Which patients with lower respiratory tract infections need inpatient treatment? Perceptions of physicians, nurses, patients and relatives

Despite recommendations for outpatient management, low risk patients with lower respiratory tract infections (LRTIs) are often hospitalized. This survey analyzed perceptions of physicians, nurses, patients and relatives about feasibility of outpatient management and required duration of hospital stay

Effect of a 14-day course of systemic corticosteroids on the hypothalamic-pituitary-adrenal-axis in patients with acute exacerbation of chronic obstructive pulmonary disease

<p/> <p>Background</p> <p>As supra-physiological intake of corticosteroids is a well known risk factor for the development of adrenal insufficiency, we investigated the function of the hypothalamic-pituitary-adrenal (HPA) axis during a 14-day course of systemic corticosteroids in patients with acute exacerbation of chronic obstructive pulmonary disease using clinical and laboratory measures.</p> <p>Methods</p> <p>A systematic clinical and laboratory assessment including measurement of basal cortisol levels and the response to low dose (1 μg) ACTH stimulation was performed in nine patients before, on the first and the last day of treatment, as well as 2, 7 and 21 days after corticosteroid withdrawal.</p> <p>Results</p> <p>At baseline, all nine patients had normal responses to 1 μg ACTH. On the first day of steroid treatment, 78% had a blunted peak cortisol response. This percentage increased to 89% after 14 days of steroid treatment. 78%, 33% and 33% of the patients had a blunted cortisol response to ACTH 2, 7, and 21 days after corticosteroid withdrawal, respectively. ROC curve analysis revealed that only basal cortisol concentrations (AUC 0.89), but not ACTH concentrations (AUC 0.49) or clinical signs (AUC 0.47) were predictive of an impaired function of the HPA axis. Basal cortisol levels of > 400 and < 150 nmol/l were 96% and 100% sensitive for a normal or pathological response to the ACTH stimulation test, respectively.</p> <p>Conclusion</p> <p>Immediate and prolonged suppression of the HPA axis is a common finding in otherwise asymptomatic patients undergoing systemic steroid treatment for acute exacerbation of chronic obstructive pulmonary disease and can reliably be assessed with the low-dose ACTH test.</p

Bei Eintritt den Austritt bereits im Blick : der PACD am Kantonsspital Aarau

Die Erfassung und Bewertung des «biopsychosozialen Risikos» ermöglicht es, bereits frühzeitigerkennen und entscheiden zu können, ob ein Patient nach einem stationären Aufenthalt aufUnterstützung in einer post-akuten Institution zu Hause angewiesen sein wird. Das KantonsspitalAarau setzt dafür das Einschätzungsinstrument «Post-acute-care-discharge» (PACD) ein

ROC curve analysis to predict adrenal insufficiency for basal cortisol, ACTH, the cortisol/ACTH ratio and the clinical score

<p><b>Copyright information:</b></p><p>Taken from "Effect of a 14-day course of systemic corticosteroids on the hypothalamic-pituitary-adrenal-axis in patients with acute exacerbation of chronic obstructive pulmonary disease"</p><p>http://www.biomedcentral.com/1471-2466/8/1</p><p>BMC Pulmonary Medicine 2008;8():1-1.</p><p>Published online 26 Jan 2008</p><p>PMCID:PMC2246097.</p><p></p

Cortisol values basal (black) and after stimulation with 1 μg corticotropin (grey) and corresponding basal ACTH concentrations for all patients at six clinical visits

<p><b>Copyright information:</b></p><p>Taken from "Effect of a 14-day course of systemic corticosteroids on the hypothalamic-pituitary-adrenal-axis in patients with acute exacerbation of chronic obstructive pulmonary disease"</p><p>http://www.biomedcentral.com/1471-2466/8/1</p><p>BMC Pulmonary Medicine 2008;8():1-1.</p><p>Published online 26 Jan 2008</p><p>PMCID:PMC2246097.</p><p></p

Screening by Social Workers in Medical Patients with Risk of Post-Acute Care Needs: A Stepped Wedge Cluster Randomized Trial / Evaluation eines Screenings durch Sozialarbeiter bei medizinischen Patienten mit einem Risiko für post-akuten Nachsorgebedarf: eine stepped wedge clusterrandomisierte Studie

Elderly patients often need post-acute care after hospital discharge. Involvement of social workers can positively affect the discharge planning process

Screening by social workers in medical patients with risk of post-acute care needs ::a stepped wedge cluster randomized trial

Background : Elderly patients often need post-acute care after hospital discharge. Involvement of social workers can positively affect the discharge planning process. Aim : To investigate the effect of screening patients at risk for post-acute care needs by social workers on time with respect to social workers’ notification, length of stay and delays in discharge compared to usual care. Methods : Cluster randomized stepped wedge trial design for five clusters (wards) and two steps (control to intervention) was used. A total of 400 patients (200 per period) with high risk of post-acute care needs (defined as Post-Acute Care Discharge score, PACD ≥ 7) were included. Social workers performed a screening to decide about self-referral to their services (intervention period), which was compared to a highly structured standard SW notification by physicians and nurses (control period). A Generalized Estimating Equations model adjusted the clustering and baseline differences. Results : A total of 139 patients were referred to social services (intervention: n = 76; control: n = 63). Time to social workers’ notification was significantly shorter in the intervention period when adjusted for all the differences in baseline (Mdn 1.2 vs 1.7, Beta = -0.73, 95%-CI 1.39 to -0.09). Both the length of stay and the delayed discharge time in nights showed no significant differences (Mdn 10.0 vs 9.1, Beta = -0.12, 95%-CI 0.46 to .22 nights 95%-CI, resp. Mdn 0.0 vs 0.0, Beta = .1 1, 95%-CI -0.64 to 0.86). Conclusion : Screening speeded up social workers’ notification but did not accelerate the discharge processes. The screening by social workers might show process improvement in settings with less structured discharge planningHintergrund: Ältere Patienten benötigen nach dem Spitalaufenthalt oft post-akute Versorgungsangebote, die zu verlängerten Spitalaufenthalten führen. Ein früherer Einbezug von Sozialarbeitern vermag die Austrittsplanung zu verbessern. Ziel: Es wurde untersucht, ob ein durch Sozialarbeiter durchgeführtes Screening von medizinischen Patienten, die ein Risiko für einen post-akuten Nachsorgebedarf aufweisen, im Vergleich zum Standardprozess Unterschiede beim Zeitpunkt der Sozialdienstanmeldung, der Spitalaufenthaltstage und der Wartezeit zeigt. Methode: Ein cluster-randomisiertes stepped-wedge -Studiendesign für fünf Cluster (Stationen) und zwei Perioden (Kontroll- zu Interventionsperiode) wurde angewendet. Insgesamt wurden 400 männliche und weibliche Patienten (200 pro Periode) mit einem hohen Risiko für einen post-akuten Nachsorgebedarf (PACD-Score ≥7) eingeschlossen. Sozialarbeiter führten ein Screening in der Interventionsperiode durch, um zu entscheiden, ob die Patienten einen post-akuten Nachsorgebedarf haben. Als Kontrolle diente der bisherige Prozess, bei dem Patienten mit einem potenziellen Nachsorgebedarf von der Pflege und der Ärzteschaft gemeldet wurden. Zur Analyse wurde ein Generalized-Estimating-Equations -Modell gerechnet. Resultate: Insgesamt wurden 139 Patienten beim Sozialdienst angemeldet (Intervention: n=76, Kontrolle: n=63). Die Zeit bis zur Sozialdienstanmeldung (Median) war in der Interventionsperiode signifikant kürzer (1.2 vs. 1.7, Beta = 0.73, 95%-KI −1.39 bis −0.09 Nächte), wenn für alle Unterschiede kontrolliert wurde. Die Aufenthaltsdauer (10.0 vs. 9.1, Beta = −0.12, 95%-KI −0.46 bis 0.22 Nächte) und die Wartezeiten (0.0 vs. 0.0, Beta = 0.11, 95%-KI −0.64 bis 0.86 Nächte) zeigten keine Unterschiede. Schlussfolgerung: Das Screening durch Sozialarbeiter verkürzte die Zeit bis zur Anmeldung beim Sozialdienst, beschleunigte aber nicht den Austrittsprozess. Das Screening durch Sozialarbeiter könnte in Spitälern mit geringerer strukturierter Austrittsplanung positive Effekte aufzeigen

Effectiveness of Proadrenomedullin Enhanced CURB65 Score Algorithm in Patients with Community-Acquired Pneumonia in “Real Life”, an Observational Quality Control Survey

Background: An intervention trial found a trend for shorter length of stay (LOS) in patients with community-acquired pneumonia (CAP) when the CURB65 score was combined with the prognostic biomarker proadrenomedullin (ProADM) (CURB65-A). However, the efficacy and safety of CURB65-A in real life situations remains unclear. Methods: From September, 2011, until April, 2012, we performed a post-study prospective observational quality control survey at the cantonal Hospital of Aarau, Switzerland of consecutive adults with CAP. The primary endpoint was length of stay (LOS) during the index hospitalization and within 30 days. We compared the results with two well-defined historic cohorts of CAP patients hospitalized in the same hospital with the use of multivariate regression, namely 83 patients in the observation study without ProADM (OPTIMA I) and the 169 patients in the intervention study (OPTIMA II RCT). Results: A total of 89 patients with confirmed CAP were included. As compared to patients with CURB65 only observed in the OPTIMA I study, adjusted regression analysis showed a significant shorter initial LOS (7.5 vs. 10.4 days; −2.32; 95% CI, −4.51 to −0.13; p = 0.04) when CURB65-A was used in clinical routine. No significant differences were found for LOS within 30 days. There were no significant differences in safety outcomes in regard to mortality and ICU admission between the cohorts. Conclusion: This post-study survey provides evidence that the use of ProADM in combination with CURB65 (CURB65-A) in “real life” situations reduces initial LOS compared to the CURB65 score alone without apparent negative effects on patient safety