in Northern Ireland.

Nationwide disparities in managing neurological patients have rarely been reported. We compared neurological health care between the population who reside in a Health and Social Care Trust with a tertiary neuroscience center and those living in the four non-tertiary center Trusts in Northern Ireland. Using the tertiary center Trust population as reference, neurodisparity indices (NDIs) defined as the number of treated patients resident in each Trust per 100,000 residents compared to the same ratio in the tertiary center Trust for a fixed time period. NDIs were calculated for four neurological pathways-intravenous thrombolysis (iv-tPA) and mechanical thrombectomy (MT) for acute ischemic stroke (AIS), disease modifying treatment (DMT) in multiple sclerosis (MS) and admissions to a tertiary neurology ward. Neurological management was recorded in 3,026 patients. Patients resident in the tertiary center Trust were more likely to receive AIS treatments (iv-tPA and MT) and access to the neurology ward (p < 0.001) than patients residing in other Trusts. DMT use for patients with MS was higher in two non-tertiary center Trusts than in the tertiary center Trust. There was a geographical gradient for MT for AIS patients and ward admissions. Averaged NDIs for non-tertiary center Trusts were: 0.48 (95%CI 0.32-0.71) for patient admissions to the tertiary neurology ward, 0.50 (95%CI 0.38-0.66) for MT in AIS patients, 0.78 (95%CI 0.67-0.92) for iv-tPA in AIS patients, and 1.11 (95%CI 0.99-1.26) for DMT use in MS patients. There are important neurodisparities in Northern Ireland, particularly for MT and tertiary ward admissions. Neurologists and health service planners should be aware that geography and time-dependent management of neurological patients worsen neurodisparities

A Neurodisparity Index of Nationwide Access to Neurological Health Care in Northern Ireland

Nationwide disparities in managing neurological patients have rarely been reported. We compared neurological health care between the population who reside in a Health and Social Care Trust with a tertiary neuroscience center and those living in the four non-tertiary center Trusts in Northern Ireland. Using the tertiary center Trust population as reference, neurodisparity indices (NDIs) defined as the number of treated patients resident in each Trust per 100,000 residents compared to the same ratio in the tertiary center Trust for a fixed time period. NDIs were calculated for four neurological pathways—intravenous thrombolysis (iv-tPA) and mechanical thrombectomy (MT) for acute ischemic stroke (AIS), disease modifying treatment (DMT) in multiple sclerosis (MS) and admissions to a tertiary neurology ward. Neurological management was recorded in 3,026 patients. Patients resident in the tertiary center Trust were more likely to receive AIS treatments (iv-tPA and MT) and access to the neurology ward (p < 0.001) than patients residing in other Trusts. DMT use for patients with MS was higher in two non-tertiary center Trusts than in the tertiary center Trust. There was a geographical gradient for MT for AIS patients and ward admissions. Averaged NDIs for non-tertiary center Trusts were: 0.48 (95%CI 0.32–0.71) for patient admissions to the tertiary neurology ward, 0.50 (95%CI 0.38–0.66) for MT in AIS patients, 0.78 (95%CI 0.67–0.92) for iv-tPA in AIS patients, and 1.11 (95%CI 0.99–1.26) for DMT use in MS patients. There are important neurodisparities in Northern Ireland, particularly for MT and tertiary ward admissions. Neurologists and health service planners should be aware that geography and time-dependent management of neurological patients worsen neurodisparities

Outlier admissions of medical patients: Prognostic implications of outlying patients. The experience of the Hospital of Mestre

ABSTRACT The admission of a patient in wards other than the appropriate ones, known as the patient outlying phenomenon, involves both Medicine and Geriatric Units of many Hospitals. The aims were to learn more about the prognosis of the outlying patients, we investigated 3828 consecutive patients hospitalized in Medicine and Geriatrics of our hub Hospital during the year 2012. We compared patients\u2019 mean hospital length of stay, survival, and early readmission according to their outlying status. The mean hospital length of stay did not significantly differ between the two groups, either for Medicine (9.8 days for outliers and 10.0 for in-ward) or Geriatrics (13.0 days for both). However, after adjustment for age and sex, the risk of death was about twice as high for outlier patients admitted into surgical compared to medical areas (hazard ratio 1.8, 1.2-2.5 95% confidence interval). Readmission within 90 days from the first discharge was more frequent for patients admitted as outliers (26.1% vs 14.2%, P<0.0001). We highlight some critical aspects of an overcrowded hospital, as the shortage of beds in Medicine and Geriatrics and the potential increased clinical risk denoted by deaths or early readmission for medical outlier patients when assigned to inappropriate wards. There is the need to reorganize beds allocation involving community services, improve in-hospital bed management, an extent diagnostic procedures for outlier patients admitted in nonmedical wards

Adherence to UK national guidance for discharge information: an audit in primary care

Aims: Poor communication of clinical information between healthcare settings is associated with patient harm. In 2008, the UK National Prescribing Centre (NPC) issued guidance regarding the minimum information to be communicated upon hospital discharge. This study evaluates the extent of adherence to this guidance and identifies predictors of adherence. Methods: This was an audit of discharge summaries received by medical practices in one UK primary care trust of patients hospitalized for 24 h or longer. Each discharge summary was scored against the applicable NPC criteria which were organized into: ‘patient, admission and discharge’, ‘medicine’ and ‘therapy change’ information. Results: Of 3444 discharge summaries audited, 2421 (70.3%) were from two teaching hospitals and 906 (26.3%) from three district hospitals. Unplanned admissions accounted for 2168 (63.0%) of the audit sample and 74.6% (2570) of discharge summaries were electronic. Mean (95% CI) adherence to the total NPC minimum dataset was 71.7% [70.2, 73.2]. Adherence to patient, admission and discharge information was 77.3% (95% CI 77.0, 77.7), 67.2% (95% CI 66.3, 68.2) for medicine information and 48.9% (95% CI 47.5, 50.3) for therapy change information. Allergy status, co-morbidities, medication history and rationale for therapy change were the most frequent omissions. Predictors of adherence included quality of the discharge template, electronic discharge summaries and smaller numbers of prescribed medicines. Conclusions: Despite clear guidance regarding the content of discharge information, omissions are frequent. Adherence to the NPC minimum dataset might be improved by using comprehensive electronic discharge templates and implementation of effective medicines reconciliation at both sides of the health interface

DEMENTIA CARE ON MEDICAL AND MEDICINE FOR THE ELDERLY WARDS

Dementia is associated with increased health care resource utilisation and greater co-morbidity burden. Due to the psychophysiological and social demands of dementia, specific approaches to care, communication, environment and clinical treatment are needed. Timely diagnosis can greatly improve quality of life. Dementia is often not coded in hospitals as it is not considered the primary reason for admission. These missed opportunities have potential to serve as important checkpoints for proper diagnostic assessment. Upon discharge, adjustments can be made to manage these patients better. In April 2012, the dementia CQUIN was introduced with goals for early diagnosis of dementia at point of hospital admission. This study aims to investigate if the raised profile of dementia care has been generalised across the whole system, the impact on management and whether there is a difference in dementia care between geriatric and medical wards. There was excellent performance across the board for review of medication, prescription of anti-psychotics, ordering of routine bloods and neurological examinations. . Increased awareness is needed for dementia-specific blood tests, namely: thyroid function test, B12 and folate. Geriatric wards performed consistently better than medical wards for all aspects of clinical care examined. For medical wards, incorporating multi-disciplinary care would be useful in managing these patients more holistically

Pattern and outcomes of admissions to the Medical Acute Care Unit of a tertiary teaching hospital in South Africa

A research report submitted to the University of the Witwatersrand, in fulfilment for the requirements of the degree of Master of Medicine in the branch of Internal Medicine. Johannesburg 2018.Background A Medical Acute Care Unit (MACU) was established at Chris Hani Baragwanath Academic Hospital (CHBAH) to provide comprehensive medical specialist care to the patients presenting with acute medical emergencies. Improved standards of health care delivery systems at the MACU may result in shorter hospital stay, better outcomes and less mortality. Objectives The objective of the study was to describe the demographics, diagnoses, pattern of diseases and the outcomes, including mortality of patients admitted to the MACU at the Chris Hani Baragwanath Academic Hospital (CHBAH). Methods A record review of 200 patients admitted to the MACU at CHBAH was performed from March 2015 to August 2015. The records were analysed for patient demographics, diagnosis at admission and duration of stay in MACU. The outcome was defined as transfer to the medical ward, Intensive Care Unit (ICU) or discharged home. The main causes of mortality were also recorded. Results Of the 200 patients, 59% were females. The mean age of the patients was 46 ± 17.2 years and the mean duration of stay at the MACU was 1.45 ± 1.25 days. Noncommunicable diseases accounted for 76% of admissions. The most frequently diagnosed conditions included: diabetic ketoacidosis acidosis (DKA) and hyperosmolar non-ketotic (HONK) (17.5%), non-accidental self-poisoning (16%), hypertensive emergencies (9.5%), decompensated cardiac failure (8%) and ischemic v heart disease (7%). Infectious diseases comprised 14% of the diagnoses of which pneumonias were the most common (5%). Most patients (77.5%) were transferred to medical wards, 12% to ICU, while 10% demised at the MACU. The main causes of death included sepsis (25%), DKA/HONK (20%), non-accidental self-poisoning (10%) and cardiac failure (10%). Conclusion Non-communicable diseases particularly diabetic emergencies were the main causes of admission to the MACU at CHBAH. During the study period, high rates of case improvement, patient discharge, shorter hospital stay, and less mortality were observed. The main cause of mortality was sepsis related.LG201

Transient Ischemic Attack and Admission to a Dedicated Unit

Transient ischemic attacks account for admissions of approximately 70% of patients who present to the emergency department with transient vascular symptoms, with an average length of stay of one to seven days, costing, on average, $22,087 (Qureshi et al., 2013). A hospital organization\u27s bed efficiency directly affects quality metrics. Reducing the length of stay in TIA patients by having them admitted to a dedicated unit with whom the staff has experience managing stroke patients and the understanding of specific criteria needing to be met before discharge can directly impact quality metrics and provide cost-effective delivery of care. The PICOT question that guided this project was, in patients who present to the emergency department with a transient ischemic attack (TIA), how does the implementation of a rapid, protocol-based pathway for admission to a dedicated stroke unit versus conventional admission methods decrease the length of stay over eight weeks? The evidence for this project revealed several articles establishing that a protocol-based pathway initiated in the emergency department could reduce the length of stay in the specified group. Additional evidence indicated the use of an algorithm and ABCD2 scoring in conjunction with meeting \u27Get with the Guidelines\u27 criteria provided a reduction in cost to the organization (see Table 2). Using a rapid, protocol-based pathway, in collaboration with emergency department physicians, general neurologists, and other clinicians, and the ABCD2 score assisted with diagnosis and direct admissions. A checklist was provided to the dedicated unit staff to ensure all criteria for admission and discharge were met. The results of this project demonstrated patients were being discharged at 2.84 days, slightly above the national average of 2.24 days. These results indicated an increase but withstanding efficacy of assessment and treatment. The reason for the subtle increase was secondary to patients with incidental findings requiring intervention increasing the length of stay for recovery