Prediction of future hospital admissions - what is the tradeoff between specificity and accuracy?

Large amounts of electronic medical records collected by hospitals across the developed world offer unprecedented possibilities for knowledge discovery using computer based data mining and machine learning. Notwithstanding significant research efforts, the use of this data in the prediction of disease development has largely been disappointing. In this paper we examine in detail a recently proposed method which has in preliminary experiments demonstrated highly promising results on real-world data. We scrutinize the authors' claims that the proposed model is scalable and investigate whether the tradeoff between prediction specificity (i.e. the ability of the model to predict a wide number of different ailments) and accuracy (i.e. the ability of the model to make the correct prediction) is practically viable. Our experiments conducted on a data corpus of nearly 3,000,000 admissions support the authors' expectations and demonstrate that the high prediction accuracy is maintained well even when the number of admission types explicitly included in the model is increased to account for 98% of all admissions in the corpus. Thus several promising directions for future work are highlighted.Comment: In Proc. International Conference on Bioinformatics and Computational Biology, April 201

Being safe & taking risks : how a group of nurses managed children's pain : a thesis presented in partial fulfilment of the requirements for the degree of Master of Philosophy in Nursing at Massey University

A small, grounded theory study was conducted in a children's surgical ward in a large, urban teaching hospital involving registered nurse volunteers. The purpose of the study was to investigate how nurses' deal with children's acute pain. Ten unstructured, but focused in-depth, taped interviews were conducted with five nurses. The constant comparative method as proposed by Glaser and Strauss (1967) and Glaser (1978) was used to generate substantive theoretical categories, a core category and basic social process. Analysis revealed that what nurses may want to do and what they can do when managing children's pain is not necessarily the same thing. A number of structural barriers to prompt and effective pain management were identified, such as doctors not always being available to write prescriptions, under prescribing or doctors even refusing to prescribe opioids for children at times. Lack of equipment for delivering continuous analgesic infusions meant that optimal methods could not always be used. The predominant method used was intermittent incremental intravenous doses of morphine, which appeared to provide poor pain control in many cases. The analgesic protocols the nurses were expected to follow were time consuming and impractical when they had several children needing analgesia at once. The nurses' solution to such dilemmas was to still act to relieve pain even when this involved some risk because the nurses' believed that the risk-taking was done responsibly, and that it was more important to promote the child's wellbeing. The types of risks they took included administering several doses of morphine in quick succession without always monitoring for respiratory depression, and altering prescriptions (but not in writing). Being Safe and Taking Risks emerged as a paradoxical core category, which reflected the pattern for the nurses' pain management decision-making and practice. It also emerged that a moral interest (Being Ethical) appeared to direct and connect the nurse's thinking and practice; they tended to do what they considered was in the child's best interests and believed that the benefits outweighed potential harms

Gaining insight from patient journey data using process-oriented analysis approach

Hospitals are continually struggling to cater for the increasing demand for inpatient services. This is due to increased population, aging, and the rising incidence of chronic diseases associated with modern life. The high demand for hospital services leads to unpredictable bed availability, longer waiting period for acute admission, difficulties in keeping planned admission, stressed hospital staff, undesirable patient and family experience, as well as unclear long term impact on health care capacity. This study aims to derive some correlation between various factors contributing to ward occupancy rate and operation efficiency. The aim is also to discover the inpatient flow process model proposing to use process mining techniques combined with data analysis to depict the relationships among inpatients, wards and Length of Stay (LOS) in an effort to gain insight into factors that could be focused to relieve access block. Open source process mining software - ProM is used for this study. The study is done in collaboration with Flinders Medical Centre (FMC) using data from their Patient Journey Database as case study

Automatic knowledge extraction from EHRs

Increasing efforts in the collection, standardization, and maintenance of large scale longitudinal elec- tronic health care records (EHRs) across the world provide a promising source of real world medical data with the potential of providing major novel insights of benefit both to specific individuals in the context of personalized medicine, as well as on the level of population-wide health care and policy. The present paper builds upon the existing and intensifying efforts at using machine learning to provide predictions on future diagnoses likely to be experienced by a particular individual based on the person’s existing diagnostic history. The specific model adopted as the baseline predictive framework is based on the concept of a binary diagnostic history vector representation of a patient’s diagnostic medical record. The technical novelty introduced herein concerns the manner in which transitions between diagnostic history vectors are learnt. We demonstrate that the proposed change prima fasciae enables greater learning specificity. We present a series of experiments which demon- strate the effectiveness of the proposed techniques, and which reveal novel insights regarding the most promising future research directions.Postprin

Student health professionals' attitudes and experience after watching 'Ida's diary', a first-person account of living with borderline personality disorder:mixed methods study

BACKGROUND: There is increasing interest in the use of commercial movies in nursing education, or 'cinenurducation'. There is a need for educational interventions which target mental health nurses' attitudes towards people with borderline personality disorder.OBJECTIVES: To investigate and evaluate the experience and effects of attendance at a screening of the movie Ida’s Diary, a first-person account of living with borderline personality disorder.DESIGN: Mixed methods design comprising a within-subjects AB longitudinal survey, and a qualitative analysis of participant-generated data and researcher field notes from a World Ca-fé discussion group.SETTINGS: One university in Scotland.PARTICIPANTS: N=66 undergraduate and postgraduate mental health nursing and coun-selling students.METHODS: Participants completed measures of cognitive and emotional attitudes towards, and knowledge about, people with borderline personality disorder before and after one of two film screenings. We conducted a World Café discussion group after the second screen-ing. Resulting data were subject to a qualitative thematic analysis.RESULTS: Quantitative analysis revealed a five-factor cognitive and a single-factor emo-tional attitude structure. Cognitive-attitudinal items related to treatment deservingness and value of mixed treatment approaches improved across iterations. Total knowledge score did not change, but one item about borderline personality disorder as a precursor to schizophrenia received considerably more incorrect endorsement post-screening. Qualitative analysis re-vealed five themes: Facilitation and inhibition of learning; promotion but not satiation of appe-tite for knowledge; challenging existing understanding; prompting creativity and anxiety; and initiating thinking about the bigger picture.CONCLUSIONS: Participants found the film thought provoking; it increased their appetite for knowledge. Findings suggest that screening should be delivered in conjunction with more didactic information about borderline personality disorder

ACORN (A Clinically-Oriented Antimicrobial Resistance Surveillance Network) II: protocol for case based antimicrobial resistance surveillance

Background: Antimicrobial resistance surveillance is essential for empiric antibiotic prescribing, infection prevention and control policies and to drive novel antibiotic discovery. However, most existing surveillance systems are isolate-based without supporting patient-based clinical data, and not widely implemented especially in low- and middle-income countries (LMICs). Methods: A Clinically-Oriented Antimicrobial Resistance Surveillance Network (ACORN) II is a large-scale multicentre protocol which builds on the WHO Global Antimicrobial Resistance and Use Surveillance System to estimate syndromic and pathogen outcomes along with associated health economic costs. ACORN-healthcare associated infection (ACORN-HAI) is an extension study which focuses on healthcare-associated bloodstream infections and ventilator-associated pneumonia. Our main aim is to implement an efficient clinically-oriented antimicrobial resistance surveillance system, which can be incorporated as part of routine workflow in hospitals in LMICs. These surveillance systems include hospitalised patients of any age with clinically compatible acute community-acquired or healthcare-associated bacterial infection syndromes, and who were prescribed parenteral antibiotics. Diagnostic stewardship activities will be implemented to optimise microbiology culture specimen collection practices. Basic patient characteristics, clinician diagnosis, empiric treatment, infection severity and risk factors for HAI are recorded on enrolment and during 28-day follow-up. An R Shiny application can be used offline and online for merging clinical and microbiology data, and generating collated reports to inform local antibiotic stewardship and infection control policies. Discussion: ACORN II is a comprehensive antimicrobial resistance surveillance activity which advocates pragmatic implementation and prioritises improving local diagnostic and antibiotic prescribing practices through patient-centred data collection. These data can be rapidly communicated to local physicians and infection prevention and control teams. Relative ease of data collection promotes sustainability and maximises participation and scalability. With ACORN-HAI as an example, ACORN II has the capacity to accommodate extensions to investigate further specific questions of interest

Telehealthcare for chronic obstructive pulmonary disease

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a disease of irreversible airways obstruction in which patients often suffer exacerbations. Sometimes these exacerbations need hospital care: telehealthcare has the potential to reduce admission to hospital when used to administer care to the pateint from within their own home. OBJECTIVES: To review the effectiveness of telehealthcare for COPD compared with usual face‐to‐face care. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register, which is derived from systematic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED, and PsycINFO; last searched January 2010. SELECTION CRITERIA: We selected randomised controlled trials which assessed telehealthcare, defined as follows: healthcare at a distance, involving the communication of data from the patient to the health carer, usually a doctor or nurse, who then processes the information and responds with feedback regarding the management of the illness. The primary outcomes considered were: number of exacerbations, quality of life as recorded by the St George's Respiratory Questionnaire, hospitalisations, emergency department visits and deaths. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials for inclusion and extracted data. We combined data into forest plots using fixed‐effects modelling as heterogeneity was low (I(2) < 40%). MAIN RESULTS: Ten trials met the inclusion criteria. Telehealthcare was assessed as part of a complex intervention, including nurse case management and other interventions. Telehealthcare was associated with a clinically significant increase in quality of life in two trials with 253 participants (mean difference ‐6.57 (95% confidence interval (CI) ‐13.62 to 0.48); minimum clinically significant difference is a change of ‐4.0), but the confidence interval was wide. Telehealthcare showed a significant reduction in the number of patients with one or more emergency department attendances over 12 months; odds ratio (OR) 0.27 (95% CI 0.11 to 0.66) in three trials with 449 participants, and the OR of having one or more admissions to hospital over 12 months was 0.46 (95% CI 0.33 to 0.65) in six trials with 604 participants. There was no significant difference in the OR for deaths over 12 months for the telehealthcare group as compared to the usual care group in three trials with 503 participants; OR 1.05 (95% CI 0.63 to 1.75). AUTHORS' CONCLUSIONS: Telehealthcare in COPD appears to have a possible impact on the quality of life of patients and the number of times patients attend the emergency department and the hospital. However, further research is needed to clarify precisely its role since the trials included telehealthcare as part of more complex packages

ICU-Associated Acinetobacter baumannii Colonisation/Infection in a High HIV-Prevalence Resource-Poor Setting

BACKGROUND: There are hardly any data about the incidence, risk factors and outcomes of ICU-associated A.baumannii colonisation/infection in HIV-infected and uninfected persons from resource-poor settings like Africa. METHODS: We reviewed the case records of patients with A.baumannii colonisation/infection admitted into the adult respiratory and surgical ICUs in Cape Town, South Africa, from January 1 to December 31 2008. In contrast to colonisation, infection was defined as isolation of A.baumannii from any biological site in conjunction with a compatible clinical picture warranting treatment with antibiotics effective against A.baumannii . RESULTS: The incidence of A.baumannii colonisation/infection in 268 patients was 15 per 100 person-years, with an in-ICU mortality of 26.5 per 100 person-years. The average length of stay in ICU was 15 days (range 1-150). A.baumannii was most commonly isolated from the respiratory tract followed by the bloodstream. Independent predictors of mortality included older age (p = 0.02), low CD4 count if HIV-infected (p = 0.038), surgical intervention (p = 0.047), co-morbid Gram-negative sepsis (p = 0.01), high APACHE-II score (p = 0.001), multi-organ dysfunction syndrome (p = 0.012), and a positive blood culture for A.baumannii (p = 0.017). Of 21 A.baumannii colonised/infected HIV-positive persons those with clinical AIDS (CD4<200 cells/mm 3 ) had significantly higher in-ICU mortality and were more likely to have a positive blood culture. Conclusion In this resource-poor setting A.baumannii infection in critically ill patients is common and associated with high mortality. HIV co-infected patients with advanced immunosuppression are at higher risk of death