Delay in discharge of psychiatric patients frequently is attributed to the lack of available community resources, or to the unwillingness of the patient or his family to accept discharge or transfer to another facility. The role of the psychiatric system itself rarely is mentioned as a factor. A study of 138 psychiatric patients in a Canadian community hospital in 1978 showed that 35 per cent were judged to be delayed in their discharge. By far the greatest source of delay was the administration of the various psychiatric services within the system. Delayed patients were found to be statistically similar to nondelayed patients, except for the delayed patients tendency to be poorer and to be overrepresented on two of the six wards studied. The cost implications of the delays in discharge are discussed, as are suggestions for solving the problems within the administrative framework.
The ten-year mortality in patients with suspected myocardial infarction with (AMI) and without (non-AMI) confirmed diagnosis was evaluated in 1897 non-AMI patients and 1401 AMI patients who were consecutively admitted to hospital during The Danish Verapamil Infarction Study. The following risk factors contained independent prognostic information about mortality for non-AMI patients: age, previous AMI, sex and diabetes. In patients with AMI the risk factors were: age, previous AMI, clinical heart failure, diabetes and angina pectoris. When the diagnosis at discharge for non-AMI patients was included in the Cox-analysis, only the diagnoses of bronchopneumonia, musculoskeletal disorders and observation only of added prognostic information. We conclude that non-AMI patients are at high risk for mortal events in the long-term. High risk patients can be identified from the medical history and should be carefully evaluated regarding coronary artery disease at the time of discharge in order to improve the risk stratification, treatment and prognosis.
Seclusion and restraint are frequent but controversial coercive measures used in psychiatric treatment. Legislative efforts have started to emerge to control the use of these measures in many countries. In the present study, the nationwide trends in the use of seclusion and restraint were investigated in Finland over a 15-year span which was characterised by legislative changes aiming to clarify and restrict the use of these measures.
The data were collected during a predetermined week in 1990, 1991, 1994, 1998 and 2004, using a structured postal survey of Finnish psychiatric hospitals. The numbers of inpatients during the study weeks were obtained from the National Hospital Discharge Register.
The total number of the secluded and restrained patients declined as did the number of all inpatients during the study weeks, but the risk of being secluded or restrained remained the same over time when compared to the first study year. The duration of the restraint incidents did not change, but the duration of seclusion increased. A regional variation was found in the use of coercive measures.
Legislative changes solely cannot reduce the use of seclusion and restraint or change the prevailing treatment cultures connected with these measures. The use of seclusion and restraint should be vigilantly monitored and ethical questions should be under continuous scrutiny.
The Norwegian Knowledge Centre for the Health Services (NOKC) reports 30-day survival as a quality indicator for Norwegian hospitals. The indicators have been published annually since 2011 on the website of the Norwegian Directorate of Health (www.helsenorge.no), as part of the Norwegian Quality Indicator System authorized by the Ministry of Health. Openness regarding calculation of quality indicators is important, as it provides the opportunity to critically review and discuss the method. The purpose of this article is to describe the data collection, data pre-processing, and data analyses, as carried out by NOKC, for the calculation of 30-day risk-adjusted survival probability as a quality indicator.
Three diagnosis-specific 30-day survival indicators (first time acute myocardial infarction (AMI), stroke and hip fracture) are estimated based on all-cause deaths, occurring in-hospital or out-of-hospital, within 30 days counting from the first day of hospitalization. Furthermore, a hospital-wide (i.e. overall) 30-day survival indicator is calculated. Patient administrative data from all Norwegian hospitals and information from the Norwegian Population Register are retrieved annually, and linked to datasets for previous years. The outcome (alive/death within 30 days) is attributed to every hospital by the fraction of time spent in each hospital. A logistic regression followed by a hierarchical Bayesian analysis is used for the estimation of risk-adjusted survival probabilities. A multiple testing procedure with a false discovery rate of 5% is used to identify hospitals, hospital trusts and regional health authorities with significantly higher/lower survival than the reference. In addition, estimated risk-adjusted survival probabilities are published per hospital, hospital trust and regional health authority. The variation in risk-adjusted survival probabilities across hospitals for AMI shows a decreasing trend over time: estimated survival probabilities for AMI in 2011 varied from 80.6% (in the hospital with lowest estimated survival) to 91.7% (in the hospital with highest estimated survival), whereas it ranged from 83.8% to 91.2% in 2013.
Since 2011, several hospitals and hospital trusts have initiated quality improvement projects, and some of the hospitals have improved the survival over these years. Public reporting of survival/mortality indicators are increasingly being used as quality measures of health care systems. Openness regarding the methods used to calculate the indicators are important, as it provides the opportunity of critically reviewing and discussing the methods in the literature. In this way, the methods employed for establishing the indicators may be improved.
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Accelerated surgical stay programs represent a multi-modal, multi-disciplinary concept to reduce postoperative morbidity, hospitalisation and convalescence based upon recent advantages in surgical pathophysiology and pain treatment. Preliminary data from a variety of surgical procedures suggest major improvements in quality of surgical care and cost reduction and call for further controlled or large-size multicenter studies.
To identify predictors of survival in a retrospective multicentre cohort of patients with cardiogenic shock undergoing coronary angiography and to address whether complete revascularization is associated with improved survival in this cohort.
Early revascularization is the standard of care for cardiogenic shock. Coronary bypass grafting and percutaneous intervention have complimentary roles in achieving this revascularization.
A total of 210 consecutive patients (mean age 66 ± 12 years) at two tertiary centres from 2002 to 2006 inclusive with a diagnosis of cardiogenic shock were evaluated. Univariate and multivariate predictors of in-hospital survival were identified utilizing logistic regression.
ST elevation infarction occurred in 67% of patients. Thrombolysis was administered in 34%, PCI was attempted in 62% (88% stented, 76% TIMI 3 flow), CABG was performed in 22% (2.7 grafts, 14 valve procedures), and medical therapy alone was administered to the remainder. The overall survival to discharge was 59% (CABG 68%, PCI 57%, medical 48%). Independent predictors of mortality included complete revascularization (P = 0.013, OR = 0.26 (95% CI: 0.09-0.76), hyperlactatemia (P = 0.046, OR = 1.14 (95% CI: 1.002-1.3) per mmol increase), baseline renal insufficiency (P = 0.043, OR = 3.45, (95% CI: 1.04-11.4), and the presence of anoxic brain injury (P = 0.008, OR = 8.22 (95% CI: 1.73-39.1). Within the STEMI with concomitant multivessel coronary disease subgroup of this population (N = 101), independent predictors of survival to discharge included complete revascularization (P = 0.03, OR = 2.5 (95% CI: 1.1-6.2)) and peak lactate (P = 0.02).
The ability to achieve complete revascularization may be strongly associated with improved in-hospital survival in patients with cardiogenic shock.
Comment In: Catheter Cardiovasc Interv. 2011 Oct 1;78(4):549-5021953751
INTRODUCTION: The aim of the study was to assess the results of a well-defined rehabilitation programme after hip arthroplasty. METHODS: The effects of a revised, optimised, perioperative care programme with continuous epidural analgesia, oral nutrition, and physiotherapy were assessed in 60 patients before intervention and 60 patients after intervention. RESULTS: The hospital stay was reduced from nine to six days (p
Accelerated surgical stay programs represent a multi-modal, multi-disciplinary concept to reduce postoperative morbidity, hospitalisation and convalescence based upon recent advantages in surgical pathophysiology and pain treatment. Preliminary data from a variety of surgical procedures suggest major improvements in quality of surgical care and cost reduction and call for further controlled or large-size multi-center studies.
Comment In: Ugeskr Laeger. 2001 Jan 22;163(4):41511218774
INTRODUCTION: The goal of this study was to evaluate patient satisfaction with the hospital stay in relation to the length of stay for patients operated on with primary total hip- and knee-arthroplasty (THA and TKA). MATERIALS AND METHODS: According to the National Register on Patients, the three departments with the shortest and the three departments with the longest postoperative hospital stay at the end of 2003 were chosen for evaluation. The patients, operated on with THA or TKA from September 2004 to April 2005, from the selected departments answered a questionnaire regarding satisfaction with elected parts of their stay, co-morbidity, sex and age. RESULTS: The patients from the departments with the shortest stay were not younger nor had they less co-morbidities than patients from departments with longer stays. Apart from staying a significantly shorter time, they were either as satisfied--or sometimes more satisfied--with all parts of their stay compared to patients from the departments with longer hospital stay. CONCLUSION: Patients in accelerated stays are not less satisfied with their hospital stay (or any part of it) compared to patients with longer and more conventional hospital stays. These results support the implementation of fast-track total hip- and knee arthroplasty.