A follow-up study of older adults with traumatic brain injury: taking into account decreasing length of stay

OBJECTIVE: To examine age-related differences in rehabilitation outcomes following traumatic brain injury (TBI). DESIGN: Retrospective collaborative study. SETTING: Patients received acute neurotrauma and inpatient rehabilitation services at 1 of the 17 National Institute on Disability and Rehabilitation Research-designated Traumatic Brain Injury Model Systems (TBIMS) centers. PARTICIPANTS: A sample of 273 older patients (> or =55y) admitted for TBI were taken from the TBIMS National Database. Older patients were matched with subjects 44 years of age or younger, based on severity of injury (Glasgow Coma Scale score, length of coma, intracranial pressure elevations). Due to decreasing length of stay (LOS), only patients admitted from 1996 through 2002 were included. INTERVENTION: Inpatient interdisciplinary brain injury rehabilitation. MAIN OUTCOME MEASURES: Acute care LOS, inpatient rehabilitation LOS, admission and discharge FIM instrument and Disability Rating Scale (DRS) scores, FIM and DRS efficiency, acute and rehabilitative charges, and discharge disposition. RESULTS: One-way analyses of variance demonstrated a statistically significant difference between older and younger patients with respect to LOS in rehabilitation but not for acute care. Total rehabilitative charges, and admission and discharge DRS and FIM scores also showed statistically significant differences between groups. Older patients progressed with significantly less efficiency on both the DRS and FIM scales. Significantly more charges were generated per unit for older patients to improve on the DRS scale, but not the FIM scale. Using chi-square analysis, a statistically significant difference in rate of discharge to home was identified between older (80.5%) and younger (94.4%) patients. CONCLUSIONS: Results in this study are similar to those in earlier studies with smaller sample sizes. Major differences observed include significantly slower and more costly progress in inpatient rehabilitation for older patients with TBI, as well as a significantly lower rate of discharge to community for older patients. However, even with decreasing LOS in both settings, community discharge rate is still encouraging for older patients with TBI.     

Potential impact of the new medicare prospective payment system on reimbursement for traumatic brain injury inpatient rehabilitation

OBJECTIVE: To evaluate the potential impact of the new Medicare prospective payment system (PPS) on traumatic brain injury (TBI) rehabilitation. DESIGN: Retrospective cohort study of patients with TBI. Patients were assigned to their appropriate case-mix group (CMG) based on Medicare criteria. SETTING: Fourteen urban rehabilitation facilities throughout the United States. PARTICIPANTS: Patients with TBI admitted to inpatient rehabilitation and enrolled in the Traumatic Brain Injury Model Systems from 1998 to 2001 (N=1807). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Cost of inpatient rehabilitation admission, length of stay (LOS), and functional outcomes. RESULTS: The median cost of inpatient rehabilitation for patients with TBI exceeded median PPS payments for all TBI CMGs by 16%. Only 3 of the 14 hospitals received reimbursement under PPS that exceeded costs for their TBI patients. CONCLUSIONS: Compared with current costs, the new Medicare payment system may reimburse facilities significantly less than their costs for the treatment of TBI. To maintain their current financial status, facilities may have to reduce LOS and/or reduce resource use. With a decreased LOS, inpatient rehabilitation services will have to improve FIM efficiency or discharge patients with lower discharge FIM scores.     

The Impact of Input and Output Factors on Emergency Department Throughput

Objectives: To quantify the impact of input and output factors on emergency department (ED) process outcomes while controlling for patient-level variables.
Methods: Using patient- and system-level data from multiple sources, multivariate linear regression models were constructed with length of stay (LOS), wait time, treatment time, and boarding time as dependent variables. The products of the 20th to 80th percentile ranges of the input and output factor variables and their regression coefficients demonstrate the actual impact (in minutes) of each of these factors on throughput outcomes.
Results: An increase from the 20th to the 80th percentile in ED arrivals resulted in increases of 42 minutes in wait time, 49 minutes in LOS (admitted patients), and 24 minutes in ED boarding time (admitted patients). For admit percentage (20th to 80th percentile), the increases were 12 minutes in wait time, 15 minutes in LOS, and 1 minute in boarding time. For inpatient bed utilization as of 7 am (20th to 80th percentile), the increases were 4 minutes in wait time, 19 minutes in LOS, and 16 minutes in boarding time. For admitted patients boarded in the ED as of 7 am (20th to 80th percentile), the increases were 35 minutes in wait time, 94 minutes in LOS, and 75 minutes in boarding time.
Conclusions: Achieving significant improvement in ED throughput is unlikely without determining the most important factors on process outcomes and taking measures to address variations in ED input and bottlenecks in the ED output stream.     

Validation of Length of Hospital Stay as a Surrogate Measure for Injury Severity and Resource Use Among Injury Survivors

Objectives: While hospital length of stay (LOS) has been used as a surrogate injury outcome when more detailed outcomes are unavailable, it has not been validated. This project sought to validate LOS as a proxy measure of injury severity and resource use in heterogeneous injury populations. Methods: This observational study used four retrospective cohorts: patients presenting to 339 California emergency departments (EDs) with a primary International Classification of Diseases, Ninth Revision (ICD‐9), injury diagnosis (years 2005–2006); California hospital injury admissions (a subset of the ED population); trauma patients presenting to 48 Oregon EDs (years 1998–2003); and injured Medicare patients admitted to 171 Oregon and Washington hospitals (years 2001–2002). In‐hospital deaths were excluded, as they represent adverse outcomes regardless of LOS. Duration of hospital stay was defined as the number of days from ED admission to hospital discharge. The primary composite outcome (dichotomous) was serious injury (Injury Severity Score [ISS] ≥ 16 or ICD‐9 ISS ≤ 0.90) or resource use (major surgery, blood transfusion, or prolonged ventilation). The discriminatory accuracy of LOS for identifying the composite outcome was evaluated using receiver operating characteristic (ROC) analysis. Analyses were also stratified by age (0–14, 15–64, and ≥65 years), hospital type, and hospital annual admission volume. Results: The four cohorts included 3,989,409 California ED injury visits (including admissions), 236,639 California injury admissions, 23,817 Oregon trauma patients, and 30,804 Medicare injury admissions. Composite outcome rates for the four cohorts were 2.1%, 29%, 27%, and 22%, respectively. Areas under the ROC curves for overall LOS were 0.88 (California ED), 0.74 (California admissions), 0.82 (Oregon trauma patients), and 0.68 (Medicare patients). In general, the discriminatory value of LOS was highest among children, tertiary trauma centers, and higher volume hospitals, although this finding differed by the injury population and outcome assessed. Conclusions: Hospital LOS may be a reasonable proxy for serious injury and resource use among injury survivors when more detailed outcomes are unavailable, although the discriminatory value differs by age and the injury population being studied. ACADEMIC EMERGENCY MEDICINE 2010; 17:142–150 © 2010 by the Society for Academic Emergency Medicine     

Body Temperature after EMS Transport: Association with Traumatic Brain Injury Outcomes

Introduction: Low body temperatures following prehospital transport are associated with poor outcomes in patients with traumatic brain injury (TBI). However, a minimal amount is known about potential associations across a range of temperatures obtained immediately after prehospital transport. Furthermore, a minimal amount is known about the influence of body temperature on non-mortality outcomes. The purpose of this study was to assess the correlation between temperatures obtained immediately following prehospital transport and TBI outcomes across the entire range of temperatures. Methods: This retrospective observational study included all moderate/severe TBI cases (CDC Barell Matrix Type 1) in the pre-implementation cohort of the Excellence in Prehospital Injury Care (EPIC) TBI Study (NIH/NINDS: 1R01NS071049). Cases were compared across four cohorts of initial trauma center temperature (ITCT): <35.0°C [Very Low Temperature (VLT)]; 35.0–35.9°C [Low Temperature (LT)]; 36.0–37.9°C [Normal Temperature (NT)]; and ≥38.0°C [Elevated Temperature (ET)]. Multivariable analysis was performed adjusting for injury severity score, age, sex, race, ethnicity, blunt/penetrating trauma, and payment source. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) for mortality were calculated. To evaluate non-mortality outcomes, deaths were excluded and the adjusted median increase in hospital length of stay (LOS), ICU LOS and total hospital charges were calculated for each ITCT group and compared to the NT group. Results: 22,925 cases were identified and cases with interfacility transfer (7361, 32%), no EMS transport (1213, 5%), missing ITCT (2083, 9%), or missing demographic data (391, 2%) were excluded. Within this study cohort the aORs for death (compared to the NT group) were 2.41 (CI: 1.83–3.17) for VLT, 1.62 (CI: 1.37–1.93) for LT, and 1.86 (CI: 1.52–3.00) for ET. Similarly, trauma center (TC) LOS, ICU LOS, and total TC charges increased in all temperature groups when compared to NT. Conclusion: In this large, statewide study of major TBI, both ETs and LTs immediately following prehospital transport were independently associated with higher mortality and with increased TC LOS, ICU LOS, and total TC charges. Further study is needed to identify the causes of abnormal body temperature during the prehospital interval and if in-field measures to prevent temperature variations might improve outcomes.     

Co-occurring traumatic brain injury and acute spinal cord injury rehabilitation outcomes

Macciocchi S, Seel RT, Warshowsky A, Thompson N, Barlow K. Co-occurring traumatic brain injury and acute spinal cord injury rehabilitation outcomes.ObjectiveTo determine the impact of co-occurring traumatic brain injury (TBI) on functional motor outcome and cognition during acute spinal cord injury (SCI) rehabilitation.DesignProspective, longitudinal cohort.SettingSingle-center National Institute of Disability and Rehabilitation Research SCI Model System.ParticipantsPersons aged 16 to 59 years (N=189) admitted for acute SCI rehabilitation during the 18-month recruitment window who met inclusion criteria.InterventionsNot applicable.Main Outcome MeasuresFIM Motor Scale (Rasch transformed) and acute rehabilitation length of stay (LOS).ResultsIn the tetraplegia sample, co-occurring TBI was not related to FIM Motor Scale scores or acute rehabilitation LOS despite having negative impacts on memory and problem solving. Persons with paraplegia who sustained co-occurring severe TBI had lower admission and discharge FIM Motor Scale scores and longer acute rehabilitation LOS than did persons with paraplegia and either no TBI or mild TBI. Persons with paraplegia and severe TBI had lower functional comprehension, problem solving, and memory and impairments on tests of processing speed compared with persons with paraplegia and no TBI, mild TBI, and moderate TBI. Persons with paraplegia and co-occurring mild and moderate TBI had equivalent acute rehabilitation motor outcomes and cognitive functioning compared with persons with paraplegia and no TBI.ConclusionsThis study provides evidence that persons aged 16 to 59 years with paraplegia and co-occurring severe TBI had worse motor outcomes and longer acute rehabilitation LOS than did persons with paraplegia and no TBI. Impairments in processing speed, comprehension, memory, and problem solving may explain suboptimal motor skill acquisition. Research with larger samples is required to determine whether mild and moderate TBI impact acute rehabilitation motor outcomes and LOS.     

Predictors of intensive care unit length of stay and intracranial pressure in severe traumatic brain injury

ObjectiveThe aim of this study was to explore the relationship of intracranial pressure (ICP) with intensive care unit (ICU) length of stay in a large cohort of severe traumatic brain injury patients and identify factors associating with prolonged ICU course.MethodsThis was a single-center database review of de-identified research data that had been prospectively collected; setting: neurosurgical ICU, Ben Taub General Hospital, Houston, TX.ResultsIn a cohort of 438 severe traumatic brain injury (TBI) patients, 149 (34%) had a motor Glasgow Coma Scale score of 1 to 3 on admission and 284 (65%) had 4 to 5. Intracranial pressure during the ICU course was 19.8 ± 11.2 mm Hg. Favorable outcome was obtained in 148 (34%), and unfavorable, in 211 (48%) patients with a mortality of 28%. ICU length of stay (LOS) was 19.4 ± 13.9 days. Joint modeling of ICP and ICU LOS was undertaken, adjusted for the International Mission for Prognosis and Analysis of Clinical Trials in TBI admission prognostic indicators. A higher ICP was not significantly associated with longer ICU LOS (P = .4). However, presence of a mass lesion on admission head computed tomography was strongly correlated with a prolonged ICU LOS (P = .0007). Diffuse injuries with basal cistern compression or midline shift were marginally associated with a longer ICU LOS (P = .053).ConclusionsICP, as monitored and managed according to BTF guidelines, is not associated with ICU length of stay. Patients with severe TBI and a mass lesion on admission head computed tomography were found to have prolonged ICU LOS independently of other indicators of injury severity and intracranial pressure course.     

Course of functional improvement after stroke, spinal cord injury, and traumatic brain injury.

OBJECTIVE: To examine functional improvement patterns of persons with stroke, traumatic brain injury (TBI), and spinal cord injury (SCI). DESIGN: Statistical analysis of data from a multisite study evaluating rehabilitation outcomes. SETTING: Eight inpatient rehabilitation facilities. PARTICIPANTS: A total of 314 consecutive admissions of persons with stroke, SCI, and TBI who received acute medical rehabilitation between 1994 and 1998. INTERVENTION: Calibration of motor and cognitive items from the FIM instrument, grouping of cases by number of weeks of rehabilitation (length of stay [LOS] groups), and plotting of weekly averages across time. MAIN OUTCOME MEASURES: Weekly motor and cognitive functional status. RESULTS: With the exception of cognitive functioning for persons with SCI, LOS was related to initial functional status, with patients with greater disability having longer LOS (eg, initial motor status for persons with stroke was 48.3 for those with a 2-week stay, 36.8 for a 6-week stay, with the averages between decreasing monotonically). With the exception of cognitive gains for person with TBIs, the amount of functional gain during rehabilitation was essentially the same for all LOS groups (eg, the overall average total motor gain for persons with SCI is 22.3, with no patterns of increase or decrease across LOS groups); however, the rate of improvement in motor (but not cognitive) functioning differed across LOS groups, with patients with shorter stays having the greater rates of improvement (eg, the overall average weekly motor gain for persons with SCI was 3.6, with the averages by LOS group monotonically decreasing from 6.4 for those with 4-week stays to 2.7 for those with 9-week stays). CONCLUSIONS: When examined separately for persons grouped by LOS, functional status improved linearly during the rehabilitation stay, with differences in rate of improvement depending on initial functional status.     

Characteristics and functional outcomes of elderly rehabilitation patients

Sixty-seven patients admitted to a geriatric rehabilitation unit were assessed from admission to discharge by their primary nurses for functional outcomes and demographic characteristics. The patients had a mean age of 78.1 years and a mean length of stay of 58.6 days. Patients with an admitting diagnosis of a recent leg amputation were discharged more independent in ADL than those admitted following a recent stroke. Sixty-nine percent of the patients were discharged home. Patients sent home were significantly more independent in ADL than those who did not return home. Almost all patients continued to improve in physical ADL and felt they were managing adequately or well in the home setting.     

Economics of trauma in a small academic medical center

The recent changes in the mechanisms of health care funding have complicated trauma care and trauma center development. Hard data are needed on the current financial position of trauma care to plan for the future. To reduce the cost of trauma care without sacrificing the quality, we must know how the trauma dollar is spent. We reviewed the records of 100 random admissions to the trauma service of our institution in 1985. The records were examined for length of stay (LOS), intensive care unit length of stay (ICU-LOS), total hospital bill, types of third-party coverage, and overall collection rate. The hospital bill was broken down to identify the origins of trauma costs. To provide a control group, 100 patients admitted to the general surgical service and 100 other admissions were also analyzed. Trauma patients had greater LOS, ICU-LOS, total bills, and costs per day. Blunt trauma resulted in a greater LOS than penetrating trauma, but similar total bills. The collection rate from the blunt trauma patients was significantly greater. The greatest differences between trauma patients and others in resource utilization are the result of longer ICU-LOS and greater use of blood products. We did not identify any sites of potentially significant cost cutting that would not compromise patient care.     

Mobility status during inpatient rehabilitation: a comparison of patients with stroke and traumatic brain injury

OBJECTIVES: To compare the mobility status (admission and discharge status, change in status) between patients with stroke and traumatic brain injury (TBI) during inpatient rehabilitation and to determine the relationship between mobility status and outcome variables including length of stay (LOS). DESIGN: Prospective study. SETTING: Free-standing tertiary rehabilitation center. PARTICIPANTS: A total of 210 patients with stroke (n = 136) and TBI (n = 74) consecutively admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Clinical Outcome Variable Scale (COVS), a 13-item scale of mobility status (measured on admission and discharge from inpatient rehabilitation), and rehabilitation LOS. RESULTS: With age and time since injury controlled in the model, the TBI group showed a significantly higher mobility status on admission and discharge over the stroke group, but the change (improvement) in mobility status did not differ. The admission mobility status accounted for 61% and 60% of variability of the discharge mobility status for the stroke and TBI groups, respectively. The admission mobility status accounted for 40% and 50% of the variability in rehabilitation LOS for the stroke and TBI groups, respectively. Either the admission mobility status or the physical therapist's prediction of the discharge status could be used to determine the actual discharge mobility status, although the physical therapist's predictions were more accurate than using a statistical model. CONCLUSIONS: The TBI group showed a higher mobility status at admission and discharge from inpatient rehabilitation than the stroke group; however, the rate of improvement (improvement in mobility status per day) did not differ between groups. Admission mobility status using the COVS was an excellent predictor of discharge mobility status and rehabilitation LOS in stroke and TBI patients.     

Severe penetrating head injury: a study of outcomes

OBJECTIVE: To determine and describe the demographics and functional outcomes of persons who require inpatient rehabilitation for severe penetrating head injury resulting from a gunshot wound to the head. DESIGN: Data were collected prospectively from the time of admission to acute care through discharge from inpatient rehabilitation. SETTING: Two sites: an urban, level I, acute care, trauma center and an inpatient rehabilitation hospital with a specialized brain injury unit. PARTICIPANTS: Twenty-seven persons with severe penetrating head injury. MAIN OUTCOME MEASURES: The FIM instrument, the Disability Rating Scale (DRS), and the length of stay (LOS). RESULTS: Demographic data showed our population to be similar to other groups of persons at high risk for violent injury. Eighty-five percent of the subjects were men with a mean age of 34 years. The majority were African American (93%), reflective of our general patient population. Average acute care LOS was 31 days and average rehabilitation LOS was 44 days. Average FIM gain was 40.2 and, on average, DRS scores improved 7.6 points from rehabilitation admission to discharge. All study participants made enough progress to be discharged to private residences. CONCLUSION: Although the mortality rate is high among patients with penetrating head injury, those who survive to receive inpatient rehabilitation can achieve functional improvement.     

Outcomes of admitted geriatric trauma victims

Conflicting data exist as to the outcome of elderly victims of trauma. With recent improved outcomes for functional recovery, aggressive management of these patients has been advocated. The purpose of this study is to determine outcomes of admitted elderly trauma victims based on initial mechanism of injury and the degree to which other factors affected their overall outcome. A prospective study involving admitted patients > or =65 years was performed at an urban university center from September 15, 1996 until August 31, 1997. Patients sustaining any potentially serious form of trauma were included. Data about mechanism of injury (MOI), comorbid conditions, preinjury medications, types of injuries sustained, length of stay, functional outcome, and ultimate disposition were recorded. Two hundred thirty-nine consecutive patients were enrolled. Mean age was 78.1 +/- 8.1 years. There were 130 women (54%) and 109 men (46%). MOI was as follows: 132 low-mechanism falls (LMFs), 64 high-mechanism motor vehicle crashes (HMMVCs), 22 high-mechanism falls (HMFs), 8 pedestrian versus car (PVCs), and 13 other types. Mean length of stay surviving beyond the ED was 12.9 days. 8 patients were either DOA or died in the ED. There were 19 in-hospital deaths. Deaths were seen in 14% of HMMVCs, 13.6% HMFs, 9.1% LMFs, 25% PVCs, and 7.7% for other mechanisms. Overall outcomes by mechanism were categorized as functional (or baseline), fair, alive but poor, and dead. Functional outcomes were seen in 76.6% of HMMVCs, 81.8% of HMFs, 84.1% of LMFs, 50% of PVCs, and 84.6% for all other injuries. Forty-five percent were discharged home, 26% went to rehabilitation units, 16% went to nursing homes, and 11% died; the remaining 2% were either transferred to a psychiatric facility or to another hospital. Preexisting comorbid conditions did not appear to play a significant role in the ultimate outcomes of these patients. Severity of injury was the leading determinant of death, but severely injured patients often had functional outcomes. Elderly trauma victims most often achieve functional outcomes despite multiple or severe injuries.     

Antimicrobial selection for hospitalized patients with presumed community-acquired pneumonia: a survey of nonteaching US community hospitals

OBJECTIVE: To describe and evaluate empiric antimicrobial regimens chosen for hospitalized patients with presumed community-acquired pneumonia (CAP) in US hospitals, including compliance with the American Thoracic Society (ATS) guidelines. Secondary outcomes included length of stay (LOS) and mortality associated with the choice of therapy. METHODS: A nonrandomized, prospective, observational study was performed in 72 nonteaching hospitals affiliated with a national group purchasing organization. Patients with an admission diagnosis of physician-presumed CAP and an X-ray taken within 72 hours of admission were eligible for the study. Demographic, antibiotic selection, and outcomes data were collected prospectively from patient charts. RESULTS: 3035 patients were enrolled; 2963 were eligible for analysis. Compliance with the ATS guidelines was 81% in patients with nonsevere CAP. The most common antibiotic regimen used for empiric treatment was ceftriaxone alone or in combination with a macrolide (42%). The overall mortality rate was 5.5%. The addition of a macrolide to either a second- or third-generation cephalosporin or a beta-lactam/beta-lactamase inhibitor was associated with decreased mortality and reduced LOS. CONCLUSIONS: Most hospitalized patients with CAP receive antimicrobial therapy consistent with the ATS guidelines. The addition of a macrolide may be associated with improved patient outcomes.     

Impact of transfer delays to rehabilitation in patients with severe trauma

OBJECTIVE: To measure the effect on rehabilitation outcomes of administrative delays in transferring patients from a level I trauma center to inpatient rehabilitation. DESIGN: Retrospective cohort study. SETTINGS: Level I trauma center and an inpatient rehabilitation center in Quebec, Canada. PARTICIPANTS: A total of 289 patients with severe trauma admitted to inpatient rehabilitation from a level I trauma center between 1994 and 1999. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Length of stay (LOS) in rehabilitation, motor and cognitive function at discharge from rehabilitation, interruptions in rehabilitation, and disposition at discharge. RESULTS: Shorter administrative delays were associated with shorter rehabilitation LOS (P<.01) improved cognitive function (P=.02) and had a negative but statistically nonsignificant association with motor function at discharge. No effect was observed for rehabilitation interruptions or dispositions at discharge. CONCLUSIONS: Transferring trauma patients more quickly to inpatient rehabilitation can affect rehabilitation outcomes positively. It can also lead to an economy of resource use in both acute and rehabilitation settings.     

Comparing different patterns for managing febrile children in the ED between emergency and pediatric physicians: impact on patient outcome

Objective

The management of children with fever of indefinite source still remains controversial. This study aimed to compare different practice patterns between pediatric physicians (PPs) and emergency physicians (EPs) in the management of pediatric fever in the emergency department (ED) and correlate them to existing practice guidelines. Their impact on patient outcomes was also discussed.

Methods

Medical records of patients 3 to 36 months of age who presented to the ED with fever of indefinite source from June 1 to December 31, 2006, were retrospectively reviewed on day 5 after the patient's first visit. At the same time, telephone follow-up was carried out to determine whether the patient had been visiting or being admitted to another clinic or hospital after discharge. Variation in practice patterns were compared for the number of laboratory tests, ED length of stay (LOS), and the rate of immediate admission. Patient outcomes were measured as the rate of unscheduled revisit within 72 hours and the rate of subsequent admission. Compliance with existing practice guidelines between PPs and EPs were evaluated by dividing all eligible patients into 3 groups: (1) toxic appearing patients (group A), (2) nontoxic patients with body temperature (BT) ≧39°C (group B), and (3) nontoxic patients with BT below 39°C (group C).

Results

A total of 345 patients who met the inclusion and exclusion criteria were enrolled into this study. Pediatric physicians and EPs treated 163 and 182 febrile children, respectively. In group A, PPs admitted more patients than EPs (41% vs 12 %), whereas more unscheduled revisits were seen in EP-treated patients (44% vs 10%). In group B, PPs ordered more laboratory tests than EPs (2.3 vs 0.7 tests per patient), and their patients also had a longer ED LOS (3.4 ± 3.2 vs 1.5 ± 1.1 hours). However, no difference was found in their rates of immediate admission and unscheduled revisit. In group C, PPs admitted more patients (15% vs 0%) and ordered more laboratory tests (2.0 vs 0.5 tests/patient) than EPs. Longer ED LOS (3.3 ± 3.9 vs 1.0 ± 1.4 hours) was also noted among PP-treated patients. However, no difference was noted in their rates of unscheduled revisit. In all groups, the rates of subsequent admission were similar.

Conclusion

Compliance with existing practice guidelines (admit the toxic cases and work up those with BT ≧39°C) was higher among PPs, which resulted in a lower rate of unscheduled revisit, but no significant difference was found in the rate of subsequent admission.     

Adherence to ATS guidelines for hospitalized patients with community-acquired pneumonia.

OBJECTIVE: To compare outcomes of care and antibiotic utilization for community-acquired pneumonia (CAP) throughout a group of not-for-profit hospitals. METHODs: A retrospective chart review of patients from community hospitals with a diagnosis of pneumonia at discharge admitted from December 1997 to May 1998. Data were collected based on American Thoracic Society (ATS) criteria. RESULTS: Medical records of 330 patients were reviewed; mortality was 7%. Using ATS guidelines, 51 (15.5%) patients were not treated with recommended antimicrobial therapy. Of these patients, 14 had nonsevere cases of CAP and 37 cases were severe. Factors found to be associated with in-hospital mortality included nonadherence to ATS guidelines (OR 4.46; 95% CI 1.38 to 14.43), decreased urine output (OR 7.72; 95% CI 1.70 to 35.04), and increasing age (OR 1.06; 95% CI 1.01 to 1.12). Significant predictors of length of stay (LOS) included age, nonadherence to ATS criteria, suspected aspiration, discharge status, low pulse oximetry on admission, decreased urine output, use of vasopressor medications, and interstitial lung disease; More than 80% of patients had at least one culture performed, but only 27.5% of these cultures were positive. The most cpmmonly prescribed antibiotic was cefuroxime injection, representing 25% of the antibiotic orders. CONCLUSIONS: Patients with CAP treated inconsistently with ATS guidelines had a 4.46-d higher risk of inpatient mortality and had significantly longer LOS.