The inpatient neurology consultation service: value and cost

Neurological conditions comprise a significant proportion of patient admissions to hospital but, in the majority of cases, are admitted under the care of non-neurological physicians. As a consequence, neurological ward consultations are commonly requested by the admitting medical teams to review diagnoses and management plans. The outcomes of neurological ward consultations were examined and the time required for the referral process recorded by performing a detailed prospective three-month audit of inpatient referrals to the neurology service. The consultations of 120 patients were recorded, categorised and analysed. These consultations were beneficial in the vast majority of cases, with a clear impact on patient diagnoses or management plans. The consultation process was time consuming, however, both in respect of the initial review, but also with follow-up visits. This audit highlights the importance of neurological input in the diagnosis and management of hospital inpatients. The time taken for this process should be resourced appropriately.     

Reducing falls among older people in hospital

Thousands of patients fall on hospital wards each year, leading to potentially devastating consequences for them and their families. Falls among inpatients usually arise from a complex combination of risk factors, including dementia, delirium, incontinence and medication. This article discusses the FallSafe project that aimed to reduce falls in inpatient settings. The results suggested a 25 per cent reduction in falls on average across the wards involved. The project also had a positive effect on patients and staff. A case study of a staff nurse involved in leading the project on her ward and the care bundle that comprised the project intervention are explored.     

A one-day,hospital-wide survey of dying inpatients

We attempted to identify and briefly follow until discharge all terminally ill patients in a large general hospital. On 1 day, nurse case managers reviewed all hospitalized patients and identified those whom they believed were likely to die in the next 6 months (Category A) or whom might be considered terminally ill but with a longer prognosis (Category B). Twelve percent of all adult and pediatric medical-surgical inpatients were detected, equally divided between the two categories. In Category A, 63% were on the medical service, 7% were receiving intensive care, 54% had cancer, and 46% had do-not-resuscitate (DNR) orders. In Category B, 40% were on the medical service, 10% were in intensive care, 52% had cancer, and only 5% had DNR orders. Case managers expected 6% of identified patients to die in the hospital. After 1 month, at least 19% of identified patients had died (2.3% of the medical-surgical inpatient census on the day of the survey). The average length of stay in both categories, excluding outliers, was 24 days or approximately 4 times the average length of stay for the hospital. Patients who actually died in the hospital had an average length of stay of 62 days. This study presents a simple method for estimating the number of dying patients in a hospital--the target population for a palliative care program--and for determining their location, principal diagnosis, length of stay, and disposition. We present information indicating that the survey underestimates the number of dying hospitalized patients. We discuss possible policy implication of this study, primarily that general hospitals should consider developing specialized palliative care services for this substantial group of inpatients.     

A New Stroke Unit: Implementation Issues

Stroke units are geographically distinct units providing dedicated care for people who have suffered a stroke. This study aimed to understand the financial benefits of stroke unit care. The cost of acute beds and the average length of hospital stays were compared between the stroke unit group and the general ward group. The mean length of inpatient stay in the stroke unit group was 43.7 days; in the general medical wards, it was 69.3 days with a significant 95% confidence interval of 36.96–14.19. The reduced length of stay reduced the cost of care provided by the stroke unit. Stroke units provide more cost-effective care.     

Outcomes-based trial of an inpatient nurse practitioner service for general medical patients

Although teaching hospitals are increasingly using nurse practitioners (NPs) to provide inpatient care, few studies have compared care delivered by NPs and housestaff or the ability of NPs to admit and manage unselected general medical patients. In a Midwest academic teaching hospital 381 patients were randomized to general medical wards staffed either by NPs and a medical director or medical housestaff. Data were obtained from medical records, interviews and hospital databases. Outcomes were compared on both an intention to treat (i.e. wards to which patients were randomized) and actual treatment (i.e. wards to which patients were admitted) basis. At admission, patients assigned randomly to NP-based care (n = 193) and housestaff care (n= 188) were similar with respect to demographics, comorbidity, severity of illness and functional parameters. Outcomes at discharge and at 6 weeks after discharge were similar (P>0.10) in the two groups, including: length of stay; charges; costs; consultations; complications; transfers to intensive care; 30-day mortality; patient assessments of care; and changes in activities of daily living, SF-36 scores and symptom severity. However, after randomization, 90 of 193 patients (47%) assigned to the NP ward were actually admitted to housestaff wards, largely because of attending physicians and NP requests. None the less, outcomes of patients admitted to NP and housestaff wards were similar (P>0.1). NP-based care can be implemented successfully in teaching hospitals and, compared to housestaff care, may be associated with similar costs and clinical and functional outcomes. However, there may be important obstacles to increasing the number of patients cared for by NPs, including physician concerns about NPs' capabilities and NPs' limited flexibility in managing varying numbers of patients and accepting off-hours admissions.     

基于主成分分析法的天津市某三级甲等医院CCU患者满意度分析

目的：采用主成分分析法分析影响住院患者满意度的主要因素指标权重,为进一步提高医疗护理服务质量,提升患者就医感受提供理论依据。方法：采用自行设计的住院患者满意度调查问卷,对天津市某三级甲等医院CCU的100名住院患者进行调查。指标权重采用主成分分析,各指标评价采用象限图法。结果：指标权重分析结果显示,对患者满意度影响较大的指标分别为医院提供的心理辅导、家属的关心、健康教育、医生沟通能力、病房探视制度、就医费用、病房软件环境（隔音、温湿度、气味等）、医院提供的饮食。象限图显示非常重要但是满意度相对不高的指标依次为医院提供的饮食、医院提供的心理辅导、就医费用、病房软件环境、病房探视制度、健康教育。结论：医院应优先改进医院提供的饮食、心理辅导、就医费用、病房软件环境、病房探视制度及健康教育这6个方面,以提高医疗护理服务质量,提升患者就医感受。     

Outcomes of acutely ill older hospitalized patients following implementation of tailored models of care: a repeated measures (pre- and post-intervention) design

BACKGROUND: There is a lack of research investigating models of nursing care for older hospitalised patients that address the nursing needs of this group. OBJECTIVES: The objective of this study is to evaluate the efficacy of models of care for acutely older patients tailored to two contexts: an aged care specific ward and a medical ward. DESIGN: This is a repeated measures design. Efficacy of the models was evaluated in terms of: patient and nurses' satisfaction with care provided; increased activities of daily living; reduced unplanned hospital readmissions; and medication knowledge. SETTINGS: An aged care specific ward and a medical ward in two Sydney teaching hospitals. PARTICIPANTS: There were two groups of patients aged 65 years or older who were admitted to hospital for an acute illness: those admitted prior to model implementation (n=232) and those admitted during model implementation (n=116). Patients with moderate or severe dementia were excluded. The two groups of nurses were the pre-model group (n=90) who were working on the medical and aged care wards for the study prior to model implementation, and the post-model group (n=22), who were the nurses working on the wards during model implementation. METHODS: Action research was used to develop the models of care in two wards: one for an aged care specific ward and another for a general medical ward where older patients were admitted. The models developed were based on empirical data gathered in an earlier phase of this study. RESULTS: The models were successful in both wards in terms of increasing satisfaction levels in patients and nurses (p<0.001), increasing functional independence as measured by activities of daily living (p<0.01), and increasing medication knowledge (p<0.001). CONCLUSIONS: Findings indicate that models of care developed by nurses using an evidence-based action research strategy can enhance both satisfaction and health outcomes in older patients.     

The ED‐inpatient dashboard: Uniting emergency and inpatient clinicians to improve the efficiency and quality of care for patients requiring emergency admission to hospital

Patients who require emergency admission to hospital require complex care that can be fragmented, occurring in the ED, across the ED‐inpatient interface (EDii) and subsequently, in their destination inpatient ward. Our hospital had poor process efficiency with slow transit times for patients requiring emergency care. ED clinicians alone were able to improve the processes and length of stay for the patients discharged directly from the ED. However, improving the efficiency of care for patients requiring emergency admission to true inpatient wards required collaboration with reluctant inpatient clinicians. The inpatient teams were uninterested in improving time‐based measures of care in isolation, but they were motivated by improving patient outcomes. We developed a dashboard showing process measures such as 4 h rule compliance rate coupled with clinically important outcome measures such as inpatient mortality. The EDii dashboard helped unite both ED and inpatient teams in clinical redesign to improve both efficiencies of care and patient outcomes.     

Raising the profile of older people's care in hospital through training

Two-thirds of patients requiring inpatient acute hospital care are aged over 65. Older people also have a greater need for the use of health and social care (Department of Health (DH) 2001). It is therefore no surprise that the majority of patients cared for by nurses care in general wards are older people. It is vital that health professionals caring for patients, in all ward settings, have the knowledge and skills to care for the complex needs of older people. This article describes a project carried out at East and North Hertfordshire NHS Trust, to address aspects of general hospital care for older people.     

安全防护图标在神经内科患者安全管理中的应用

目的探讨安全防护图标在神经内科住院患者安全管理中的应用效果。方法将自行设计的安全防护图标应用于神经内科三病区826例住院患者的安全管理中,并与同期收治的神经内科一病区912例患者进行比较,观察医护患各方对患者安全隐患的识别情况、两组患者不安全事件的发生率、医护患各方对安全管理的满意度等。结果采用安全防护图标进行安全管理后,有助于医护患各方准确识别患者潜在的安全隐患,降低了不安全事件的发生率,提高了医护患各方对安全管理的满意度,差异均有统计学意义(均P<0.05)。结论安全防护图标可让患者及家属体会到规范化、专业化的护理服务,提高了对安全管理的满意度,降低了患者意外事件的发生,符合优质护理服务的要求,达到了国际患者安全管理目标。     

Recovery orientation in mental health inpatient settings: Inpatient experiences?

Offering mental health treatment in line with a recovery‐oriented practice has become an objective in the mental health services in many countries. However, applying recovery‐oriented practice in inpatient settings seems challenged by unclear and diverging definitions of the concept in and the organization of these settings. In Denmark, educational and organizational efforts have been made to organize inpatient services with a recovery‐oriented approach. Hence, we aimed to explore whether and how these efforts are reflected in the inpatients’ experiences of their care and treatment. Semi‐structured interviews were conducted with 14 inpatients from two mental health inpatient wards using an interview guide based on factors from the Recovery Self‐Assessment. Qualitative content analysis was applied in the analysis. Six themes covering the participants’ experiences were identified. The participants felt accepted and protected in the ward and found comfort in being around other people but missed talking and engaging with health professionals. They described limited choice and influence on the course of their treatment, and low information levels regarding their treatment, which they considered to consist predominantly of medication. Furthermore, they described feeling continuously observed and assessed from a distance by health professionals. Like the sparse previous research among inpatients, the results highlight ambivalent experiences of health professionals’ support and ward structure as well as the medical treatment hegemony. As such, the educational and organizational efforts of introducing recovery‐oriented practices in the wards seemed not very well reflected in the participants’ experiences of their stay.     

Benefits of an accident and emergency short stay ward in the staged hospital care of elderly patients.

OBJECTIVE: To study the potential of a short stay ward attached to an accident and emergency (A&E) department to improve care and reduce admissions to hospital by enabling elderly patients to be monitored closely for up to 24 h before being formally admitted to hospital or discharged home. Patients admitted to the short stay ward were those who appeared to need only a brief period of assessment or treatment. METHODS: The medical records of all patients aged 65 years and above admitted to the short stay ward over a nine month period (April to December 1993, inclusive) were reviewed. RESULTS: 13% of all the patients over 65 attending A&E were admitted to the A&E ward. Of patients over 65 who were admitted to hospital, 20% were first admitted to the A&E ward. There were 502 admissions to the short stay ward of patients aged 65 years and above, who constituted 38% of the total admissions to that ward. Admitting these selected patients to the short stay ward allowed 71% to be discharged home, usually within 24 h, rather than being formally admitted to hospital. CONCLUSIONS: The addition of a short stay ward can shorten the hospital stay for selected elderly patients and reduce the demand for inpatient hospital beds. This ward also improves the quality of care to elderly patients attending the A&E department.     

Nursing attitudes to the care of elderly patients at risk of continuing hospital care

This study assesses changes in nurses' attitudes to the process of decision-making regarding the care of elderly patients identified as being at risk of continuing (long-term) hospital care It was undertaken during the course of an evaluation of an intervention programme which involved a new approach to decision-making concerning the long-term care of dependent elderly patients Complementary components of the intervention programme were (a) an early discharge planning service, and (b) an extended home care programme The programme involved close liaison of specially trained community health nurses with staff members of the general medical wards of a large general hospital At the onset of the evaluation, it was perceived by management that the staff of the general medical wards favoured continuing hospital care for very dependent elderly patients rather than community care It was hypothesized that the intervention programme would result in a change in ward staffs' attitudes concerning the feasibility of home-based care and how decisions about care should be made To test this, attitude changes of community health nurses and ward nurses were assessed over the period of implementation of the programme Following the introduction of the programme, the study found that some of the ward nurses' attitudes became closer to those of community health nurses There was a shift in ward nurses' attitudes away from a professional approach to decisions about the care and placement of very dependent elderly patients to a 'patient choice' approach Nurses felt more strongly that they had an important role in patient care Implications of the research are considered in relation to the process of discharge planning     

Biases in palliative care access for elderly patients dying in hospital: A prospective study in acute care

Background: Patients in the terminal phase of chronic illnesses are often admitted to acute care wards, with the risk of receiving inappropriate intensive treatments as opposed to necessary palliative care (PC).

Objective: To assess patient features and possible service biases in the activation of PC pathways, or lack thereof, for those dying in acute care.

Design and setting: This was a prospective observational study of all patients admitted to our acute medical ward from the emergency department during 6 months.

Measurements: Need for palliation was evaluated for all patients by a physician and a nurse of the Internal Medicine ward. Those proposed for PC were re-evaluated by a consultant and a nurse of the PC unit. Clinical and epidemiological data were obtained for those selected for PC, and those deceased in the acute ward without having received PC.

Results: A total of 781 patients were admitted to the acute care ward and screened during the study period. Of the 56 patients assigned to the PC pathway, those that died in hospital (n?=?30) had significantly poorer Karnofsky, Braden, and ECOG scores compared to those alive at discharge (n?=?26). Forty-eight more patients died on the ward without having received PC. The prevalence of cardiopulmonary diseases was significantly higher in this group, while more oncologic patients died in the PC cohort.

Conclusions: Palliative treatment needs to be augmented and better targeted in acute care settings. Special attention should be given to patients with cardiopulmonary illnesses, a possible bias preventing the activation of this type of care, and those at high risk of developing pressure ulcers. Further education and training in this field are crucial for healthcare professionals working in acute wards.     

The coming of age of a joint elderly medicine-psychiatric ward: 18 years' experience

INTRODUCTION: There is a large population of elderly medical inpatients with co-existent medical and mental health disorders who pose a significant management challenge for medical, nursing and allied staff. Our hospital has a joint elderly medicine-psychiatry unit to cater for this patient group; this article reviews how this unit was set up and presents a representative sample of inpatients. RESULTS: The mean age was 81 years with a female preponderance. The mean length of stay was 44 days. The commonest medical conditions were cerebrovascular disease, urinary tract infections, chest infections and falls. The commonest mental health diagnoses were cognitive impairment, delirium and depression. The mortality rate was 21%; of the remainder, 55% were discharged to long-term care, 40% returned home and 5% were transferred to the local psychiatric hospital. DISCUSSION: This cohort of elderly patients has complex medical, nursing and therapy needs in addition to complex discharge planning needs. Our unit has a shared care approach, with joint responsibility shared by a consultant in Medicine for the Elderly and a Consultant in Old Age Psychiatry. This, in combination with a multidisciplinary team approach, provides an effective means of delivering care to this patient group. CONCLUSION: A joint elderly medicine-old age psychiatry ward provides a high standard of care for elderly patients with co-existent physical and mental health needs. We hope that the information presented in this article will be of use to those hoping to set up a similar unit in their own hospitals.     

A small scale exploration of potential benefits of routine rounds by a Chronic Pain Nurse Specialist on orthopaedic wards

This study is a small-scale audit to evaluate the effectiveness of regular ward rounds by a Chronic Pain Nurse Specialist (CPNS) on orthopaedic wards in a UK District General Hospital. Objectives were to assess existing practice in relation to pain management, identify the impact of regular ward rounds by the CPNS and identify key improvements for patient care.A retrospective audit of current practice was undertaken using patients’ medical records. This was followed by the CPNS commencing bi-weekly ward rounds and then a further audit. Participants were those admitted to orthopaedic wards with non-malignant musculoskeletal pain for which surgery was not appropriate. The length of hospital stay of these patients was significantly reduced (p = 0.0001). The largest sub-group of patients admitted had chronic back pain, and a greater number of patients received pain management interventions. The introduction of ward rounds by the CPNS appeared to have an effect on the length of stay of this sub-group and on pain management.     

Pain prevalence and predictors among inpatients in a major Italian teaching hospital. A baseline survey towards a pain free hospital.

Pain prevalence among inpatients is an important indicator of quality care; it may reach over 80% in various clinical settings. A cross-sectional survey was conducted in a teaching hospital to depict benchmark data regarding pain prevalence and predictors among the entire inpatient population. Overall 892 patients, 6 years old and hospitalized for at least 24 h in 57 hospital wards were interviewed using an internationally applied questionnaire. Patients self-reported their pain intensity at the time of the interview (T(0)) and worst pain perceived during the previous 24 h (T(-1)), using a numerical rating scale (NRS) and indicated current pain duration. Specific pain predictor data (hospital stay, gender, age and marital status) were obtained from patient medical charts. Pain prevalence at T(0) was 38% and 52% at T(-1). Pain was moderate to severe (NRS4) in approximately 25% of the patients at T(0) and in 40% at T(-1). High pain prevalence was found (at T(0) and T(-1), respectively) in Radiotherapy (63%;77%), Obstetrics (68%;54%), and Surgery (59%;45%) wards. Gender was a prominent determinant as pain was significantly associated with females. Pain prevalence was high among young adults or divorced/separated individuals and low among pediatric patients ( approximately 20%). Protracted hospitalization and prolonged pain duration were associated with major pain severity. Results yield Quality Assurance interventions to ameliorate pain undertreatment. Predictor analysis suggests that attention should be paid to pain management in young adults, socially vulnerable patients and those with protracted hospitalization and pain.     

Inpatient satisfaction with nursing care and factors influencing satisfaction in a teaching hospital in China

This study examined inpatient satisfaction with nursing care in a teaching hospital in China. Patient satisfaction with nursing care was assessed by a self-designed questionnaire administered to 320 inpatients selected by a convenience sampling method. The patients had a relatively high level of satisfaction with nursing care. Patients' age, educational background, occupation, methods of payment, and hospital wards were main factors influencing their satisfaction with nursing care. The study provides a new tool for measuring patient satisfaction with nursing care in China.     

Improving care on mental health wards with hourly nurse rounds

Hourly rounds are becoming more popular on inpatient medical wards and are known to be beneficial to patients and nurses. However, there is little evidence about their impact in psychiatry and what hourly rounds would look like on inpatient mental health units. This article examines the introduction of hourly nurse rounds on inpatient mental health wards in an American hospital, and how they were adapted to the needs of psychiatric patients. The positive effects on patient care and staff are reported.