The effect of a 'fast-track' unit on the performance of a cardiothoracic department.
OBJECTIVE: The objective of this study was to describe the impact of a 'fast-track' unit, combined with a computerised system for information collection and analysis, on the clinical practice and finance of a cardiothoracic department over the first 12 month period of its application. METHODS: Within 12 months, starting December 1996, 642 major cardiothoracic cases were performed at the Cardiothoracic Department, St Mary's Hospital, London, after the establishment of a 3-bed 'fast-track' unit, which was supported by a computerised system for admission planning and a pre-admission clinic. The main outcome measures were operating numbers, financial income, patient recovery and operative mortality. RESULTS: The 'fast-track' unit resulted in an increase of the operating numbers (11.3% increase in major cardiac cases) and income (38%), as compared with the year before. Some 525 patients out of 642 (81.8%) were scheduled for the 'fast-track' unit and 492 (93.7%) were successfully 'fast-tracked'. Coronary artery bypass grafting operations had the lowest 'fast-track' failure and mortality rates. Re-do operations and complex coronary procedures presented a high 'fast-track' failure rate of approximately 20-25%. Low cardiac output, postoperative bleeding and respiratory problems were the most frequent causes for 'fast-track' failure. CONCLUSIONS: The development of a 'fast-track' unit, supported by a computerised system for information collection and analysis and a pre-admission clinic, has resulted in a substantial improvement of operating numbers and financial income, without adversely affecting the clinical results. This task demanded close collaboration between a dedicated list manager and a designated member of the medical team. Patient selection with appropriate 'fast-track,' criteria may improve further the efficiency of 'fast-track' units in the future. (+info)
Therapeutic nursing or unblocking beds? A randomised controlled trial of a post-acute intermediate care unit.
OBJECTIVES: To compare post-acute intermediate care in an inpatient nurse-led unit with conventional post-acute care on general medical wards of an acute hospital and to examine the model of care in a nurse-led unit. DESIGN: Randomised controlled trial with six month follow up. SETTING: Urban teaching hospital and surrounding area, including nine community hospitals. PARTICIPANTS: 238 patients accepted for admission to nurse-led unit. INTERVENTIONS: Care in nurse-led unit or usual post-acute care. MAIN OUTCOME MEASURES: Patients' length of stay, functional status, subsequent move to more dependent living arrangement. RESULTS: Inpatient length of stay was significantly longer in the nurse-led unit than in general medical wards (14.3 days longer (95% confidence interval 7.8 to 20.7)), but this difference became non-significant when transfers to community hospitals were included in the measure of initial length of stay (4.5 days longer (-3.6 to 12.5)). No differences were observed in mortality, functional status, or living arrangements at any time. Patients in the nurse-led unit received significantly fewer minor medical investigations and, after controlling for length of stay, significantly fewer major reviews, tests, or drug changes. CONCLUSIONS: The nurse-led unit seemed to be a safe alternative to conventional management, but a full accounting of such units' place in the local continuum of care and the costs associated with acute hospitals managing post-acute patients is needed if nurse-led units are to become an effective part of the government's recent commitment to intermediate care. (+info)
Urinary health in eldercare environments: an update from the NAFC.
The National Association For Continence elected to cancel its 2001 conference scheduled for October 2001 in Washington, DC in light of national events. Executive Director Nancy Muller has provided Ostomy/Wound Management with a synopsis of key issues, important considerations, and the syllabus. We are grateful for the opportunity to serve as a forum for this worthy organization. (+info)
Stroke unit care combined with early supported discharge: long-term follow-up of a randomized controlled trial.
BACKGROUND AND PURPOSE: Early supported discharge from a stroke unit reduces the length of hospital stay. Evidence of a benefit for the patients is still unknown. The aim of this trial was to evaluate the long-term effects of an extended stroke unit service (ESUS), characterized by early supported discharge. The short-term effects were published previously. METHODS: We performed a randomized controlled trial in which 320 acute stroke patients were allocated to either ordinary stroke unit service (OSUS) (160 patients) or stroke unit care with early supported discharge (160 patients). The ESUS consists of a mobile team that coordinates early supported discharge and further rehabilitation. Primary outcome was the proportion of patients who were independent as assessed by modified Rankin Scale (RS) (RS < or =2=global independence). Secondary outcomes measured at 52 weeks were performance on the Barthel Index (BI) (BI > or =95=independent in activities of daily living), differences in final residence, and analyses to identify patients who benefited most from an early supported discharge service. All assessments were blinded. RESULTS: We found that 56.3% of the patients in the ESUS versus 45.0% in the OSUS were independent (RS < or =2) (P=0.045). The number needed to treat to achieve 1 independent patient in ESUS versus OSUS was 9. The odds ratio for independence was 1.56 (95% CI, 1.01 to 2.44). There were no significant differences in BI score and final residence. Patients with moderate to severe stroke benefited most from the ESUS. CONCLUSIONS: Stroke service based on treatment in a stroke unit combined with early supported discharge appears to improve the long-term clinical outcome compared with ordinary stroke unit care. Patients with moderate to severe stroke benefit most. (+info)
Posthospital care transitions: patterns, complications, and risk identification.
OBJECTIVES: To (1) describe patterns of posthospital care transitions; (2) characterize these patterns as uncomplicated or complicated; (3) identify those at greatest risk for complicated transitions. DATA SOURCES/STUDY SETTING: The Medicare Current Beneficiary Survey was used to identify beneficiaries aged 65 and older who were discharged from an acute care hospital in 1997-1998. STUDY DESIGN: Patterns of posthospital transfers were described over a 30-day time period following initial hospital discharge. Uncomplicated posthospital care patterns were defined as a sequence of transfers from higher-to lower-intensity care environments without recidivism, while complicated posthospital care patterns were defined as the opposite sequence of events. Indices were developed to identify patients at risk for complicated transitions. PRINCIPAL FINDINGS: Forty-six distinct types of care patterns were observed during the 30 days following hospital discharge. Among these patterns, 444 episodes (61.2 percent) were limited to a single transfer, 130 episodes (17.9 percent) included two transfers, 62 episodes (8.5 percent) involved three transfers, and 31 episodes (4.3 percent) involved four or more transfers. Fifty-nine episodes (8.1 percent) resulted in death. Between 13.4 percent and 25.0 percent of posthospital care patterns in the 1998 sample were classified as complicated. The area under the receiver operating curve was 0.771 for a predictive index that utilized administrative data and 0.833 for an index that used a combination of administrative and self-reported data. CONCLUSIONS: Posthospital care transitions are common among Medicare beneficiaries and patterns of care vary greatly. A significant number of beneficiaries experienced complicated care transitions-a finding that has important implications for both patient safety and cost-containment efforts. Patients at risk for complicated care patterns can be identified using data available at the time of hospital discharge. (+info)
Bone mineral density during total contact cast immobilization for a patient with neuropathic (Charcot) arthropathy.
BACKGROUND AND PURPOSE: Diabetes mellitus (DM)-related neuropathic arthropathy of the foot is a destructive bone and joint process. The effect of cast immobilization and non-weight bearing on bone loss has not been well studied. The purpose of this case report is to describe the changes in bone mineral density (BMD) of the calcaneus in the feet of a patient with acute neuropathic arthropathy during total contact cast immobilization. CASE DESCRIPTION: The patient was a 34-year-old woman with type 1 DM, renal failure requiring dialysis, and a 7-week duration of neuropathic arthropathy of the midfoot. Intervention included total contact casting and minimal to no weight bearing for 10 weeks, with transition to therapeutic footwear. Ultrasound-derived estimates of BMD were taken of both involved and uninvolved calcanei. OUTCOME: Bone mineral density decreased for the involved foot (from 0.25 g/cm(2) to 0.20 g/cm(2)) and increased for the uninvolved foot (from 0.27 g/cm(2) to 0.31 g/cm(2)) during casting. DISCUSSION: The low initial BMD and further loss during casting suggest the need for transitional bracing and a well-monitored return to full activity to minimize the risk of recurrence and progression of foot deformity. (+info)
Prevention of anxiety and depression in the age group of 75 years and over: a randomised controlled trial testing the feasibility and effectiveness of a generic stepped care programme among elderly community residents at high risk of developing anxiety and depression versus usual care [ISRCTN26474556].
BACKGROUND: In frail elderly, the effects of depression and anxiety are deep encroaching. Indicated prevention studies, aimed at subjects with subthreshold disorder, have shown that well designed interventions are capable of reducing the incidence of depression and anxiety. In this randomised prevention trial for elderly, living in the community and suffering from subthreshold depression and anxiety, a stepped care programme was put together to be tested versus usual (GP) care. METHODS/DESIGN: DESIGN: randomised controlled trial. (See figure 1: organisation chart) together with two other projects, this project is part of a national consortium that investigates the prevention of anxiety and depressive disorders in later life using a stepped care programme. The three projects have their own particular focus. This project is aimed at elderly living in the community.Inclusion: subjects with a high risk for depression and anxiety without clinical evidence of these syndromes. The participants are 75 years of age and over and have subthreshold symptoms of depression and or anxiety: they score above the cut-off point on the self-report Centre for Epidemiologic Studies Depression (CES-D) scale, but the criteria for a major depressive disorder or anxiety disorder (panic disorder, agoraphobia, social phobia, generalized anxiety disorder) according to a validated interview, the Mini International Neuropsychiatric Interview (MINI) are not fulfilled. OUTCOMES: primary outcome: incidence of a depressive or anxiety disorder over a period of two years (MINI); secondary outcome: a positive influence of the intervention, a stepped care programme, on symptoms of depression and anxiety and on quality of life as assessed with the CES D, the HADS A and the SF36 respectively (i.e. stabilisation or improvement of symptoms) [see table 1]. MEASUREMENTS: Take place at baseline and at 3, 6, 9, 12, 18 and 24 months. Trained independent evaluators assess depression and anxiety status, the primary end point (6, 12, 18, 24 months) [see table 2]. DISCUSSION: Late-life depression and anxiety are characterised by high prevalence, unfavourable prognosis, reduced quality of life, excess mortality and substantial societal costs. No health service, however well equipped, will be able to effectively treat all elderly with depression and anxiety. Therefore, development of (cost) effective means to prevent these disorders is very important. (+info)
Discontinuity of chronic medications in patients discharged from the intensive care unit.
BACKGROUND: Intensive care unit (ICU) admission may connote an elevated risk of unintentional chronic medication discontinuation because of its focus on acute illnesses and the multiple care transitions. OBJECTIVE: To determine the proportion of patients discharged from the ICU whose previously prescribed chronic medications were unintentionally discontinued during their hospitalization. DESIGN AND PARTICIPANTS: Hospital records of consecutive ICU discharges at 1 academic and 2 community hospitals in Toronto, Canada, throughout 2002 were reviewed. Eligible patients were prescribed at least 1 of 6 medication groups before hospitalization: (1) HMG co-A reductase inhibitors (statins); (2) antiplatelets/anticoagulants (aspirin, clopidogrel, ticlopidine, warfarin); (3) l-thyroxine; (4) non-prn inhalers (anticholinergic, beta-agonist, or steroid); (5) acid-suppressing drugs (H2 antagonists and proton pump inhibitors); and (6) allopurinol. MEASUREMENTS: Use of explicit criteria to assess the proportion of patients whose previously prescribed chronic medications were unintentionally discontinued at hospital discharge. RESULTS: A total of 1,402 charts were eligible for the study and 834 had prescriptions for at least 1 of the medication groups. Thirty-three percent (251/834) of patients had 1 or more of their chronic medications omitted at hospital discharge. Multivariable logistic regression analysis found that patients from the academic hospital (adjusted odds ratio [OR] = 0.70, 95% confidence interval [CI] 0.49 to 1.0) and those with medical diagnoses (adjusted OR=0.48, 95% CI 0.31 to 0.75) had a decreased risk for chronic medication discontinuation. CONCLUSIONS: Patients discharged from the ICU often leave the hospital without note of their previously prescribed chronic medications. Careful review of medication lists at ICU discharge could avoid potential adverse outcomes related to unintentional discontinuation of chronic medications at hospital discharge. (+info)