Feeling an outsider left in uncertainty – a phenomenological study on the experiences of older hospital patients

This paper starts from a care ethical perspective on care and reports on a phenomenological study into older patients’ experiences of hospitalisation. Although hospital care for older patients is at the centre of attention, questions what is at stake and what defines quality of care are rarely discussed with a view to the perspective of older patients themselves. The qualitative observational method of shadowing was used. Ten patients of 75 years old or older were shadowed from admission until discharge. The reflective lifeworld approach, based on phenomenological philosophy, was used to analyse the collected data. For the older patients included in the study, the essential meaning of hospitalisation can be described as feeling an outsider left in uncertainty. The word ‘left’ reveals how hospitalisation is experienced as a solitary struggle with various uncertainties that are related both to the hospital environment and to the patient's personal situation. The essential meaning is composed of the following three constituents: (i) staying in an inhospitable place, (ii) feeling constrained and (iii) experiencing disruption. The busy walking back and forth of care professionals and the functional character of involvement, restrain older patients from participating and make them feel abandoned. Feeling constrained reveals the feelings brought on by the ageing body which are emphasised by hospitalisation but often neglected by hospital staff. The failure of healthcare professionals to recognise and respond to who older patients are aside from their illness exacerbate the experience of disruptions. To improve care, hospital staff must be more sensitive to older patients’ uncertainties. Also, hospital staff should provide older patients with understandable information and explanation which besides offering patients the possibility to feel involved, meets their need for recognition.     

Should alternatives to conventional hospitalisation be promoted in an era of financial constraint?

Background

Because the current economic crisis has led to austerity in health policies, with severe restrictions on public health care, avoiding unnecessary admissions and shortening hospital stays is rapidly becoming an urgent priority. Alternatives to hospitalisation replace or shorten hospital processes, including diagnosis, monitoring, treatment and follow‐up. This review aims to present the available evidence on alternatives to conventional hospitalisation for medical disorders; options for surgery, psychiatry and palliative care are largely excluded.

Materials and methods

Narrative review.

Results

The main alternatives to conventional hospitalisation include day centres (DC), quick diagnosis units (QDU), hospital at home (HaH) and, in some circumstances, telemonitoring. DC increase patient comfort, reduce costs and can improve efficiency. In generally healthy patients with suspected severe disease, QDU may be a good alternative to hospitalisation for diagnostic procedures. However, their cost‐effectiveness remains to be clearly proven. Randomised controlled trials have shown that hospital‐at‐home (HaH) can lead to earlier hospital discharges, improve outcomes and reduce costs in patients with prevalent chronic diseases. Although telemonitoring seems to be promising and its use is increasing, methodologically sounder studies with a higher level of evidence are needed to assess its clinical effectiveness.

Conclusions

Factors such as ageing, the need for an earlier diagnosis of suspected severe disease, the increasing complexity of medical care and the increasing costs of hospitalisation mean that, whenever possible, giving priority to less expensive alternatives to hospital admission, such as QDU, DC, HaH and telemedicine, is an urgent task in the current economic crisis.     

Reasons for hospitalisation at the end of life: differences between cancer and non-cancer patients

Purpose

Many patients are hospitalised during the final phase of life, even though most prefer to receive care at home until the end. This study aimed to explore the reasons and characteristics of hospitalisation in the final 3 months of life for patients who died non-suddenly, with a comparison between cancer patients and non-cancer patients.

Methods

This study used a nationwide retrospective cross-sectional survey among Dutch general practitioners.

Results

Of the 317 hospitalised patients, 65 % had cancer. Most common reasons for hospitalisation in the final 3 months of life were respiratory symptoms (31 %), digestive symptoms (17 %), and cardiovascular symptoms (17 %). Seventy-three percent of patients experienced an acute episode before hospitalisation, and for 46 % of patients, their own GP initiated the hospitalisation. Compared to non-cancer patients, cancer patients were significantly more likely to be aged less than 80 (81 versus 46 %), were more likely to be hospitalised because of digestive symptoms (22 versus 7 %), were less likely to have a curative treatment goal before the last hospitalisation (6 versus 22 %) and were less likely to die in hospital (22 versus 49 %).

Conclusions

Respiratory problems were the most common reasons for hospitalisation in the group of patients as a whole. Digestive problems were a frequent reason for hospitalisation in cancer patients and cardiovascular symptoms in non-cancer patients. Hospitalisation can therefore be anticipated by monitoring these relatively common symptoms. Also, timely communication with the patient is recommended about their preferences for hospital or home treatment in the case of an acute episode.     

Data Mining Nursing Care Plans of End‐of‐Life Patients: A Study to Improve Healthcare Decision Making

PURPOSE: To reveal hidden patterns and knowledge present in nursing care information documented with standardized nursing terminologies on end‐of‐life (EOL) hospitalized patients. METHOD: 596 episodes of care that included pain as a problem on a patient's care plan were examined using statistical and data mining tools. The data were extracted from the Hands‐On Automated Nursing Data System database of nursing care plan episodes (n = 40,747) coded with NANDA‐I, Nursing Outcomes Classification, and Nursing Intervention Classification (NNN) terminologies. System episode data (episode = care plans updated at every hand‐off on a patient while staying on a hospital unit) had been previously gathered in eight units located in four different healthcare facilities (total episodes = 40,747; EOL episodes = 1,425) over 2 years and anonymized prior to this analyses. RESULTS: Results show multiple discoveries, including EOL patients with hospital stays (<72 hr) are less likely (p < .005) to meet the pain relief goals compared with EOL patients with longer hospital stays. CONCLUSIONS: The study demonstrates some major benefits of systematically integrating NNN into electronic health records.     

Do pressure ulcers influence length of hospital stay in surgical cardiothoracic patients? A prospective evaluation

Aim and objective. The aim and objective of this study was to determine whether the occurrence of pressure ulcers following cardiothoracic surgery increases the length of hospitalisation. Background. Literature suggests that a pressure ulcer extends the length of hospital stay. The impact of pressure ulcers on length of hospital stay after cardiothoracic surgery is yet undetermined. Design. Prospective follow‐up study. Methods. Two hundred and four patients admitted for elective cardiothoracic surgery and with an intensive care unit stay of >48 hours were included in a prospective cohort study. The course of the skin condition in relation to pressure ulcers was monitored during their stay in a teaching hospital. Length of hospital stay was compared between the group with and without pressure ulcers. Results. Hospital stay for cardiothoracic patients with and without pressure ulcers did not differ significantly (p = 0·23). Patients that developed pressure ulcers had a median hospital stay of 13 days (interquartile range: 9–19) vs. 12 days (interquartile range: 7–15) for patients without pressure ulcers. However, we observed that length of stay in the intensive care unit was significantly (p = 0·005) longer for patients with pressure ulcers. This was not associated with the occurrence of complications. However, the occurrence of pressure ulcers was significantly correlated with length of intensive care support in postoperative care. Conclusion. Non‐complicated pressure ulcers in postsurgery patients do not significantly increase the length of total hospital stay. Relevance to clinical practice. Health professionals need to recognise that patients who have undergone major surgery (such as cardiothoracic surgery) are prone to develop pressure ulcers. Despite the fact that pressure ulcers do not necessarily extend hospital stay, monitoring the skin condition remains of crucial importance for prevention and early detection as well as treatment of pressure ulcers and to minimise patient discomfort. Moreover, as pressure ulcers often originate in the operating room, prevention in the operating room should receive more attention.     

Tracking Hospital Visitors/Chaperones during the COVID-19 Pandemic

Objective  The coronavirus disease (COVID-19) is an emerging infectious disease with strong infectious power and fatality rate. To protect national health, government agencies have regulations on hospital chaperoning and visiting. This article presents the development and implementation of a monitoring system for hospital visiting and chaperoning during the COVID-19 pandemic. The study aimed to create a hospital visiting and chaperoning monitor system that uses nation-wide data sources to more accurately screen hospital visitors and chaperones, assist contract tracing, and prevent transmission of severe acute respiratory syndrome coronavirus 2. Methods  This project was implemented in 57 ward units of an academic medical center. The system was connected to the National Health Insurance (NHI) system and Hospital Information System (HIS), and built on the data of everyone who accessed either the hospital or ward using an NHI smart card or national identification card. To shorten the time for manual identification, we also developed a new system of “app for appointment visits and chaperones” to make appointments online. Results  After the implementation of the system, data from visitors and chaperones in the nursing information system could be accessed. Given that all data were registered in the HIS visiting/chaperoning monitor system, an epidemic investigation could be performed whenever there was a confirmed case. Conclusion  Through the establishment of this system, people entering the ward can be accurately controlled, and all the contacts of potential cases can be traced.     

Economic impact of an electronic alert system to prevent venous thromboembolism in hospitalised patients

Summary. Objectives: The prevention of venous thromboembolism (VTE) is a priority for improved safety in hospitalised patients. Worldwide, there is growing concern over the undersuse of appropriate thromboprophylaxis. Computerised decision support improves the implementation of thromboprophylaxis and reduces inpatient VTE. However, an economic assessment of this approach has not yet been performed. Objectives: To evaluate the economic impact of an electronic alert (e‐alert) system to prevent VTE in hospitalised patients over a 4 year period. Patients/methods: All hospitalised patients at a single institution during the first semesters of 2005–2009 (n = 32 280) were included. All cases of VTE developed during hospitalisation were followed and direct costs of diagnosis and management collected. Results: E‐alerts achieved a sustained reduction of the incidence of in‐hospital VTE, OR 0.50 (95% CI, 0.29–0.84), the impact being especially significant in medical patients, OR 0.44 (95% CI, 0.22–0.86). No increase in prophylaxis‐related bleeding was observed. In our setting, the mean direct cost (during hospitalisation and after discharge) of an in‐hospital VTE episode is €7058. Direct costs per single hospitalised patient were reduced after e‐alerts from €21.6 to €11.8, while the increased use of thromboprophylaxis and the development of e‐alerts meant €3 and €0.35 per patient, respectively. Thus, the implementation of e‐alerts led to a net cost saving of €6.5 per hospitalised patient. Should all hospitalised patients in Spain be considered, total yearly savings would approach €30 million. Conclusions: E‐alerts are useful and cost‐effective tools for thromboprophylaxis strategy in hospitalised patients. Fewer thromboembolic complications and lower costs are achieved by its implementation.     

Visits to intensive care unit patients--frequency, duration and impact on outcome

The issue of the presence of patients' loved ones during their intensive care unit (ICU) stay is a frequently discussed topic among ICU staff. Today, ICU patients' loved ones are seen as important for the care of the patient. There is a gap in knowledge and research concerning the frequency and duration of visits by loved ones and the effect of such visits on patient outcome. The aim of this study was to explore the frequency and duration of loved ones' visits and whether or not such visits have an impact on patient outcome. A prospective, explorative observational study design was used. The sample included 198 ICU patients from a general ICU in Sweden. Twenty-five per cent of the patients had no visitors whatsoever. Forty-seven per cent of the patients who had visitors had visits of 2 h/day. The most frequent visitors were spouses and children. Significant differences between the groups were that the patients who had no visitors were older, had a shorter ICU stay, lower nine equivalents of nursing manpower score and more often lived alone. There were no significant differences in mortality and length of hospital stay over time. We could not establish that patients who had no visitors had a poorer outcome. Most of the older patients had no visitors, which indicates that elderly people may have a poorer social network; thus, there may be a greater need for professional caring relationships and care planning.     

Management of febrile neutropenia in solid tumours and lymphomas using the Multinational Association for Supportive Care in Cancer (MASCC) risk index: feasibility and safety in routine clinical practice

Goals of work Febrile neutropenia (FN) represents a spectrum of severity in which low-risk patients can be defined using the Multinational Association for Supportive Care in Cancer (MASCC) risk index. However, despite publication in 2000, there remains limited published literature to date to support the use of MASCC risk assessment in routine clinical practice and eligibility for early hospital discharge. In this study, we present our experience with the routine use of the MASCC risk index to determine the management of FN in our institution. Patients and methods Patients treated for solid tumours or lymphomas with low-risk FN (MASCC score ≥21) were eligible for oral antibiotics (ciprofloxacin plus either co-amoxiclav or doxycycline) and for early hospital discharge irrespective of first or subsequent episode. The primary outcome was rate of resolution of FN without serious medical complications (SMC). Secondary outcomes were the “success” of antibiotic therapy without treatment modifications, duration of hospitalisation and rate of readmissions. Results A total of 100 FN episodes occurring in 83 patients were treated over a 6-month period. Ninety of these episodes were low-risk (90%), of which 75 received oral antibiotics (83.3%) and 3 (3.3%) experienced SMC, and the success rate was 94.5% [95% confidence interval (CI) 89.6–99.3%] in low-risk episodes. The median duration of hospitalisation was 2.5 days (25th centile: 1.0 day; 75th centile: 5.0 days) in low-risk compared to 6.5 days (25th centile: 5.3 days; 75th centile: 9.3 days) in high-risk episodes (p = 0.003); 2 days for low-risk episodes treated with oral antibiotics compared to 4 days for low-risk receiving intravenous antibiotics (p = 0.015). Positive predictive value for the MASCC index was 96.7% (95% CI 95.0–98.6%). Conclusion The MASCC risk index is both feasible and safe when used in standard clinical practice to guide the management of FN in patients with solid tumours and lymphomas. Patients predicted to have low risk can be managed safely with oral antibiotics and early hospital discharge.     

Modeling to Optimize Hospital Evacuation Planning in EMS Systems

Objective: To develop optimal hospital evacuation plans within a large urban EMS system using a novel evacuation planning model and a realistic hospital evacuation scenario, and to illustrate the ways in which a decision support model may be useful in evacuation planning. Methods: An optimization model was used to produce detailed evacuation plans given the number and type of patients in the evacuating hospital, resource levels (teams to move patients, vehicles, and beds at other hospitals), and evacuation rules. Results: Optimal evacuation plans under various resource levels and rules were developed and high-level metrics were calculated, including evacuation duration and the utilization of resources. Using this model we were able to determine the limiting resources and demonstrate how strategically augmenting the resource levels can improve the performance of the evacuation plan. The model allowed the planner to test various evacuation conditions and resource levels to demonstrate the effect on performance of the evacuation plan. Conclusion: We present a hospital evacuation planning analysis for a hospital in a large urban EMS system using an optimization model. This model can be used by EMS administrators and medical directors to guide planning decisions and provide a better understanding of various resource allocation decisions and rules that govern a hospital evacuation.     

Precipitating factors of heart failure decompensation,short-term morbidity and mortality in patients attended in primary care

Objective To evaluate the precipitating factors for heart failure decompensation in primary care and associations with short-term prognosis. Design Prospective cohort study with a 30-d follow-up from an index consultation. Regression models to determine independent factors associated with hospitalisation or death.Setting Primary care in ten European countries. Patients Patients with diagnosis of heart failure attended in primary care for a heart failure decompensation (increase of dyspnoea, unexplained weight gain or peripheral oedema).Main outcome measures Potential precipitating factors for decompensation of heart failure and their association with the event of hospitalisation or mortality 30 d after a decompensation.Results Of 692 patients 54% were women, mean age 81 (standard deviation [SD] 8.9) years; mean left ventricular ejection fraction (LVEF) 55% (SD 12%). Most frequently identified heart failure precipitation factors were respiratory infections in 194 patients (28%), non-compliance of dietary recommendations in 184 (27%) and non-compliance with pharmacological treatment in 157 (23%). The two strongest precipitating factors to predict 30 d hospitalisation or death were respiratory infections (odds ratio [OR] 2.8, 95% confidence interval [CI] (2.4–3.4)) and atrial fibrillation (AF) > 110 beats/min (OR 2.2, CI 1.5–3.2). Multivariate analysis confirmed the association between the following variables and hospitalisation/death: In relation to precipitating factors: respiratory infection (OR 1.19, 95% CI 1.14–1.25) and AF with heart rate > 110 beats/min (OR 1.22, 95% CI 1.10–1.35); and regarding patient characteristics: New York Heart Association (NYHA) III or IV (OR 1.22, 95% CI 1.15–1.29); previous hospitalisation (OR 1.15, 95% CI 1.11–1.19); and LVEF < 40% (OR 1.14, 95% CI 1.09–1.19).Conclusions In primary care, respiratory infections and rapid AF are the most important precipitating factors for hospitalisation and death within 30 d following an episode of heart failure decompensation.

Key points

• Hospitalisation due to heart failure decompensation represents the highest share of healthcare costs for this disease.
• So far, no primary care studies have analysed the relationship between precipitating factors and short term prognosis of heart failure decompensation episodes.
• We found that in 692 patients with heart failure decompensation in primary care, the respiratory infection and rapid atrial fibrillation (AF) increased the risk of short-term hospital admission or death.
• Patients with a hospital admission the previous year and a decompensation episode caused by respiratory infection were even more likely to be hospitalized or die within 30 d.

     

Access to intensive care units: A survey in North-East Italy

The factors associated with policies for allowing visitors into intensive care units (ICUs) are a debated issue in the nursing literature.The aim of this survey was to describe visiting policies in the ICUs of North-East Italy and to verify the hypothesis of an association between attitudes regarding accessibility to visitors and environmental, organisational or logistic variables. Data were collected by means of questionnaires sent by mail to head nurses of ICUs.The questionnaires were completed for 104 of the 110 ICUs contacted (94.5%). Visiting hours were generally less than 4 h a day (86%) and only 14% of the ICUs reported imposing no restrictions. Children under 12 years old were rarely admitted (22%). Twenty-one percent of the ICUs reported always allowing exceptions, while 77% did so only under ‘particular’ circumstances. Visiting times were not associated with logistic and organisational factors, but rather with the type of ICU (p = 0.000), city setting (p = 0.009), exceptions to rules (p = 0.029), allowing more than one person (p = 0.016) and opening to children (p = 0.001).Restrictive visiting policies emerged; paediatric units were generally more flexible. The association between the variables regarding visiting policy, such as visiting times and exceptions to rules, or allowing more than one person or children, seem to confirm how the rules are influenced mainly by the staff's attitude, which could be changed by continuing professional education.     

An observational study of hand hygiene compliance in paediatric wards

Aims and objectives. To measure healthcare workers’, children’s and visitors’ hand hygiene compliance in a paediatric oncology ward and a paediatric respiratory ward in an English hospital. Background. Children are especially vulnerable to healthcare‐associated infections, yet few studies have reported on hand hygiene compliance in paediatric clinical areas. Design. This was an observational study. Method. We measured hand hygiene compliance over an eight‐hour period in two hospital wards using the ‘five moments of hand hygiene’ observation tool. We monitored a total of 407 hand hygiene opportunities. Results. Overall opportunities for compliance were 74% for healthcare workers (n = 315) and children and visitors 23% (n = 92). Compliance was 84% for allied health professionals, 81% for doctors, 75% for nurses and 73% for ancillary and other staff. Hand hygiene compliance varied depending on which of the five moments of hygiene healthcare workers were undertaking (p < 0·001), with compliance before child contact 90% (140/155); after child contact 78% (89/114); after body fluid exposure 75% (3/4); and after surroundings contact 36% (15/42). For healthcare workers and visitors, there was no evidence of an association between time of day and their hand hygiene compliance, and for visitors to the oncology ward, hand hygiene compliance was higher (p < 0·05). Conclusion. Owing to the nature of the clinical environments, we are unable to draw conclusions about children’s hand hygiene compliance; however, visitors’ compliance was low. Among healthcare workers, levels of compliance were higher compared with previous reported estimates. Relevance to clinical practice. Visitors had the lowest level of compliance yet owing to the nature of the clinical environments, nearly a quarter of care is delivered by them rather than healthcare workers, and so, this offers opportunities for specific future interventions aimed at families and carers.     

Review article: Primary aeromedical retrievals in Australia: An interrogation and search for context

Primary aeromedical retrievals are a direct scene response to patients with a critical injury or illness using a medically equipped aircraft. They are often high‐acuity taskings. In Australia, information on primary retrieval taskings is housed by service providers, of which there are many across the country. This exploratory literature review aims to explore the contemporary peer‐reviewed literature on primary aeromedical retrievals in Australia. The focus is on adult primary aeromedical retrievals undertaken in Australia and clinical tools used in this pre‐hospital setting. Included articles were reviewed for research theme (clinical and equipment, systems and/or outcomes), data coverage and appraisal of the evidence. Of the 37 articles included, majority explored helicopter retrievals (n = 32), retrieval systems (n = 21), compared outcomes within a service (n = 10) and explored retrievals in the state of New South Wales (n = 19). Major topics of focus included retrieval of trauma patients and airway management. Overall, the publications had a lower strength of evidence because of the preponderance of cross‐sectional and case‐study methodology. This review provides some preliminary but piecemeal insight into primary retrievals in Australia through a localised systems lens. However, there are several areas for research action and service outcome improvements suggested, all of which would be facilitated through the creation of a national pre‐hospital and retrieval registry. The creation of a registry would enable consideration of the frequency and context of retrievals, comparison across services, more sophisticated data interrogation. Most importantly, it can lead to service and pre‐hospital and retrieval system strengthening.     

Continuous Passive Motion (CPM) in Rehabilitation Following Total Knee Arthroplasty: A Randomised Controlled Trial

Abstract

Objective: Continuous passive motion (CPM) has been shown to increase the amount of knee flexion in knee patients at the acute care hospital. Changing postoperative management leads to shorter hospitalisation periods. The objective of the present randomised controlled trial was to assess whether there is additional benefit in CPM use during such a short hospitalisation period.

Design: Forty patients undergoing total knee arthroplasty were randomly allocated to either a group receiving CPM in addition to physical therapy or a group receiving physical therapy alone. Both programmes were delivered during a 5-day postoperative period on an inpatient basis, starting on the first day after surgery. Main outcome measures were mobility and function; secondary measures included muscle strength, pain, satisfaction and length of hospital stay.

Results: The results indicate a significant difference in function score, pain and strength between the CPM group and the control group. Four days after surgery, the CPM group scored an average of 56 points on the Hospital for Special Surgery scale (HSS), versus 45 points in the control group (P = 0.005).

Conclusions: The results indicate that, in addition to an improved range of motion, a protocol including CPM seems to have a favourable effect on pain and muscle strength in the first two weeks after surgery.     

Factors associated with delayed hospital arrival among patients with acute myocardial infarction: a cross-sectional study in Greece

BROKALAKI H., GIAKOUMIDAKIS K., FOTOS N.V., GALANIS P., PATELAROU E., SIAMAGA E. & ELEFSINIOTIS I.S. (2011) Factors associated with delayed hospital arrival among patients with acute myocardial infarction: a cross‐sectional study in Greece. International Nursing Review 58 , 470–476 Background: It is proven that early admission to hospital contributes significantly to the successful management of acute myocardial infarction (AMI). Aim: This study aimed to examine the factors associated with delayed hospital arrival among patients with AMI. Methods: A cross‐sectional study among 477 AMI patients was conducted during a 2‐year period in two large tertiary hospitals in Greece. Structured face‐to‐face interviews were conducted and information regarding their socio‐demographic characteristics, medical history and factors that might be correlated with delayed hospital arrival were collected. Results: The main factors that were found to be correlated with delayed hospital arrival among AMI patients were the absence of companion/attendant/escort present during the AMI [odds ratio (OR) 2.1, 95% confidence interval (CI) 0.98–4.4, P = 0.049], previous medical history of diabetes mellitus (OR 3.4, CI 1.6–7.2, P = 0.002), absence of dyspepsia (OR 9.2, CI 3.6–23.3, P < 0.001) and nausea/vomiting symptoms (OR 16.9, CI 4.1–69.1, P < 0.001), and also being at a distance of more than 10 km from the hospital (OR 19.6, CI 5.4–70.6, P < 0.001). Conclusion: A number of factors that might delay hospital arrival among patients with AMI should be taken into account in healthcare service planning. Health policy actions that will improve the accessibility to healthcare services, the restructuring of the Greek primary healthcare system and the provision of effective patient education by nurses could reduce the pre‐hospital delay. Limitations: The study was conducted in two hospitals which limits the generalization of the findings. Also, the onset of AMI symptoms relied on self‐report by the patients.     

Factors influencing the length of hospital stay of patients with substance use disorders

ABSTRACT

Objective: This study aimed to identify factors influencing the length of hospital stay of individuals with substance use disorder (SUD).

Methods: This is a cohort study of patients with SUD admitted to a specialized addiction unit of a large university hospital from February 2015 to September 2019. Generalized Estimating Equations were used to analyze the length of stay. The length of stay (LOS) per episode was regressed on sex, number of hospitalizations, age, Brief Symptom Check List and Health of Nation Outcome Scales (HoNOS) score on admission.

Results: The study included 547 patients with SUD who had 970 admissions during the reported period. Number of hospitalizations and HoNOS scores significantly correlated with LOS per episode. As time passed or equivalently as the number of hospitalizations increased, the LOS per episode tended to decrease while an increased HoNOS score on admission was a significant risk factor of increased LOS. The other predictors were not statistically significant.

Conclusions: Higher HoNOS scores on admission, implying higher overall symptom level and more psychosocial problems were positively associated with increased LOS. In view of these findings, strategies to reduce LOS should focus on improving transition into outpatient treatment, as well as offering sufficient help for psychosocial problems.