Adverse effects of nosocomial infection

The effects of noscomial infection on duration of hospital stay and outcome of hospitalization were measured by matching two control patients to each of 85 patients found to have qctive nosocomial infection during a prevalence survey at Boston City Hospital in 1973. The control patients were selected from all patients discharged from this hospital during the same time period; they were matched by exact primary discharge diagnosis, similar operative procedure, and age. Patients with a single infection remained in hospital on average 13.0 days longer than their matched controls, and those with two such infections stayed on average 35.4 days longer. This effect of extra stay associated with nosocomial infection was consistent when data were stratified by primary discharge diagnosis, hospital service, site of infection, or outcome of hospitalization. The outcome of hospitalization for these infected patients was slightly, but not significantly, worse than for their matched controls.     

An evaluation of an alternative to long-stay hospital care for frail elderly patients: II. Costs and effectiveness.

This paper provides the main findings of an evaluation of a service to provide alternative care at home for patients receiving long-stay hospital care. Elderly people receiving the service were compared with a group of similar patients in an adjacent health district. The paper presents data on length of time at home and in hospital, changes in quality of life and care of elderly people, and effects upon informal carers for the two groups. Elderly people receiving community-based care had a higher quality of life, and there was no evidence of greater stress upon their carers. The community-based service, although it involved extra costs to the social services department, had lower costs for the health service and society as a whole than long-stay hospital provision. It is concluded that the model of care can effectively integrate the new approach of case management into an existing geriatric multidisciplinary team.     

Stroke rehabilitation after hospital discharge: a randomized trial comparing domiciliary and day-hospital care

OBJECTIVES: To compare the effectiveness and costs of a new domiciliary rehabilitation service for elderly stroke patients with geriatric day-hospital care. DESIGN: Randomized controlled trial. PARTICIPANTS: Stroke patients aged 55+ who required further rehabilitation after hospital discharge or after referral to geriatricians from the community. SETTING: Poole area, East Dorset, a mixed urban/rural area on the south coast of England. MAIN OUTCOMES: Primary-changes between hospital discharge and 6-month follow-up in physical function as measured by Barthel index. Secondary-changes over this period in Rivermead Mobility Index and mental state (Philadelphia Geriatric Centre Morale Scale) and differences in social activity (Frenchay Activities Index) and generic health status (SF-36). Health service and social service cost per patient were compared for the two groups. RESULTS: 180 patients were eligible and 140 (78%) were randomized. The groups were well balanced for age, sex, social class and initial Barthel index. We achieved follow-up in 88% of subjects who were alive at 6 months. We detected no significant differences in patient outcomes, although there was a non-significant improvement in measures of physical function and social activity in the domiciliary group. Domiciliary patients had more physiotherapy time per session and more district nurse time, and made greater use of social service day centres and home helps. Total cost per patient did not differ significantly between the two groups, with reduced health service costs in the domiciliary arm offset by higher social service costs. CONCLUSION: No significant differences were detected in the effectiveness of the two services. Neither service influenced patients' mental state, and their social activity remained low. Total costs were similar. A mixed model of day-hospital and domiciliary care may be most cost-effective for community stroke rehabilitation, but this requires further evaluation.     

Prospective study of early discharge after acute myocardial infarction (SHORT)

AIMS: To identify, without additional investigation, a large group of myocardial infarction patients at low risk who would qualify for early discharge. METHODS: The decision rule was developed in 647 unselected patients with consecutively admitted myocardial infarction, and validated in 825 others. Daily event-rates were calculated for major (death, ventricular fibrillation, recurrent infarction, heart failure, advanced AV-block) and minor (unstable angina and rhythm-abnormalities) cardiac complications. RESULTS: Patients free from major complications until day 7 (44% of all patients) were found to constitute a very low risk group and thus would qualify for discharge at day 7. Of the 39% of patients with an uncomplicated infarction (low risk) in the validation group, 31% were discharged at day 7, while 8% stayed longer because of non-cardiac co-morbidity, for social reasons or logistic problems. No major adverse event occurred within 7 days after hospital discharge and only 1.8% developed complications within 1 month. The median duration of hospital stay for all in-hospital survivors was 7 days compared to 10 days in the control group. CONCLUSION: Prospective application of the early discharge decision rule, based upon simple clinical variables and without the need for additional non-invasive and/or invasive tests, resulted in a significant reduction of hospital stay. The decision rule correctly classified patients into high and low risk groups and appeared feasible and safe. Its efficacy was demonstrated by its ability to identify a large group of post infarction survivors at low risk for complications during follow-up.     

Sooner and healthier: a randomised controlled trial and interview study of an early discharge rehabilitation service for older people

BACKGROUND: Hospitals are under pressure from admissions of increasing numbers of older people. Older people may suffer unnecessary activity limitation after acute illnesses through lack of appropriate rehabilitation. OBJECTIVE: To evaluate an early discharge and rehabilitation service for older people. DESIGN: A randomised controlled trial comparing an early discharge and rehabilitation with standard hospital aftercare. Outcome measures assessed at 3 and 12 months were the Barthel Index, Nottingham Extended Activities of Daily Living and EuroQol (for patients) the General Health Questionnaire (for patients and carers). Use of services over 12 months was recorded. An interview study of patients and staff was conducted. SETTING AND INTERVENTION: The early discharge and rehabilitation service offered a home-based rehabilitation and care programme for up to 4 weeks. PARTICIPANTS: 370 hospitalised older medical and surgical patients were included in the randomised controlled trial. Twenty patients and 11 staff were interviewed. RESULTS: Subjects in the early discharge rehabilitation service group used fewer days in hospital at 3 months (mean difference 9, median difference 4 days, 95% CI of median difference 2-8). At 3 months the early discharge and rehabilitation service patients had better Barthel scores (mean difference 1.2, 95% CI 0.4-1.9), Nottingham Extended Activities of Daily Living kitchen scores (mean difference 1.2, 95% CI 0.2-2.3), Nottingham Extended Activities of Daily Living domestic scores (mean difference 1.1, 95% CI 0.2-2.0) and General Health Questionnaire scores (mean difference 2.4, 95% CI 0.7-4.1). Significant Nottingham Extended Activities of Daily Living domestic and General Health Questionnaire benefits remained at 12 months. The early discharge and rehabilitation service carers had better General Health Questionnaire scores at 3 months (mean difference 2.0, 95% CI 0.1-3.8). The interviews suggested that the early discharge and rehabilitation service was patient-centred, set clear goals, worked as a team, and considered physical, psychological, social and environmental issues. It was found to be highly satisfactory. CONCLUSIONS: Some older people can be discharged from hospital sooner, with better health outcomes using a well-staffed and organised patient-centred early discharge service providing rehabilitation.     

Role of pharmacist counseling in preventing adverse drug events after hospitalization

BACKGROUND: Hospitalization and subsequent discharge home often involve discontinuity of care, multiple changes in medication regimens, and inadequate patient education, which can lead to adverse drug events (ADEs) and avoidable health care utilization. Our objectives were to identify drug-related problems during and after hospitalization and to determine the effect of patient counseling and follow-up by pharmacists on preventable ADEs. METHODS: We conducted a randomized trial of 178 patients being discharged home from the general medicine service at a large teaching hospital. Patients in the intervention group received pharmacist counseling at discharge and a follow-up telephone call 3 to 5 days later. Interventions focused on clarifying medication regimens; reviewing indications, directions, and potential side effects of medications; screening for barriers to adherence and early side effects; and providing patient counseling and/or physician feedback when appropriate. The primary outcome was rate of preventable ADEs. RESULTS: Pharmacists observed the following drug-related problems in the intervention group: unexplained discrepancies between patients' preadmission medication regimens and discharge medication orders in 49% of patients, unexplained discrepancies between discharge medication lists and postdischarge regimens in 29% of patients, and medication nonadherence in 23%. Comparing trial outcomes 30 days after discharge, preventable ADEs were detected in 11% of patients in the control group and 1% of patients in the intervention group (P = .01). No differences were found between groups in total ADEs or total health care utilization. CONCLUSIONS: Pharmacist medication review, patient counseling, and telephone follow-up were associated with a lower rate of preventable ADEs 30 days after hospital discharge. Medication discrepancies before and after discharge were common targets of intervention.     

Anticipating care needs of patients after discharge from hospital: Frail and elderly patients without physiological abnormality on day of admission are more likely to require social services input

IntroductionAcute admissions to hospital are rising. As a part of a service evaluation we examined pathways of patients following hospital discharge depending on data available on admission to hospital.MethodsWe merged data available on admission to the Wrexham Maelor hospital from an existing data-base in the Acute Medical Unit with follow up data from local social services as part of a data sharing agreement. Patients requiring support by social services post-discharge were matched with patients not requiring social services from the same post-code.ResultsStepwise logistic regression analysis identified candidate variables predicting likely support need. Decision tree analysis identified sub-groups of patients with higher likelihood to require support by social services after discharge from hospital. We found patients with normal physiology on admission as evidenced by a value of zero for the National Early Warning Score who were frail or older than 85 years were most likely to require support after discharge.ConclusionsInformation available on admission to hospital might inform long term care needs. Prospective testing is needed. The algorithms are prone to be dependent on availability of local services but our methodology is expected to be transferable to other organizations.     

Continuity of care: when do patients visit community healthcare providers after leaving hospital?

Background/Aims: Enhanced communication and transfer of information between healthcare providers and healthcare settings can reduce medication and healthcare errors post‐hospital discharge. The timeframes within which patients access community healthcare providers post‐hospital discharge are not well studied. This study aimed to determine length of time from hospital discharge until a general practice, pharmacy or specialist visit, or care planning service. Methods: We conducted a retrospective analysis of Department of Veterans' Affairs health claims data. All 109 860 veterans hospitalized in 2006 were included. Main outcome measures were time from first hospital discharge to first claim for a general practice, pharmacy, specialist visit and/or care planning service. Results: Within 30 days of hospital discharge 71% of subjects visited a general practitioner (GP), 86% had medicines dispensed from a community pharmacy and 44% saw a specialist. Median time to first pharmacy visit was 6 days (interquartile range 2–14) and 12 days for a GP visit (interquartile range 4–31). Less than 2% of the cohort received a discharge plan, case conference or medication review in the month after discharge. Conclusions: With 25% of patients having a claim for a GP service within 4 days of discharge, discharge summaries need to reach community‐based health professionals within this time. Most patients visited their community pharmacy within 2 weeks of hospital discharge and before they saw their GP. Pharmacists are not routinely advised of hospitalization or provided with discharge summaries. More active engagement of this professional group in the continuum of care might improve care after hospital discharge.     

The impact of family interactions on recovery from stroke: help or hindrance?

The family networks of 47 geriatric stroke patients were examined for social supports and social problems as they related to well-being after hospital discharge. Structured interviews assessed positive and negative family interactions and patients' independence in activities of daily living (ADL), time use, personal adjustment, and cognitive functioning. After controlling for patients' medical status at hospital discharge, social supports were not associated with any of the outcomes examined. Social problems explained additional variance in personal adjustment and ADL independence.     

The impact of social factors on the content of care. Treatment of ischemic heart disease at a public and a voluntary hospital.

To assess the impact of social factors on the content of care, panels of patients with ischemic heart disease at a public and its affiliated voluntary hospital were followed up through their acute hospitalizations and 3 months after discharge. Data were collected from firsthand observation of rounds, chart review, and a 3-month patient follow-up survey. Among patients for whom cardiac catheterization was indicated, 100% from the voluntary hospital underwent this procedure compared with 41% from the public institution. For patients for whom exercise stress testing was indicated, 90% from the voluntary hospital compared with 50% from the public institution underwent the procedure. Factors observed to contribute to these patterns emanated from the hospital setting as well as from the patients' social environment, including difficulties in arranging transfers for procedures, obstacles to coordinating inpatient and ambulatory care, and patient problems in keeping outpatient appointments.     

Economic analysis of an early discharge rehabilitation service for older people

OBJECTIVE: to measure the cost-effectiveness of an early discharge and rehabilitation service (EDRS) in Nottingham, UK. DESIGN: data were collected during a randomised controlled trial. METHODS: cost and cost-effectiveness analyses were conducted from the perspective of service providers (health and social services) over a period of 12 months. Resource variables included were the EDRS intervention, the initial acute hospital admission (from randomisation), readmission to hospital, hospital outpatient visits, stays in nursing and residential homes, general practitioner contact, community health services and social services. The effectiveness measure was the EuroQol EQ-5D score, from which quality-adjusted life years (QALY) were calculated. Cost-effectiveness was calculated as cost per QALY gained. RESULTS: at 12 months the mean untransformed total cost for the EDRS was 8,361 pound sterling compared to 10,088 pound sterling for usual care, a saving of 1,727 pound sterling (P = 0.05). Cost-effectiveness acceptability curves showed a high probability that the EDRS was cost effective across a range of monetary values for a QALY. CONCLUSIONS: the Nottingham EDRS was likely to be more cost effective than usual care.     

直肠癌术后患者出院准备度现状及影响因素分析

目的探讨直肠癌术后患者出院准备度现状及其影响因素。 方法采用一般资料调查表、出院准备度量表（RHDS）对2018年10月至2019年10月在中国医学科学院肿瘤医院结直肠外科的175例直肠癌术后患者进行调查研究。 结果直肠癌患者出院准备度评总分为（142.14±33.54）分。多因素分析显示,年龄、是否独居、自理状态、是否做好出院准备为影响直肠癌术后患者出院准备度影响的独立危险因素。 结论直肠癌术后患者出院准备度现状处于中等水平,应根据个体化差异给予延续护理建议,有效利用社会卫生服务资源,以提高出院准备水平。     

Tying up loose ends: discharging patients with unresolved medical issues

BACKGROUND: Patients are increasingly being discharged from the hospital with unresolved medical problems requiring outpatient follow-up. This study evaluates the frequency with which hospital physicians recommend outpatient workups to address patients' unresolved medical problems and the impact that availability of discharge summaries has on workup completion. METHODS: We conducted a retrospective cohort study of patients discharged from the medicine or geriatrics service of a large teaching hospital between June 1, 2002, and December 31, 2003. Each subject's inpatient medical record was reviewed to determine if the hospital physician recommended an outpatient workup. Subjects' outpatient medical records were then reviewed to determine if the workups were completed. RESULTS: Of 693 hospital discharges, 191 discharged patients (27.6%) had 240 outpatient workups recommended by their hospital physicians. The types of workups were diagnostic procedures (47.9%), subspecialty referrals (35.4%), and laboratory tests (16.7%). The most common diagnostic procedures were computed tomographic scans to follow up abnormalities seen on previous radiographic studies and endoscopic procedures to follow up gastrointestinal tract bleeding. Of recommended workups, 35.9% were not completed. Increasing time to the initial postdischarge primary care physician visit decreased the likelihood that a recommended workup was completed (odds ratio, 0.77; P=.002), and availability of a discharge summary documenting the recommended workup increased the likelihood of workup completion (odds ratio, 2.35; P=.007). CONCLUSIONS: Noncompletion of recommended outpatient workups after hospital discharge is common. Primary care physicians' access to discharge summaries documenting the recommended workup is associated with better completion of recommendations. Future research should focus on interventions to improve the quality and dissemination of discharge information to primary care physicians.     

Risk factors for social isolation in post-hospitalized older adults

IntroductionSocial isolation in older adults is associated with high rates of adverse health outcomes. Older adults who have had a recent significant health event are likely to be at risk of social isolation following hospitalization. This study aims to identify risk factors amongst older adults at hospital discharge that are associated with social isolation at three months post-hospitalization.MethodsOlder adults were surveyed at hospital discharge and three months post-hospitalization. Baseline data including demographics, self-reported quality of life, physical activity and capacity levels, lifestyle factors, symptoms of depression and anxiety were collected at discharge. Social isolation was measured using the Friendship Scale at the three-month follow-up. Regression analyses were used to examine the relationship between baseline characteristics and social isolation at three months post-hospitalization.ResultsOlder adults (n = 311) participated in the baseline survey, of whom 241 (78 %) completed the three-month survey. Higher depressive and anxiety symptoms at hospital discharge, comorbidity of cancer, history of cigarette smoking, prior access to community and respite service, and arrangement for shopping assistance post-discharge were factors independently associated with an increased risk of social isolation at three months post-hospitalization.DiscussionThis study identified risk factors for social isolation that are unique to older post-hospitalized adults. These findings can help clinicians identify individuals at risk of social isolation and to target interventions that address these risk factors for the prevention of social isolation in older adults after hospitalization.     

Fewer Emergency Readmissions and Better Quality of Life for Older Adults at Risk of Hospital Readmission: A Randomized Controlled Trial to Determine the Effectiveness of a 24-Week Exercise and Telephone Follow-Up Program

OBJECTIVES: To evaluate the effect of an exercise‐based model of hospital and in‐home follow‐up care for older people at risk of hospital readmission on emergency health service utilization and quality of life. DESIGN: Randomized controlled trial. SETTING: Tertiary metropolitan hospital in Australia. PARTICIPANTS: One hundred twenty‐eight patients (64 intervention, 64 control) with an acute medical admission, aged 65 and older and with at least one risk factor for readmission (multiple comorbidities, impaired functionality, aged ≥75, recent multiple admissions, poor social support, history of depression). INTERVENTION: Comprehensive nursing and physiotherapy assessment and individualized program of exercise strategies and nurse‐conducted home visit and telephone follow‐up commencing in the hospital and continuing for 24 weeks after discharge. MEASUREMENTS: Emergency health service utilization (emergency hospital readmissions and visits to emergency department, general practitioner (GP), or allied health professional) and health‐related quality of life (Medical Outcomes Study 12‐item Short Form Survey (SF‐12v2^?) collected at baseline and 4, 12, and 24 weeks after discharge. RESULTS: The intervention group required significantly fewer emergency hospital readmissions (22% of intervention group, 47% of control group, P=.007) and emergency GP visits (25% of intervention group, 67% of control group, P<.001). The intervention group also reported significantly greater improvements in quality of life than the control group as measured using SF‐12v2^? Physical Component Summary scores (F (3, 279)=30.43, P<.001) and Mental Component Summary scores (F (3, 279)=7.20, P<.001). CONCLUSION: Early introduction of an individualized exercise program and long‐term telephone follow‐up may reduce emergency health service utilization and improve quality of life of older adults at risk of hospital readmission.     

Randomized study of early hospital discharge following autologous blood SCT: medical outcomes and hospital costs

We report the first randomized study comparing early hospital discharge with standard hospital-based follow-up after high-dose chemotherapy (HDCT) and PBSCT. Patients aged 18-65 years, with an indication of PBSCT for non-leukemic malignant diseases were randomly assigned between two arms. Arm A consisted of early hospital discharge (HDCT during hospitalization, discharge at day 0, home stay with a caregiver, outpatient clinic follow-up). In arm B patients were followed up as inpatients. In total 131 patients were analyzed (66 in arm A and 65 in arm B). Patient characteristics and hematological reconstitution were comparable between the two groups. In arm A, 26 patients were actually discharged early. Patients in group A spent fewer days in hospital (11 vs 12 days, P=0.006). This strategy resulted in a 6% mean cost reduction per patient when compared with the conventional hospital-based group. The early discharge approach within the French health system, while safe and feasible, is highly dependent on social criteria (caregiver availability and home to hospital distance). It is almost always associated with conventional hospital readmission during the aplasia phase, and limits cost savings when considering the whole population of patients benefiting from HDCT in routine clinical practice.     

A pharmacy discharge plan for hospitalized elderly patients--a randomized controlled trial

OBJECTIVES: to investigate the effectiveness of a pharmacy discharge plan in elderly hospitalized patients. DESIGN: randomized controlled trial. SUBJECTS AND SETTINGS: we randomized patients aged 75 years and older on four or more medicines who had been discharged from three acute general and one long-stay hospital to a pharmacy intervention or usual care. INTERVENTIONS: the hospital pharmacist developed discharge plans which gave details of medication and support required by the patient. A copy was given to the patient and to all relevant professionals and carers. This was followed by a domiciliary assessment by a community pharmacist. In the control group, patients were discharged from hospital following standard procedures that included a discharge letter to the general practitioner listing current medications. OUTCOMES: the primary outcome was re-admission to hospital within 6 months. Secondary outcomes included the number of deaths, attendance at hospital outpatient clinics and general practice and proportion of days in hospital over the follow-up period, together with patients' general well-being, satisfaction with the service and knowledge of and adherence to prescribed medication. RESULTS: we recruited 362 patients, of whom 181 were randomized to each group. We collected hospital and general practice data on at least 91 and 72% of patients respectively at each follow-up point and interviewed between 43 and 90% of the study subjects. There were no significant differences between the groups in the proportion of patients re-admitted to hospital between baseline and 3 months or 3 and 6 months. There were no significant differences in any of the secondary outcomes. CONCLUSIONS: we found no evidence to suggest that the co-ordinated hospital and community pharmacy care discharge plans in elderly patients in this study influence outcomes.     

Frequent attenders to an emergency department: a study of primary health care use,medical profile,and psychosocial characteristics

STUDY OBJECTIVE: We describe, in comparison with a control group, frequent attenders to an emergency department in terms of their general health service use and their clinical, psychological, and social profiles. METHODS: One hundred frequent attenders (those who had made > or =4 visits in the previous year) and 100 nonfrequent attenders matched for sex, age, and triage category were interviewed in the ED. Data were gathered on health service use, mental health (by using the General Health Questionnaire-12 item), and perceived social support (by using the Multidimensional Scale of Perceived Social Support). Patients' general practitioners were contacted to validate attendance data. Medical charts were searched for evidence of psychological problems and alcohol or drug abuse. RESULTS: In the overall sample of 200 patients, 32% were female, and the mean age was 55 years (SD 20). Frequent attenders had made more visits to their general practitioner in the past year compared with control patients (median 12 versus 3 visits); a higher proportion of frequent attenders had used public health nursing services, community welfare services, social work services, addiction counseling, and psychiatric services in the past year. Frequent attenders had made more other hospital visits and had spent more nights in the hospital than control patients. General Health Questionnaire-12 item scores were higher for frequent attenders than control patients, indicating poorer mental health. Frequent attenders had lower levels of perceived social support. CONCLUSION: Frequent attenders to the ED are also heavy users of general practice services, other primary care services, and other hospital services. General Medical Services-eligible patients (84% of frequent attenders) frequently attend the ED, even though they have free access to primary care. Frequent attenders are a psychosocially vulnerable group, and service providers and policy makers need to take account of this vulnerable patient profile as they endeavor to meet their service needs.     

Causative factors for prolonged hospitalization beyond the point of engraftment in patients after autologous peripheral blood stem cell transplantation

In order to assess the incidence and analyze reasons which cause prolongation of hospital stay in patients engrafted after peripheral blood stem cell transplantation (PBSCT), we performed this retrospective analysis. One hundred patients (receiving 123 conditioning regimens) were included in the analysis. Criteria for discharge were presence of myeloid engraftment and absence of severe concomitant problems. Ninety subjects (73%) were discharged just after engraftment was reached on day +12 (10-14). Discharge was delayed in 33 patients (27%) and the mean prolongation was 3 days (1-11). In 31 patients (25%) delayed discharge was due to complications: in 14 patients (11.4%) because of GIT problems, in 16 patients (13%) because of infectious complications and in one patient because of cardiotoxicity. A significantly higher number of infectious complications was found in patients conditioned with BEAM (19.7% vs 4.2%, P < 0.05) while GIT toxicity was the most common reason for discharge delays in patients conditioned with melfalan 200 mg/m2 (8.2% vs 14.7%, NS). No risk factors of hospital stay prolongation were determined. We conclude that in spite of rapid engraftment, non-hematological toxicities and infections remain important limitations for further reduction of the length of patient hospitalization in a significant number of patients after PBSCT.     

Analysis of the problem of "difficult hospital discharges" in the University Hospital of Parma

We analyzed, in a middle-sized hospital, the problems related to the so-called "difficult discharges", conceived as situations involving an economic, human and organizational burden exceeding patients' and their families' capacities and requiring a specific involvement of territorial services. During a whole year (July 1, 2001-June 30, 2002) the cases found were 591. We demonstrated that the problem concerns mainly elderly patients, almost equally distributed between males and females, a quarter of the sample being represented by patients who had recently undergone surgery and whose discharge difficulties were mostly related to mixed social and sanitary problems. This kind of patients is faced with long-term hospitalization implicating a large number of intra-hospital transfers due to the presence of severe and disabling pathologies, mainly neoplasms and strokes, often associated with other serious diseases, various complications and difficult situations from the health point of view. About half of the patients had the possibility to go back home, while the rest required lodging in territorial structures such as nursing homes and retirement homes. The average time-lapse between the possible discharge indicated by the hospital physician and the actual discharge was 10 days, with global annual 6106 days of "improper" hospitalization. Our conclusion is that the phenomenon of difficult discharges is nowadays a very topical problem and that it should be faced with a new model of continuous and integrated assistance organization.