Emergency department length of stay independently predicts excess inpatient length of stay

OBJECTIVE: To examine the association between emergency department length of stay (EDLOS) and inpatient length of stay (IPLOS). DESIGN: Retrospective review of presentations and admissions data. SETTING: Three metropolitan hospitals in Melbourne, 1 July 2000 to 30 June 2001. MAIN OUTCOME MEASURES: Mean IPLOS for four categories of EDLOS (12 hours); excess IPLOS, defined as IPLOS exceeding state average length of stay; odds ratios for excess IPLOS adjusted for age, sex and time of presentation. RESULTS: 17 954 admissions were included. Mean IPLOS for the four categories of EDLOS were 12 hours, 7.20 days (P < 0.001). The corresponding excess IPLOS were 0.39, 1.30, 1.96 and 2.35 days (P < 0.001). Compared with EDLOS 4-8 hours, odds ratios (95% CIs) for excess IPLOS associated with the other three categories of EDLOS were 12 hours, 1.49 (1.36-1.63), after adjusting for elderly status, sex and time of ED presentation. CONCLUSION: EDLOS correlates strongly with IPLOS, and predicts whether IPLOS exceeds the state benchmark for the relevant diagnosis-related group, independently of elderly status, sex and time of presentation to ED. Strategies to reduce EDLOS (including countering access block) may significantly reduce healthcare expenditure and patient morbidity.     

The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments

OBJECTIVE: To examine the relationship between hospital and emergency department (ED) occupancy, as indicators of hospital overcrowding, and mortality after emergency admission. DESIGN: Retrospective analysis of 62 495 probabilistically linked emergency hospital admissions and death records. SETTING: Three tertiary metropolitan hospitals between July 2000 and June 2003. PARTICIPANTS: All patients 18 years or older whose first ED attendance resulted in hospital admission during the study period. MAIN OUTCOME MEASURES: Deaths on days 2, 7 and 30 were evaluated against an Overcrowding Hazard Scale based on hospital and ED occupancy, after adjusting for age, diagnosis, referral source, urgency and mode of transport to hospital. RESULTS: There was a linear relationship between the Overcrowding Hazard Scale and deaths on Day 7 (r=0.98; 95% CI, 0.79-1.00). An Overcrowding Hazard Scale>2 was associated with an increased Day 2, Day 7 and Day 30 hazard ratio for death of 1.3 (95% CI, 1.1-1.6), 1.3 (95% CI, 1.2-1.5) and 1.2 (95% CI, 1.1-1.3), respectively. Deaths at 30 days associated with an Overcrowding Hazard Scale>2 compared with one of <3 were undifferentiated with respect to age, diagnosis, urgency, transport mode, referral source or hospital length of stay, but had longer ED durations of stay (risk ratio per hour of ED stay, 1.1; 95% CI, 1.1-1.1; P<0.001) and longer physician waiting times (risk ratio per hour of ED wait, 1.2; 95% CI, 1.1-1.3; P=0.01). CONCLUSIONS: Hospital and ED overcrowding is associated with increased mortality. The Overcrowding Hazard Scale may be used to assess the hazard associated with hospital and ED overcrowding. Reducing overcrowding may improve outcomes for patients requiring emergency hospital admission.     

Determinants of hospital admission among HIV-positive people in British Columbia

BACKGROUND: This study was initiated to evaluate the demographic and clinical determinants of admission to hospital among HIV-positive men and women receiving antiretroviral therapy in British Columbia. METHODS: The analysis was restricted to participants enrolled in the HIV/AIDS Drug Treatment Program between September 1992 and March 1997 who had completed an annual participant survey, had a viral load determination and had signed a consent form allowing electronic access to their inpatient hospital records. A record linkage was conducted with the BC Ministry of Health to obtain all records of hospital admissions from April 1991 to March 1997. Statistical analyses were carried out using parametric and nonparametric methods and multivariate logistic analyses. RESULTS: The study sample comprised 947 participants (859 men, 88 women). Of these, 165 (17%) were admitted to hospital during the study period from May 1, 1996, to Mar. 31, 1997. The median number of admissions was 1 (interquartile range [IQR] 1-2 admissions), and the median length of stay per admission was 3 days (IQR 1-8 days). Admission to hospital was associated with being unemployed (82% of those admitted v. 58% of those not admitted), being an injection drug user (24% v. 17%), reporting a fair or poor health status (46% v. 29%) and having a physician experienced in the management of HIV/AIDS (31% v. 24%). Examination of clinical determinants demonstrated that hospital admission was associated with a previous admission (72% v. 46%), a high viral load (median 74,000 v. 14,000 HIV-1 RNA copies/mL), a low CD4 count (median 0.16 v. 0.27 x 10(9)/L) and an AIDS diagnosis (44% v. 24%). Multivariate logistic regression analysis revealed that being admitted to hospital was independently associated with being unemployed (odds ratio [OR] 2.64, 95% confidence interval [CI] 1.66-4.20), having been previously admitted to hospital (OR 2.30, 95% CI 1.53-3.46), having a high viral load at baseline (OR 1.45, 95% CI 1.16-1.80), being an injection drug user (OR 1.63, 95% CI 1.02-2.62) and having an experienced physician (OR 1.98, 95% CI 1.29-3.03). INTERPRETATION: Hospital admission among participants in this study was found to be associated with marginalization and poor health status.     

Incidence of hip fracture in New South Wales: are our efforts having an effect?

OBJECTIVE: To examine trends in hospital admission for hip fracture in New South Wales between July 1990 and June 2000. DESIGN: Analysis of routinely collected hospital separation data. SETTING: Public and private acute-care hospitals in NSW. PARTICIPANTS: Admissions of patients aged 50 years and over with a primary diagnosis of fracture of the neck of femur (International classification of diseases, 9th revision [ICD-9] code 820 or ICD-10 codes S72.0-S72.2). MAIN OUTCOME MEASURES: Number and rates of hospital admission for fracture of the neck of femur per 1000 population; inpatient mortality rates per 1000 admissions. RESULTS: Between July 1990 and June 2000, the number of admissions to NSW acute-care hospitals for hip fracture increased by 41.9% in men (from 1059 to 1503 per year) and by 31.2% in women (from 3160 to 4145 per year). However, age-specific and age-adjusted rates remained practically unchanged. The average length of stay for admissions for hip fracture decreased significantly from 19.2 days (95% CI, 18.5-19.8 days) in 1990-1991 to 14.2 days (95% CI, 13.8-14.6 days) in 1999-2000. No significant change was observed in the overall inpatient death rates per 1000 admissions. CONCLUSIONS: The findings support recent reports that the increase in hip fracture rates during most of the past century may have ended. However, the number of admissions for hip fracture is still rising. Preventive measures to reduce the burden of this condition on the healthcare system and community need to be pursued and strengthened.     

Evaluating the effectiveness of evidence-based guidelines for the use of spacer devices in children with acute asthma

OBJECTIVE: To change standard practice from using nebulisers to metered dose inhalers and holding chambers (spacers) in children presenting with mild to moderate acute asthma. DESIGN: A before-after comparison of children with acute asthma presenting to the emergency department (ED) between August and October 1999 with those presenting between June and August 1997. SETTING: A tertiary care metropolitan children's hospital. INTERVENTIONS: Evidence-based clinical practice guidelines for using spacers were developed by a local multidisciplinary consensus process. A multifaceted guideline implementation program was used in 1999. MAIN OUTCOME MEASURES: Physician prescribing practices (spacer use); clinical outcomes (need for hospitalisation, admission to intensive care unit, and length of stay [LOS]). RESULTS: 75 of 247 children (30%; 95% CI, 25%-36%) required hospital admission in 1999. This was similar to the 1997 study period, when 95 of 326 (29%; 95% CI, 24%-34%) children were admitted. Of those with mild to moderate asthma, 160 (68%) received bronchodilators in the ED; 151 (94%) were initially treated with a spacer device in 1999. In 1997, no children were initially treated with spacers in the ED. The median (range) LOS in hospital for children with asthma of all severities was 1.7 (0.5-19.8) days in 1999 and 1.7 (0.2-7.6) days in 1997 (P=0.85). CONCLUSIONS: We successfully changed standard practice from using nebulisers to spacers for bronchodilator delivery in children with mild to moderate acute asthma, with no difference in the need for or duration of hospitalisation.     

Relationship between trauma center volume and outcomes

CONTEXT: The premise underlying regionalization of trauma care is that larger volumes of trauma patients cared for in fewer institutions will lead to improved outcomes. However, whether a relationship exists between institutional volume and trauma outcomes remains unknown. OBJECTIVE: To evaluate the association between trauma center volume and outcomes of trauma patients. DESIGN: Retrospective cohort study. SETTING: Thirty-one academic level I or level II trauma centers across the United States participating in the University Healthsystem Consortium Trauma Benchmarking Study. PATIENTS: Consecutive patients with penetrating abdominal injury (PAI; n = 478) discharged between November 1, 1997, and July 31, 1998, or with multisystem blunt trauma (minimum of head injury and lower-extremity long-bone fractures; n = 541) discharged between June 1 and December 31, 1998. MAIN OUTCOME MEASURES: Inpatient mortality and hospital length of stay (LOS), comparing high-volume (>650 trauma admissions/y) and low-volume (相似文献   

Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: The Rapid Early Action for Coronary Treatment (REACT) Trial

CONTEXT: Delayed access to medical care in patients with acute myocardial infarction (AMI) is common and increases myocardial damage and mortality. OBJECTIVE: To evaluate a community intervention to reduce patient delay from symptom onset to hospital presentation and increase emergency medical service (EMS) use. DESIGN AND SETTING: The Rapid Early Action for Coronary Treatment Trial, a randomized trial conducted from 1995 to 1997 in 20 US cities (10 matched pairs; population range, 55,777-238,912) in 10 states. PARTICIPANTS: A total of 59,944 adults aged 30 years or older presenting to hospital emergency departments (EDs) with chest pain, of whom 20,364 met the primary population criteria of suspected acute coronary heart disease on admission and were discharged with a coronary heart disease-related diagnosis. INTERVENTION: One city in each pair was randomly assigned to an 18-month intervention that targeted mass media, community organizations, and professional, public, and patient education to increase appropriate patient actions for AMI symptoms (primary population, n=10,563). The other city in each pair was randomly assigned to reference status (primary population, n=9801). MAIN OUTCOME MEASURES: Time from symptom onset to ED arrival and EMS use, compared between intervention and reference city pairs. RESULTS: General population surveys provided evidence of increased public awareness and knowledge of program messages. Patient delay from symptom onset to hospital arrival at baseline (median, 140 minutes) was identical in the intervention and reference communities. Delay time decreased in intervention communities by -4.7% per year (95% confidence interval [CI], -8.6% to -0.6%), but the change did not differ significantly from that observed in reference communities (-6. 8% per year; 95% CI, -14.5% to 1.6%; P=.54). EMS use by the primary study population increased significantly in intervention communities compared with reference communities, with a net effect of 20% (95% CI, 7%-34%; P<.005). Total numbers of ED presentations for chest pain and patients with chest pain discharged from the ED, as well as EMS use among patients with chest pain released from the ED, did not change significantly. CONCLUSIONS: In this study, despite an 18-month intervention, time from symptom onset to hospital arrival for patients with chest pain did not change differentially between groups, although increased appropriate EMS use occurred in intervention communities. New strategies are needed if delay time from symptom onset to hospital presentation is to be decreased further in patients with suspected AMI. JAMA. 2000;284:60-67     

Hospital utilisation among people born in refugee-source countries: an analysis of hospital admissions, Victoria, 1998-2004

OBJECTIVE: To investigate whether hospital utilisation and health outcomes in Victoria differ between people born in refugee-source countries and those born in Australia. DESIGN AND SETTING: Analysis of a statewide hospital discharge dataset for the 6 financial years from 1 July 1998 to 30 June 2004. Hospital admissions of people born in eight countries for which the majority of entrants to Australia arrived as refugees were included in the analysis. MAIN OUTCOME MEASURES: Age-standardised rates and rate ratios for: total hospital admissions; emergency admissions; surgical admissions; total days in hospital; discharge at own risk; hospital deaths; admissions due to infectious and parasitic diseases; and admissions due to mental and behavioural disorders. RESULTS: In 2003-04, compared with the Australia-born Victorian population, people born in refugee-source countries had lower rates of surgical admission (rate ratio [RR], 0.85; 95% CI, 0.81-0.88), total days in hospital (RR, 0.74; 95% CI, 0.73-0.75), and admission due to mental and behavioural disorders (RR, 0.70; 95% CI, 0.65-0.76). Over the 6-year period, rates of total days in hospital and rates of admission due to mental and behavioural disorders for people born in refugee-source countries increased towards Australian-born averages, while rates of total admissions, emergency admissions, and admissions due to infectious and parasitic diseases increased above the Australian-born averages. CONCLUSIONS: Use of hospital services among people born in refugee-source countries is not higher than that of the Australian-born population and shows a trend towards Australian-born averages. Our findings indicate that the Refugee and Humanitarian Program does not currently place a burden on the Australian hospital system.     

Weather patients will come?

OBJECTIVES: To determine whether weather conditions affect emergency department (ED) attendance and admissions from the ED. DESIGN AND SETTING: A retrospective observational study in a large metropolitan ED. MAIN OUTCOME MEASURES: ED attendance (total and via ambulance) and admissions to hospital from ED, as a function of weather variables. RESULTS: On warm, dry, sunny and good weather days there were significantly more ED attendances in total than there were on cool, rainy, dull and bad weather days, respectively (P < or = 0.001). There were significant correlations between ED attendance and temperature (r = 0.36, P < 0.001), rainfall (r = - 0.20, P < 0.001) and hours of sunshine (r = 0.17, P = 0.001). Attendance via ambulance was not affected by weather variables. Admissions from the ED were positively correlated with temperature (r = 0.15, P < 0.01) and negatively correlated with rainfall (r = - 0.12, P = 0.02). CONCLUSIONS: As there is a clear relationship between weather conditions and ED attendance, incorporating meteorological forecasting into emergency medicine training may improve ED scheduling. To improve the morale of ED staff coping with an onslaught of patients on good weather days, the ED environment should simulate sunny weather, with swimming pools, sun lamps, palm trees and Beach Boys music.     

Treatment and outcomes of community-acquired pneumonia at Canadian hospitals

BACKGROUND: Community-acquired pneumonia is a common disease with a large economic burden. We assessed clinical practices and outcomes among patients with community-acquired pneumonia admitted to Canadian hospitals. METHODS: A total of 20 hospitals (11 teaching and 9 community) participated. Data from the charts of adults admitted during November 1996, January 1997 and March 1997 were reviewed to determine length of stay (LOS), admission to an intensive care unit and 30-day in-hospital mortality. Multivariate analyses examined sources of variability in LOS. The type and duration of antibiotic therapy and the proportion of patients who were treated according to clinical practice guidelines were determined. RESULTS: A total of 858 eligible patients were identified; their mean age was 69.4 (standard deviation 17.7) years. The overall median LOS was 7.0 days (interquartile range [IQR] 4.0-11.0 days); the median LOS ranged from 5.0 to 9.0 days across hospitals (IQR 6.0-7.8 days). Only 22% of the variability in LOS could be explained by known factors (disease severity 12%; presence of chronic obstructive lung disease or bacterial cause for the pneumonia 2%; hospital site 7%). The overall 30-day mortality was 14.1% (95% confidence interval [CI] 11.8%-16.6%); 13.6% of the patients were admitted to an intensive care unit (95% CI 11.4%-16.1%). The median duration of intravenous antibiotic therapy was 5 days (range 3.0-6.5 days across hospitals). Although 79.8% of patients received treatment according to clinical practice guidelines, the rate of compliance with the guidelines ranged from 47.9% to 100% across hospitals. INTERPRETATION: Considerable heterogeneity exists in the management of community-acquired pneumonia at Canadian hospitals, the causes of which are poorly understood.     

Higher neonatal morbidity after routine early hospital discharge: Are we sending newborns home too early?

BACKGROUND: A growing body of evidence suggests that the trend toward earlier discharge may affect newborn morbidity. The authors assessed how hospital readmission rates were affected by a clinical guideline aimed at discharging newborns from hospital 24 hours after birth. METHOD: A retrospective before-after cohort study was conducted involving 7009 infants born by uncomplicated vaginal delivery at a large level II hospital in Toronto between Dec. 31, 1993, and Sept. 29, 1997. The primary outcome was a comparison of the rate of hospital readmission among newborns before (5936 infants) and after (1073 infants) the early-discharge policy was implemented (Apr. 1, 1997). The causes for readmission were secondary outcomes. RESULTS: Before the early-discharge guideline was implemented, the mean length of stay declined from 2.25 days (95% confidence interval [CI] 2.18-2.32) to 1.88 days (95% CI 1.84-1.92) (p < 0.001). After implementation there was a further decline, to 1.62 days (95% CI 1.56-1.67) (p < 0.001). A total of 126 infants (11.7%) in the early-discharge cohort required readmission by 1 month, as compared with 396 infants (6.7%) in the preguideline cohort (odds ratio 1.86, 95% CI 1.51-2.30). The main reason for early readmission was neonatal jaundice, with a higher rate among infants in the early-discharge cohort than among those in the preguideline cohort (8.6% v. 3.1%; odds ratio 2.96, 95% CI 2.29-3.84). INTERPRETATION: Decreases in newborn length of stay may result in substantial increases in morbidity. Careful consideration is needed to establish whether a reduction in length of stay to less than 24 to 36 hours is harmful to babies.     

Characteristics of deaths occurring in hospitalised children: changing trends

BACKGROUND: Despite a gradual shift in the focus of medical care among terminally ill patients to a palliative model, studies suggest that many children with life-limiting chronic illnesses continue to die in hospital after prolonged periods of inpatient admission and mechanical ventilation. OBJECTIVES: To (1) examine the characteristics and location of death among hospitalised children, (2) investigate yearwise trends in these characteristics and (3) test the hypothesis that professional ethical guidance from the UK Royal College of Paediatrics and Child Health (1997) would lead to significant changes in the characteristics of death among hospitalised children. METHODS: Routine administrative data from one large tertiary-level UK children's hospital was examined over a 7-year period (1997-2004) for children aged 0-18 years. Demographic details, location of deaths, source of admission (within hospital vs external), length of stay and final diagnoses (International Classification of Diseases-10 codes) were studied. Statistical significance was tested by the Kruskal-Wallis analysis of ranks and median test (non-parametric variables), chi(2) test (proportions) and Cochran-Armitage test (linear trends). RESULTS: Of the 1127 deaths occurring in hospital over the 7-year period, the majority (57.7%) were among infants. The main diagnoses at death included congenital malformations (22.2%), perinatal diseases (18.1%), cardiovascular disorders (14.9%) and neoplasms (12.4%). Most deaths occurred in an intensive care unit (ICU) environment (85.7%), with a significant increase over the years (80.1% in 1997 to 90.6% in 2004). There was a clear increase in the proportion of admissions from in-hospital among the ICU cohort (14.8% in 1998 to 24.8% in 2004). Infants with congenital malformations and perinatal conditions were more likely to die in an ICU (OR 2.42, 95% CI 1.65 to 3.55), and older children with malignancy outside the ICU (OR 6.5, 95% CI 4.4 to 9.6). Children stayed for a median of 13 days (interquartile range 4.0-23.25 days) on a hospital ward before being admitted to an ICU where they died. CONCLUSIONS: A greater proportion of hospitalised children are dying in an ICU environment. Our experience indicates that professional ethical guidance by itself may be inadequate in reversing the trends observed in this study.     

Morbidity and mortality during heatwaves in metropolitan Adelaide

OBJECTIVE: To investigate morbidity and mortality associated with heatwaves in metropolitan Adelaide using ambulance, hospital admission, and mortality data. DESIGN, PARTICIPANTS AND SETTING: Case-series study comparing health risks in the Adelaide metropolitan population during heatwaves and non-heatwave periods. MAIN OUTCOME MEASURES: Daily observations for ambulance transports (1993-2006), hospital admissions (1993-2006), and mortality (1993-2004), categorised using International classification of diseases (ninth and tenth revisions) codes for the relevant disease groups. RESULTS: During heatwaves, total ambulance transport increased by 4% (95% CI, 1%-7%), including significant assault-related increases for people aged 15-64 years. Reductions were observed in relation to cardiac, sports- and falls-related events. Total hospital admissions increased by 7% (95% CI, - 1% to 16%). Total mental health admissions increased by 7% (95% CI, 1%-13%), and total renal admissions by 13% (95% CI, 3%-25%). Ischaemic heart disease admissions increased by 8% (95% CI, 1%-15%) among people aged 65-74 years. Total mortality, disease- and age-specific mortality did not increase, apart from a small increase in mental health-related mortality in people aged 65-74 years. Significant decreases were observed in cardiovascular-related mortality. CONCLUSION: In contrast to evidence from extreme heatwaves in the northern hemisphere, we found no excess mortality during heatwaves in metropolitan Adelaide, perhaps because of adaptive behaviour to regular hot weather spells. Projected temperature increases and evidence of modest increases in morbidity during heatwaves indicate the need for a heatwave response plan for Adelaide.     

Using checklists and reminders in clinical pathways to improve hospital inpatient care

OBJECTIVES: To determine whether the quality of hospital inpatient care can be improved by using checklists and reminders in clinical pathways. DESIGN: Comparison of key indicators before and after the introduction of clinical pathways incorporating daily checklists and reminders of best practice integrated into patient medical records. SETTING AND PARTICIPANTS: The study, at Wimmera Base Hospital in Horsham, Victoria, included patients admitted between 1 January 1999 and 31 December 2002 with ST-elevation acute myocardial infarction (AMI) and patients admitted between 31 July 1999 and 31 December 2002 with stroke. MAIN OUTCOME MEASURES: Compliance with key process measures determined as best practice for each clinical pathway. RESULTS: 116 patients with AMI and 123 patients with stroke were included in the study. ST-elevation AMI. After introducing the clinical pathway program, percentage-point increases for treatment compliance were 21.4% (95% CI, 7.3%-32.7%) for patients receiving aspirin in the emergency department; 42.7% (95% CI, 26.3%-59.0%) for eligible patients receiving beta-blockers within 24 h of admission; 48.1% (95% CI, 31.4%-64.8%) for eligible patients being prescribed beta-blockers on discharge; 43.7% (95% CI, 28.4%-59.1%) for patients having fasting lipid levels measured; and 41.2% (95% CI, 19.0%-63.5%) for eligible patients having lipid therapy. Stroke. After introducing the clinical pathway program, percentage-point increases for treatment compliance were 40.7% (95% CI, 21.0%-60.2%) for dysphagia screening within 24 h of admission; 55.4% (95% CI, 32.9%-77.9%) for patients with ischaemic stroke receiving aspirin or clopidogrel within 24 h of admission; and 52.4% (95% CI, 33.8%-70.9%) for patients having regular neurological observations during the first 48 h after a stroke. There was a fall of 1.0 percentage point (ie, a difference of -1% [95% CI, -4.7% to 10.0%]) in the proportion of patients having a computed tomography brain scan within 24 h of admission. CONCLUSION: Significant improvements in the quality of patient care can be achieved by incorporating checklists and reminders into clinical pathways.     

Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction

CONTEXT: Rapid time to treatment with thrombolytic therapy is associated with lower mortality in patients with acute myocardial infarction (MI). However, data on time to primary angioplasty and its relationship to mortality are inconclusive. OBJECTIVE: To test the hypothesis that more rapid time to reperfusion results in lower mortality in the strategy of primary angioplasty. DESIGN: Prospective observational study of data collected from the Second National Registry of Myocardial Infarction between June 1994 and March 1998. SETTING: A total of 661 community and tertiary care hospitals in the United States. SUBJECTS: A cohort of 27,080 consecutive patients with acute MI associated with ST-segment elevation or left bundle-branch block who were treated with primary angioplasty. MAIN OUTCOME MEASURE: In-hospital mortality, compared by time from acute MI symptom onset to first balloon inflation and by time from hospital arrival to first balloon inflation (door-to-balloon time). RESULTS: Using a multivariate logistic regression model, the adjusted odds of in-hospital mortality did not increase significantly with increasing delay from MI symptom onset to first balloon inflation. However, for door-to-balloon time (median time 1 hour 56 minutes), the adjusted odds of mortality were significantly increased by 41% to 62% for patients with door-to-balloon times longer than 2 hours (for 121-150 minutes: odds ratio [OR], 1.41; 95% confidence interval [CI], 1.08-1.84; P=.01; for 151-180 minutes: OR, 1.62; 95% CI, 1.23-2.14; P<.001; and for >180 minutes: OR, 1.61; 95% CI, 1.25-2.08; P<.001). CONCLUSIONS: The relationship in our study between increased mortality and delay in door-to-balloon time longer than 2 hours (present in nearly 50% of this cohort) suggests that physicians and health care systems should work to minimize door-to-balloon times and that door-to-balloon time should be considered when choosing a reperfusion strategy. Door-to-balloon time also appears to be a valid quality-of-care indicator. JAMA. 2000.     

The effect on hospital admission profiles of establishing an emergency department observation ward

OBJECTIVE: To determine the effect of establishing an emergency department observation ward (OW) on admission numbers, average length of stay (ALOS) for the entire hospital and overall bed days for conditions commonly treated in the OW. SETTING: Sir Charles Gairdner Hospital (SCGH), Perth, a tertiary referral teaching hospital. DESIGN: Retrospective analysis of routinely collected hospital data for the 10 most common diagnosis-related group (DRG) categories of patients discharged from the OW for the financial years 1995-96 to 1998-99. Comparison of these data with those for adult patients at the other Perth teaching hospitals over the same period. MAIN OUTCOME MEASURES: For patients in the 10 most common DRGs: numbers of admissions to the OW compared with other inpatient wards; total number of patients admitted to the hospital compared with total bed days; ALOS at SCGH compared with other Perth teaching hospitals. RESULTS: Increased admissions to the OW were paralleled by a decrease in admissions for the same DRG codes to other inpatient wards. ALOS remained approximately the same from 1995-96 to 1998-99 for patients in the OW (one day) and other inpatient wards (4.38 to 4.20 days). However, overall ALOS for patients in these DRGs fell by over a third (from 3.97 to 2.59 days) over this time. The total number of patients in these DRGs treated by the hospital increased by 19% over the four years, but the total number of bed days fell by 23%. By contrast, the ALOS for patients in the same DRGs treated at the other Perth teaching hospitals rose 8% (from 2.12 to 2.28 days). CONCLUSION: Establishment of a formal emergency department OW results in the more efficient management of certain groups of patients, with a decrease in overall hospital bed days and length of stay.     

Delayed inpatient diagnosis and isolation of active pulmonary tuberculosis patients,a large tertiary care academic hospital experience in Riyadh,Saudi Arabia: What are we missing?

Objectives:To identify pulmonary tuberculosis (PTB) delayed inpatient diagnosis duration and contributing factors in an academic center in Saudi Arabia (SA).Methods:Retrospective review of all culture-confirmed PTB cases between May 2015 and April 2019. The outcomes were the timing between admission and suspicion of PTB or isolation to either early group (within 24 hours of admission) and late group (24 hours after admission).Results:Forty-nine cases were included with a median age of 49 years; a third of them were above 65 years of age. Most patients were of Saudi nationality and male. Approximately 38% of the cases were in the delayed group, half of them were smear-positive, with an average delay of 5.5 days. This was significant with age above 65 years (odds ratio [OR]=8.93, 95% confidence interval [CI]=2.22-35.95) presence of non-respiratory symptoms (OR=5.6, 95% CI=1.56-19.98), malignancy (OR=13.38, 95% CI=1.46-122.71), chronic medical problems (OR=4.90, 95% CI=1.31-18.32), missed chest x-ray findings (OR= 48, 95% CI=8.63-266.88) or procalcitonin level above 0.5 ng/mL (OR=12, 95% CI=1.58-91.08).Conclusion:Physicians in SA need to have a low threshold for PTB consideration in elderly patients or those with a history of malignancy. A careful review of the initial chest x-ray might help to overcome missing cases of PTB.     

Improving access to acute stroke therapies: a controlled trial of organised pre-hospital and emergency care

OBJECTIVE: To assess the effectiveness of the PAST (Pre-hospital Acute Stroke Triage) protocol in reducing pre-hospital and emergency department (ED) delays to patients receiving organised acute stroke care, thereby increasing access to thrombolytic therapy. DESIGN: Prospective cohort study using historical controls. SETTING: Hunter Region of New South Wales, September 2005 to March 2006 (pre-intervention) and September 2006 to March 2007 (post-intervention). PARTICIPANTS: Consecutive patients presenting with acute stroke to a regional, tertiary referral hospital. INTERVENTION: PAST protocol, comprising a pre-hospital stroke assessment tool for ambulance officers, an ambulance protocol for hospital bypass for potentially thrombolysis-eligible patients, and pre-hospital notification of the acute stroke team. MAIN OUTCOME MEASURES: Proportion of patients who received intravenous tissue plasminogen activator (tPA), process of care time points (symptom onset to ED arrival, ED arrival to tPA treatment, and ED transit time), and clinical outcomes of patients treated with tPA. RESULTS: The proportion of ischaemic stroke patients treated with tPA increased from 4.7% (pre-intervention) to 21.4% (post-intervention) (P < 0.001). Time point outcomes also improved, with a reduction in median times from symptom onset to ED arrival from 150 to 90.5 min (P = 0.004) and from ED arrival to stroke unit admission from 361 to 232.5 minutes (P < 0.001). Of those treated with tPA, 43% had minimal or no disability at 3 months. CONCLUSIONS: Organised pre-hospital and ED acute stroke care increases patient access to tPA treatment, which is proven to reduce stroke-related disability.     

Risk factors for ischaemic stroke recurrence after hospitalisation

OBJECTIVE: To determine risk factors for ischaemic stroke recurrence among patients admitted to hospital for a first-ever occurrence of ischaemic stroke. DESIGN, SETTING AND PATIENTS: Retrospective study involving linked hospitalisation and death records. The cohort comprised 7816 people who were hospitalised for first-ever ischaemic stroke between July 1995 and December 1999 in Western Australia. Cox's proportional hazards model was used to identify risk factors for stroke recurrence. MAIN OUTCOME MEASURES: Time to first recurrence; cumulative recurrence risk; risk factors for recurrence. RESULTS: The median time to first stroke recurrence was 255 days. The cumulative probability of first recurrence was 5.1% (95% CI, 4.6%-5.7%) at 6 months, 8.4% (95% CI, 7.6%-9.1%) at 1 year and 19.8% (95% CI, 18.1%-21.4%) at 4 years. The risk of first recurrence was increased by advancing age (hazard ratio [HR], 1.03; 95% CI, 1.02-1.04), Aboriginality (HR, 1.50; 95% CI, 1.02-2.22), diabetes (HR, 1.27; 95% CI, 1.07-1.51), a history of cardiac conditions (HR, 1.18; 95% CI, 1.01-1.38), post-stroke urinary incontinence (HR, 1.27; 95% CI, 1.03-1.57) and transfer to another hospital on index admission (HR, 1.26; 95% CI, 1.08-1.46). Admission at first stroke occurrence to a hospital maintaining a stroke unit reduced the risk of recurrence (HR, 0.84; 95% CI, 0.72-0.99). CONCLUSION: The risk factors identified in our study have implications for planning secondary prevention strategies. In particular, Aboriginality and transfer to another hospital upon admission for first-ever ischaemic stroke were important risk factors. Research into the level of compliance and access to stroke treatment by Aboriginal patients to prevent further strokes is required.     

分流早期预警评分在急诊创伤患者中的应用价值(英文)

目的：评估分流早期预警评分(triage early warning score，TEWS)在急诊创伤患者中预后及急诊科应急处置 预测的准确性。方法：在一所教育和研究型三甲医院进行为期约4个月的前瞻性研究，符合纳入标准的创伤患者均进 行TEWS，观测结局指标为28 d病死率、急诊科应急处置方式(使用心肺复苏术/电除颤和机械通气)。结果：纳入研究 的对象TEWS≤9分，10~13分，≥14分的病死率分别为0.98%，52.63%和80%，TEWS每增加1分，则死亡相对危险度为 2.14 (95% CI: 1.759~2.604)。TEWS预测患者28 d病死率时，最佳截断值>8分，敏感度为87.10% (95% CI：0.2%~96.4%)， 特异度为92.47% (95% CI：89.5%~94.8%)，ROC曲线下面积为 0.929 (95% CI：0.902~0.951)；对急诊科预测的患者使用心 肺复苏术/电除颤应急处置时，ROC曲线下面积为0.969 (95% CI：0.949~0.983)；对急诊科预测的患者使用机械通气应 急处置时，ROC曲线下面积为0.897(95% CI：0.865~0.923)。结论：TEWS能有效地预测急诊科创伤患者的预后及急诊 科内应急处置方式的使用。