The characteristics and prognostic predictors of unplanned hospital admission within 72 hours after ED discharge

ObjectivesThe aims of this study were (1) to identify the characteristics of patients who return to the emergency department (ED) within 72 hours and are admitted to the hospital and (2) to identify the characteristics and predictors of in-hospital mortality subgroup.MethodsThis study was conducted in a tertiary teaching hospital to identify characteristics of adult nontraumatic revisit-admission patients from January 1 to December 31, 2011. Demographic data, cause of revisit, and the underlying diseases as well as the in-hospital complications were reviewed.ResultsOf the 72 188 ED discharged patients, 690 revisit-admission patients were enrolled. The top 3 disease classifications were infection (38.7%), neurology (11.3%), and gastroenterology (11.2%). The etiology of the revisit included recurrent symptoms (72%), disease complications (15.8%), and inadequate diagnosis (12.1%). A total of 150 patients (21.7%) had complications, including receiving operation (17.2%), intensive care unit admission (4.2%), and cardiovascular conditions (2.5%). Forty-nine patients (7.1%) died during hospitalization owing to sepsis (57.1%), malignancy (34.7%), cardiogenic diseases (4.1%), and cerebrovascular conditions (4.1%). The nonsurvival group was older (64.1 ± 15.3 vs 55.7 ± 17.8; P < .001), had more patients with a diagnosis of moderate to severe liver disease (18.4% vs 4.8%; P < .001), malignancy (69.3% vs 20.1%; P < .001), and metastatic solid tumor (38.8% vs 6.2%; P < .001).ConclusionsAge and diagnosis with malignancy, metastatic tumors, or moderate-to-severe liver disease were predictors of in-hospital mortality among 72-hour revisit-admission patients.     

Patterns and factors associated with intensive use of ED services: implications for allocating resources

Aim

This study aims to better understand the patterns and factors associated with the use of emergency department (ED) services on high-volume and intensive (defined by high volume and high-patient severity) days to improve resource allocation and reduce ED overcrowding.

Methods

This study created a new index of “intensive use” based on the volume and severity of illness and a 3-part categorization (normal volume, high volume, intensive use) to measure stress in the ED environment. This retrospective, cross-sectional study collected data from hospital clinical and financial records of all patients seen in 2001 at an urban academic hospital ED.

Results

Multiple logistic regression models identified factors associated with high volume and intensive use. Factors associated with intensive days included being in a motor vehicle crash; having a gun or stab wound; arriving during the months of January, April, May, or August; and arriving during the days of Monday, Tuesday, or Wednesday. Factors associated with high-volume days included falling from 0 to 10 ft; being in a motor vehicle crash; arriving during the months of January, April, May, or August; and arriving during the days of Monday, Tuesday, or Wednesday.

Conclusion

These findings offer inputs for reallocating resources and altering staffing models to more efficiently provide high-quality ED services and prevent overcrowding.     

Frequent attenders in general practice: quality of life, patient satisfaction, use of medical services and GP characteristics.

OBJECTIVE: To determine the predictors of frequent attendance in general practice. DESIGN: A postal survey using a questionnaire including instruments for measuring patient satisfaction (EUROPEP), quality of life (EUROQOL), anxiety and depression (DUKE-AD). SETTING: Primary health care in Slovenia. PATIENTS: A representative sample of 2160 adult patients. MAIN OUTCOME MEASURES: Number of contacts with the health care services, levels of self-care, patient satisfaction scores, quality of life scores, well-being scores, presence of chronic condition. RESULTS: Frequent attenders were more likely to have lower educational status, were more satisfied with their GP, had higher scores of anxiety and depression, and lower perceived quality of life. They were more likely to have a chronic disease. Frequent attenders were less likely to try self-care and more likely to use health services. They were more likely to visit more experienced GPs, GPs working a greater distance from other GPs and GPs who did not use the appointment system. The multivariable modelling explained 19.7% of the variation; 16.9% was attributed to patient characteristics and 3.1% to GP characteristics. CONCLUSIONS: The study confirmed that lower education levels, chronicity and higher use of other health services are predictors of higher attendance.     

Symptoms in 400 patients referred to palliative care services: prevalence and patterns

The demographics and prevalence of symptoms in patients at first referral to the different components of palliative care services were identified by a retrospective case note study of 400 patients referred to three palliative care centres in London, UK: Michael Sobell House, Mount Vernon Hospital; The North London Hospice; St Bartholomew's and the Royal London Hospitals. One hundred consecutive referrals to each of the following service components were analysed: a hospice inpatient service; a community team; an NHS hospital support team and an outpatient service. A standardized proforma was used to collect the data. Ninety five per cent (380/400) of patients referred had a cancer diagnosis. The five most prevalent symptoms overall were pain (64%), anorexia (34%), constipation (32%), weakness (32%) and dyspnoea (31%), which is similar to other published reports. However, the commonest symptoms and their prevalence varied depending on the service component to which the patient was referred. Patients referred to hospice and community services had the highest symptom burden (mean number of symptoms per patient 7.21 and 7.13, respectively). This study suggests that different patient subgroups may have different needs in terms of symptoms, which will be relevant for the planning and rationalization of palliative care services.     

Bioterrorism preparedness. II: The community and emergency medical services systems

Disaster planning is an arduous task. Perhaps no form of disaster is more difficult to prepare for than one resulting from the intentional, covert release of a biological pathogen or toxin. The complexities of response operations and the perils of inadequate preparation cannot be overemphasized. Even with detailed planning, deviations from anticipated emergency operations plans are likely to occur. Several federal programs have been initiated to assist communities in enhancing their preparedness for events involving biological and other agents of mass destruction. Many of these, such as the Metropolitan Medical Response Systems (MMRS) Program [37,38], will be discussed elsewhere. Community preparedness will be enhanced by: 1. Implementing a real-time public health disease surveillance program linking local healthcare, emergency care, EMS, the CDC, local law enforcement, and the FBI 2. Improved real-time regional patient and healthcare capacity status management 3. Development of affordable, accurate biological agent detection systems 4. Incorporation of standardized education and training curricula (appropriate for audience) on terrorism and biological agents into healthcare training programs 5. Expansion of federal and state programs to assist communities in system development 6. Increased public awareness and education programs.     

Economic and noneconomic barriers to the use of needed medical services.

This paper introduces an index of access to medical care that describes the use of services relative to the actual need for care. Findings on this particular measure suggest that, contrary to the implications of much of the existing literature, the poor continue to use fewer services-relative to the disability they experience-than do the nonpoor. Further, despite the advent of publicly financed economic solutions to these access differentials-Medicaid and Medicare, in particular-organizational barriers to entry, such as the long queues to obtain service and long travel times to care in some areas, still exist. The implications of these findings for the evaluation of existing and proposed national health policy efforts are discussed.     

Frequent attenders in general practice: quality of life,patient satisfaction,use of medical services and GP characteristics

Objectives - To describe where patients in Danish general practice get information about health and disease, particularly how patients prepare for a visit to their GP, with special reference to use of the Internet. Design - Structured interviews. Setting - Four Danish general practices. Patients - 93 consecutive patients after visiting their GP. Main outcome measures - The patient's report about use of the Internet and different mass media in preparation for the consultation. Results - Only two patients never looked for health information. Of all patients, 20% had used the Internet to get health information, 8% because of the current visit, i.e. a third of all with Internet access had used it because of the current visit. Women used the sources of information more than men did. Personal contact with family, friends or neighbours was the most commonly used source. Conclusion - The Internet is used in direct preparation for a visit to the general practitioner. The vast majority of patients use the mass media for information. In general practice, the main source of information on a health-related subject is personal contact with family and friends.     

Psychosocial outcome and use of medical resources in patients with chest pain and normal or near-normal coronary arteries: a long-term follow-up study

Forty-six patients who were investigated in 1979–80 forchest pain, and found to have normal or insignificantly narrowedcoronary arteries on coronary angiography, were followed upafter a mean interval of 11.4 years. Patients were interviewedand given standardized questionnaires covering chest pain andother physical symptoms, psychiatric morbidity, and functionalcapacity. Medical records for the follow-up period were reviewed,as were death certificates and postmortem reports, where appropriate. All patients (100%) were traced to death or their current address.Four had died (11.4 year survival rate 91%), one from ischaemicheart disease. Continuing chest pain was reported by 74%, andin 16 patients (38%), chest pain was either frequent, severeor both. A poor outcome for chest pain was associated with otherphysical symptoms and increased psychiatric morbidity, whichfor the entire cohort was higher than at 1 year after angiography.Twenty-six patients (58%) had received further hospital treatmentfor chest pain, including, in six patients, further coronaryangiography. Twenty-nine survivors (71%) were taking cardiacmedication, 12 (29%) were unable to work for medical reasons,and levels of functional disability were similar to those foundin patients with myocardial infarction or angina. This study confirms the findings of previous studies with shorterfollow-up intervals. Mortality was low, but high levels of chestpain, psychological distress, and functional incapacity persistedlong after angiography. Patients reported many physical symptomsother than chest pain, and had made heavy use of medical resources.For many patients, reassurance after angiography had been ineffective,and the prognosis was poor. Early identification and effectivemanagement of such patients could offer the NHS substantialsavings.     

Comparison of the patient populations referred to the accident and emergency department outside working hours by general practitioners and by their deputizing services.

A comparison was made of the characteristics of patients referred to the Accident and Emergency Department of the Royal Victoria Hospital, Belfast outside normal working hours by their own general practitioners and those referred by the general practitioner deputizing service during the same period.     

慢性肾脏病病人实施出院后续医疗护理服务的效果评价

[目的]观察慢性肾脏病病人实施出院后续医疗护理服务的效果。[方法]将70例出院病人随机分为观察组和对照组（各35例）,对照组在出院时进行详细的出院指导,观察组病人在出院指导的基础上实施出院后续医疗护理服务,两组全程跟踪半年,失访3例。[结果]出院半年后观察组病人的满意度（91.18%）高于对照组（69.70%）,观察组的焦虑自评量表（SAS）评分和匹兹堡睡眠质量指数（PSQI）均较出院时有所降低（P〈0.05）,观察组的血尿素氮、血肌酐和胱抑素C与出院时比较差异均无统计学意义（P〉0.05）;对照组的血尿素氮、血肌酐和胱抑素C均较出院时有所上升（P〈0.05）,对照组SAS评分和PSQI与出院时比较差异无统计学意义（P〉0.05）。[结论]对慢性肾脏病病人实施出院后续医疗护理服务,能稳定控制病情,改善其睡眠质量及焦虑状况,并有效提高病人满意度。     

慢性肾脏病病人实施出院后续医疗护理服务的效果评价

[目的]观察慢性肾脏病病人实施出院后续医疗护理服务的效果。[方法]将70例出院病人随机分为观察组和对照组(各35例),对照组在出院时进行详细的出院指导,观察组病人在出院指导的基础上实施出院后续医疗护理服务,两组全程跟踪半年,失访3例。[结果]出院半年后观察组病人的满意度(91.18%)高于对照组(69.70%),观察组的焦虑自评量表(SAS)评分和匹兹堡睡眠质量指数(PSQI)均较出院时有所降低(P<0.05),观察组的血尿素氮、血肌酐和胱抑素C与出院时比较差异均无统计学意义(P>0.05);对照组的血尿素氮、血肌酐和胱抑素C均较出院时有所上升(P<0.05),对照组SAS评分和PSQI与出院时比较差异无统计学意义(P>0.05)。[结论]对慢性肾脏病病人实施出院后续医疗护理服务,能稳定控制病情,改善其睡眠质量及焦虑状况,并有效提高病人满意度。     

Chronic medical illness, depression, and use of acute medical services among Medicare beneficiaries

BACKGROUND: This study assessed the relation of comorbid depressive syndrome with utilization of emergency department services and preventable inpatient hospitalizations among elderly individuals with chronic medical conditions. RESEARCH DESIGN: A cross-sectional study. SETTING: Individuals greater than or equal to 65 years of age living in the United States with Medicare part A and B fee-for-service coverage in 1999. SUBJECTS: A 5% random sample of elderly Medicare recipients (N = 1,238,895) of whom 60,382 (4.9%) met criteria for a depressive syndrome. MEASUREMENTS: Medicare beneficiaries were stratified based on the presence of at least 1 of the following medical conditions: coronary artery disease, diabetes mellitus, congestive heart failure, hypertension, prostate cancer, breast cancer, lung cancer, or colon cancer. For each stratum, we compared the odds of emergency department visits, all-cause hospitalization, and hospitalization for ambulatory care sensitive conditions (ACSC), conditions for which timely and effective medical care could decrease risk of hospitalization, for beneficiaries with and without a depressive syndrome. RESULTS: Compared with those without a depressive syndrome, beneficiaries with a depressive syndrome were more likely to be older, white, and female (P <0.001). For each of the 8 chronic medical conditions, elderly beneficiaries with a depressive syndrome were at least twice as likely to use emergency department services (range of adjusted odds ratios, 2.12-3.16; P <0.001); medical inpatient hospital services (range of adjusted odds ratios, 2.59-3.71; P <0.001); and medical inpatient hospital services associated with an ACSC (range of adjusted odds ratios, 1.72-2.68; P <0.001) as compared with those without a depressive syndrome. CONCLUSIONS: For elderly individuals with at least 1 chronic medical condition, the presence of a depressive syndrome increased the odds of acute medical service use, suggesting that improvements in clinical management, access to mental health services, and coordination of medical and mental health services could reduce utilization.     

Knowledge and use of community services among family caregivers of Alzheimer's disease patients

The number of people with dementia residing within the community is steadily increasing. Community services can alleviate the burdens experienced by families, but are used infrequently by families of dementia patients. Caregivers (N = 93) of dementia patients were surveyed regarding their knowledge and use of community services. The most frequently used services were family support groups and home health aides. Overall, service use was low despite high levels of perceived availability of services. Older and less educated caregivers had higher levels of uncertainty about service availability. Depressed caregivers were less likely to know about service availability. Implications for practice and research are presented.