Predictors of inappropriate hospital days in a department of internal medicine

Background This study aimed to identify predictors of inappropriate hospital days in a deparUnent of internal medicine, as a basis for quality improvement interventions. Methods The appropriateness of 5665 hospital days contributed by 500 patients admitted to the Department of Internal Medicine, Geneva University Hospitals, Switzerland, was assessed by means of the Appropriateness Evaluation Protocol. Predictor variables included patient's age and sex, manner of admission and discharge, and characteristics of hospital days (weekend, holiday, sequence). Results Overall, 15% of hospital admissions and 28% of hospital days were rated as inappropriate. In multivariate models, inappropriate hospital days were more frequent among patients whose admission was inappropriate (odds ratio [OR] = 5.3, 95% CI: 3.1-8.4) and among older patients (80-95 years: OR = 3.6. 95% CI: 1.7-7.0, versus <50 years). The likelihood of inappropriateness also increased with each subsequent hospital day, culminating on the day of discharge, regardless of the total length of stay. Conclusions This study identified both the admission and the discharge processes as important sources of inappropriate hospital use in a department of internal medicine. The oldest patients were also at high risk of remaining in the hospital inappropriately. Surprisingly, long hospital stays did not generate a higher proportion of inappropriate days than short hospital stays. This information proved useful in developing interventions to improve the hospitalization proces

Age and quality of in-hospital care of patients with heart failure

Background: Elderly patients may be at risk of suboptimal care. Thus, the relationship between age and quality of care for patients hospitalized for heart failure was examined. Methods: A cross-sectional study based on retrospective chart review was performed among a random sample of patients hospitalized between 1996 and 1998 in the general internal medicine wards, with a principal diagnosis of congestive heart failure, and discharged alive. Explicit criteria of quality of care, grouped into three scores, were used: admission work-up (admission score); evaluation and treatment during the stay (evaluation and treatment score); and readiness for discharge (discharge score). The associations between age and quality of care scores were analysed using linear regression models. Results: Charts of 371 patients were reviewed. Mean age was 75.7 (±11.1) years and 52% were men. There was no relationship between age and admission or readiness for discharge scores. The evaluation and treatment score decreased with age: compared with patients less than 70 years old, the score was lower by −2.6% (95% CI: −7.1 to 1.9) for patients aged 70 to 79, by −8.7% (95% CI: −13.0 to −4.3) for patients aged 80 to 89, and by −19.0% (95% CI: −26.6 to −11.5) for patients aged 90 and over. After adjustment for possible confounders, this relationship was not significantly modified. Conclusions: In patients hospitalized for congestive heart failure, older age was not associated with lower quality of care scores except for evaluation and treatment. Whether this is detrimental to elderly patients remains to be evaluate

Improvement of out-of-hospital cardiac arrest survival rate after implementation of the 2010 resuscitation guidelines.

OBJECTIVE:The implementation of cardiopulmonary resuscitation guidelines, updated every five years, appears to improve patient survival rates after Out-Of-Hospital Cardiac Arrest (OHCA). The aim of this study is: 1) to measure the level of improvement in the prognosis of OHCA patient survival rates for the years 2009 and 2010 and the following two years 2011 and 2012; and 2) correlate the improvement in prognosis with the updated 2010 Advanced Cardiovascular Life Support (ACLS) Guidelines. METHOD:We performed a retrospective observational study based on Geneva's OHCA register that includes data from January 1, 2009 to December 31, 2012. We compared the evolution of prognostic factors that influenced survival at hospital discharge between the periods before and after the implementation of the 2010 guidelines. We then compared the survival rates between each period. Finally, we adjusted the effects on survival in the second period to prognostic factors not linked with the care provided by Emergency Medical Services (EMS) teams, using a multivariable logistic regression model. Changes in advanced resuscitation treatment provided by EMS personnel were also examined. RESULTS:795 OHCA were resuscitated between 1st January, 2009 and 31st December, 2012. The prognosis of patient survival at the time of hospital discharge rose from 10.33% in 2009-2010 to 17.01% in 2011-2012 (p = 0.007). After making adjustments for the effect of improved survival rates on the second period with factors not related to care provided by EMS teams, the odds ratio (OR) remains comparable (OR = 1.87, 95% CI [1.08-3.22]). Measured changes in treatment provided by EMS personnel were minor. CONCLUSIONS:Survival rate for OHCA patients improved significantly in 2011-2012. This study suggests that it was probably the improvement in the quality of care provided during CPR and post-cardiac arrest care that have contributed to the increase in survival rates at the time of hospital discharge

Prehospital emergency physician activation of interventional cardiology team reduces door-to-balloon time in ST-elevation myocardial infarction

QUESTION UNDER STUDY: To explore whether early activation of an interventional cardiology team, by prehospital emergency physicians, reduces door-to-balloon time (DTBT) in patients with ST-elevation myocardial infarction (STEMI) diagnosed with prehospital ECG. METHODS: Design: before-after comparison. Setting: emergency department (ED) of an urban teaching hospital with a catheterisation laboratory open continuously. Study subjects: patients with STEMI diagnosed in the prehospital setting or in the ED within 12 hours of symptoms. Intervention: a paging system or "STEMI alarm", activated by prehospital physicians, which simultaneously notified both the catherisation laboratory and cardiology teams before the patient's arrival to the ED. Outcome measures: DTBT and the proportion of patients with DTBT <90 minutes. RESULTS: A total of 196 patients were included; 77 before and 119 after implementation of the "STEMI alarm". Between the two periods, median DTBT decreased from 109 to 76 minutes (p <0.001) and the proportion of patients treated within 90 minutes increased from 36% to 66% (p <0.001). During intervention, the STEMI alarm was activated in 67 patients (56%). In these cases the median DTBT was 50 minutes, with 96% within 90 minutes. The alarm was inappropriately activated in 9 cases (11%). CONCLUSIONS: Catheterisation laboratory activation by a prehospital emergency physician markedly reduces DTBT in STEMI patients

Identification of older patients at risk of unplanned readmission after discharge from the emergency department - Comparison of two screening tools

STUDY HYPOTHESIS: The Identification of Senior At Risk (ISAR) and the Triage Risk Stratification Tool (TRST) are the two most studied screening tools to detect high-risk patients for unplanned readmission after an emergency department (ED)-visit. Since their performance was unclear among ED-patients over 75 years, we evaluated their capacities to predict readmission at 1, 3, 6 and 12 months as well as their usefulness in avoiding unnecessary further comprehensive geriatric assessment (CGA) in negative screened patients. METHODS: Historical cohort study with systematic routine data collection of functional status, comorbid conditions and readmission rate of patients released home after an ED-visit between 2007 and 2009 at the Geneva University Hospitals. RESULTS: 345 patients were included (mean age 84y; 63% female). Readmission rates were 25%, 38%, 49%, and 60% at 1, 3, 6, and 12 months, respectively. Positive ISAR (>/=2/6) and TRST (>/=2/5) predicted modestly unplanned readmission at each time point (AUC range: 0.607-0.664). Prediction of readmission with ISAR or TRST was not modified after adjustment for variables significantly associated with readmission (being male, having poor functional or comorbid scores). In case of negative ISAR or TRST, their high negative predictive values (NPV) would safely allow avoiding 64 useless CGA (ISAR <2: 7/64 readmissions at 1 month). CONCLUSIONS: Both ISAR and TRST tools predicted modestly unplanned readmission after an ED-visit among patients over 75 years. Nevertheless, due to their low specificity and high NPV these screening tools are useful to select elderly ED-patients who can safely return home without any further CGA

Upper-respiratory viral infection, biomarkers, and COPD exacerbations

BACKGROUND: Respiratory viruses frequently are recovered in the upper-respiratory tract during acute exacerbations of COPD (AECOPD), but their role as contributing pathogens remains unclear. The usefulness of procalcitonin and C-reactive protein as indicators of the presence or absence of viral infection in this setting also needs to be evaluated. METHODS: The study was of a prospective cohort of patients with COPD admitted to the ED for AECOPD. Reverse transcriptase-polymerase chain reaction (RT-PCR) for 14 respiratory viruses was performed on nasopharyngeal swabs collected at admission and after recovery in stable condition. RESULTS: Eighty-six patients (mean age, 72 years; male, 64%) were included. During AECOPD, upper-respiratory viral infections were detected in 44 (51%) patients: picornavirus in 22, metapneumovirus in seven, coronavirus in eight, influenza A/B in two, parainfluenza in two, and respiratory syncytial virus in three. A dual infection was present in three patients. After recovery, viruses were detected in only eight (11%) of 71 patients (P < .001 compared with AECOPD phase). In five of these patients, no virus had been identified during the initial exacerbation, thus suggesting a new viral infection acquired during follow-up. During AECOPD, procalcitonin and C-reactive protein levels did not differ significantly between patients with or without a proven viral infection. CONCLUSIONS: Prevalence of upper-respiratory viral infection, as detected from nasopharyngeal swab by RT-PCR, is high in AECOPD and low after clinical recovery, suggesting that AECOPD frequently are triggered by viral infections initiated in the upper-respiratory tract. In our study, serum procalcitonin and C-reactive protein did not discriminate virus-associated exacerbations from others. TRIAL REGISTRATION: clinicaltrials.gov; Identifier: NCT00448604

I.v. N-acetylcysteine and emergency CT: use of serum creatinine and cystatin C as markers of radiocontrast nephrotoxicity

The purpose of this study was to assess the effect of i.v. administration of N-acetylcysteine (NAC) on serum levels of creatinine and cystatin C, two markers of renal function, in patients with renal insufficiency who undergo emergency contrast-enhanced CT

Screening of Illegal Intracorporeal Containers ("Body Packing"): Is Abdominal Radiography Sufficiently Accurate? : a Comparative Study with Low-Dose CT

Purpose: To evaluate the diagnostic performance of abdominal radiography in the detection of illegal intracorporeal containers (hereafter, packets), with low-dose computed tomography (CT) as the reference standard. Materials and Methods: This study was approved by the institutional ethical review board, with written informed consent. From July 2007 to July 2010, 330 people (296 men, 34 women; mean age, 32 years [range, 18-55 years]) suspected of having ingested drug packets underwent supine abdominal radiography and low-dose CT. The presence or absence of packets at abdominal radiography was reported, with low-dose CT as the reference standard. The density and number of packets (≤12 or <12) at low-dose CT were recorded and analyzed to determine whether those variables influence interpretation of results at abdominal radiography. Results: Packets were detected at low-dose CT in 53 (16%) suspects. Sensitivity of abdominal radiography for depiction of packets was 0.77 (41 of 53), and specificity was 0.96 (267 of 277). The packets appeared isoattenuated to the bowel contents at low-dose CT in 16 (30%) of the 53 suspects with positive results. Nineteen (36%) of the 53 suspects with positive low-dose CT results had fewer than 12 packets. Packets that were isoattenuated at low-dose CT and a low number of packets (≤12) were both significantly associated with false-negative results at abdominal radiography (P = .004 and P = .016, respectively). Conclusion: Abdominal radiography is mainly limited by low sensitivity when compared with low-dose CT in the screening of people suspected of carrying drug packets. Low-dose CT is an effective imaging alternative to abdominal radiography. © RSNA, 201

Profound hyponatraemia in the emergency department: seasonality and risk factors

Profound hyponatremia (<125 mmol/l) is frequent in the emergency department. Its incidence appears to increase during hot weather. Our objectives were to investigate seasonal variations in the incidence of profound hyponatraemia and identify its risk factors