The use of cusum analysis in the early detection and management of hospital bed occupancy crises

Objective: To assess the value of cusum analysis in hospital bed management. Design: Comparative analysis of medical patient flows, bed occupancy, and emergency department admission rates and access block over 2 years. Setting: Internal Medicine Services and Emergency Department in a teaching hospital. Interventions: Improvements in bed use and changes in the level of available beds. Main outcome measures: Average length of stay; percentage occupancy of available beds; number of patients waiting more than 8 hours for admission (access block); number of medical patients occupying beds in non-medical wards; and number of elective surgical admissions. Results: Cusum analysis provided a simple means of revealing important trends in patient flows that were not obvious in conventional time-series data. This prompted improvements in bed use that resulted in a decrease of 9500 occupied bed-days over a year. Unfortunately and unexpectedly, after some initial improvement, the levels of access block, medical ward congestion and elective surgical admissions all then deteriorated significantly. This was probably caused by excessive bed closures in response to the initial improvement in bed use. Conclusion: Cusum analysis is a useful technique for the early detection of significant changes in patient flows and bed use, and in determining the appropriate number of beds required for a given rate of patient flow.

Effectiveness of case management and post-acute services in older people after hospital discharge

Objective: To evaluate the benefits of coordinating community services through the Post-Acute Care (PAC) program in older patients after discharge from hospital. Design: Prospective multicentre, randomised controlled trial with six months of follow-up with blinded outcome measurement. Setting: Four university-affiliated metropolitan general hospitals in Victoria. Participants: All patients aged 65 years and over who were discharged between August 1998 and October 1999 and required community services after discharge. Interventions: Participants were randomly allocated to receive services of a Post-Acute Care (PAC) coordinator (intervention) versus usual discharge planning (control). Main outcome measures: Comparison of quality of life and carer stress at one-month post-discharge, mortality, hospital readmissions, use of community services and community and hospital costs over the six months post-discharge. Results: 654 patients were randomised, and 598 were included in the analysis (311 in the PAC group and 287 in the control group). There was no difference in mortality between the groups (both 6%), but significantly greater overall quality-of-life scores at one-month follow-up in the PAC group. There was no difference in unplanned readmissions, but PAC patients used significantly fewer hospital bed-days in the six months after discharge (mean, 3.0 days; 95% CI, 2.1-3.9) than control patients (5.2 days; 95% CI, 3.8-6.7). Total costs (including hospitalisation, community services and the intervention) were lower in the PAC than the control group (mean difference, $1545; 95% CI, $11-$3078). Conclusions: The PAC program is beneficial in the transition from hospital to the community in older patients.

Carvedilol reduces the costs of medical care in severe heart failure: An economic analysis of the COPERNICUS study applied to the United Kingdom

Background: The aim of this study was to determine the effects of carvedilol on the costs related to the treatment of severe chronic heart failure (CHF). Methods: Costs for the treatment for heart failure within the National Health Service (NHS) in the United Kingdom (UK) were applied to resource utilisation data prospectively collected in all patients randomized into the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) Study. Unit-specific, per them (hospital bed day) costs were used to calculate expenditures due to hospitalizations. We also included costs of carvedilol treatment, general practitioner surgery/office visits, hospital out-patient clinic visits and nursing home care based on estimates derived from validated patterns of clinical practice in the UK. Results: The estimated cost of carvedilol therapy and related ambulatory care for the 1156 patients assigned to active treatment was 530,771 pound (44.89 pound per patient/month of follow-up). However, patients assigned to carvedilol were hospitalised less often and accumulated fewer and less expensive days of admission. Consequently, the total estimated cost of hospital care was 3.49 pound million in the carvedilol group compared with 4.24 pound million for the 1133 patients in the placebo arm. The cost of post-discharge care was also less in the carvedilol than in the placebo group (479,200 pound vs. 548,300) pound. Overall, the cost per patient treated in the carvedilol group was 3948 pound compared to 4279 pound in the placebo group. This equated to a cost of 385.98 pound vs. 434.18 pound, respectively, per patient/month of follow-up: an 11.1% reduction in health care costs in favour of carvedilol. Conclusions: These findings suggest that not only can carvedilol treatment increase survival and reduce hospital admissions in patients with severe CHF but that it can also cut costs in the process.

Evaluation of cyclooxygenase 2 inhibitor use in patients admitted to a large teaching hospital

Background: The heavy usage of coxibs in Australia far outstrips the predicted usage that was based on the treatment of patients with risk factors for upper gastro-intestinal adverse events from conventional anti--inflammatory agents. This raises questions regarding the appropriateness of prescribing. Aims: To determine: (i) the relationship between prescriptions for cyclooxygenase 2 (COX-2) inhibitors and objective evidence of inflammatory arthritis, (ii) prior experience with paracetamol and/or conventional non-steroidal anti-inflammatory drugs (NSAIDs), and (iii) contraindications to the use of NSAIDs. Methods: Drug utilization evaluation and rheumato-logical assessment was conducted on 70 consecutive patients admitted on COX-2 inhibitors to a 480-bed metropolitan hospital. The main outcome measures were: the indication for COX-2 inhibitor; objective -evidence of inflammatory arthritis; previous trial of -paracetamol or conventional NSAIDs; and patient -satisfaction. Results: Only 11 patients (16%) had symptoms or signs of an inflammatory arthropathy, and met Pharmaceut-ical Benefits Schedule criteria for prescribing a COX-2 inhibitor. Fifty-nine patients (84%) had chronic osteo-arthritis, degenerative spinal disease, injury or malignancy, without overt active inflammation. Fourteen patients (20%) had trialled regular paracetamol prior to using any NSAID treatment. Conventional NSAIDs had been previously used by 51 patients (73%). Eleven patients (16%) reported previous adverse gastrointestinal effects from conventional NSAIDs. On the basis of significant renal impairment (creatinine clearance 5/10). Conclusions: Drug utilization data indicate that COX-2 inhibitors are frequently used first line for degenerative osteoarthritis in the absence of overt inflammation, without prior adequate trial of paracetamol and with disregard for the cautions and contraindications of these agents. These findings may explain the unprecedented Pharmaceutical Benefits Schedule expenditure on COX-2 inhibitors in Australia.

Trends in the use of hospital beds by older people in Australia: 1993-2002

Objective: To determine trends in use of Australian acute hospital inpatient services by older patients. Design and data sources: Secondary analysis of hospital data from the Australian Institute of Health and Welfare in the period 1993-94 to 2001-02, with population data for this period from the Australian Bureau of Statistics. Outcome measures: Population-based rates of hospital separations and bed utilisation. Results: The Australian aged population (65 years and older) increased by 18% compared with total population growth of 10%, yet the proportion of hospital beds occupied by older patients remained stable at 47%. The most substantial changes were observed in the population aged 75 years and older, with separations increasing by 89%, length of stay reducing by 35% and bed utilisation increasing by 23%. However, rates of bed utilisation (in relation to population) declined among older groups (10% decline in per capita use in population 75 years and older), but increased in the younger population (1% increase in per capita use in people younger than 65 years). Conclusion: Important trends in use of inpatient services were identified in this study. These trends are contrary to common perception. Ageing of the Australian population was not associated with an increase in the proportion of hospital beds used by older patients.

Predicting functional capacity outcome 12 months after hospitalized injury

Background: There is a recognized need to move from mortality to morbidity outcome predictions following traumatic injury. However, there are few morbidity outcome prediction scoring methods and these fail to incorporate important comorbidities or cofactors. This study aims to develop and evaluate a method that includes such variables. Methods: This was a consecutive case series registered in the Queensland Trauma Registry that consented to a prospective 12-month telephone conducted follow-up study. A multivariable statistical model was developed relating Trauma Registry data to trichotomized 12-month post-injury outcome (categories: no limitations, minor limitations and major limitations). Cross-validation techniques using successive single hold-out samples were then conducted to evaluate the model's predictive capabilities. Results: In total, 619 participated, with 337 (54%) experiencing no limitations, 101 (16%) experiencing minor limitations and 181 (29%) experiencing major limitations 12 months after injury. The final parsimonious multivariable statistical model included whether the injury was in the lower extremity body region, injury severity, age, length of hospital stay, pulse at admission and whether the participant was admitted to an intensive care unit. This model explained 21% of the variability in post-injury outcome. Predictively, 64% of those with no limitations, 18% of those with minor limitations and 37% of those with major limitations were correctly identified. Conclusion: Although carefully developed, this statistical model lacks the predictive power necessary for its use as a basis of a useful prognostic tool. Further research is required to identify variables other than those routinely used in the Trauma Registry to develop a model with the necessary predictive utility.

Treatment of naphthalene-2-sulfonic acid from tannery wastewater by a granular activated carbon fixed bed inoculated with bacterial isolates Arthrobacter globiformis and Comamonas testosteroni

The kinetics of naphthalene-2-sulfonic acid (2-NSA) adsorption by granular activated carbon (GAC) were measured and the relationships between adsorption, desorption, bioavailability and biodegradation assessed. The conventional Langmuir model fitted the experimental sorption isotherm data and introduced 2-NSA degrading bacteria, established on the surface of the GAC, did not interfere with adsorption. The potential value of GAC as a microbial support in the aerobic degradation of 2-NSA by Arthrobacter globiformis and Comamonas testosteroni was investigated. Using both virgin and microbially colonised GAC, adsorption removed 2-NSA from the liquid phase up to its saturation capacity of 140 mg/g GAC within 48 h. However, between 83.2% and 93.3% of the adsorbed 2-NSA was bioavailable to both bacterial species as a source of carbon for growth. In comparison to the non-inoculated GAC, the combination of rapid adsorption and biodegradation increased the amount (by 70–93%) of 2-NSA removal from the influent phase as well as the bed-life of the GAC (from 40 to >120 d). A microbially conditioned GAC fixed-bed reactor containing 15 g GAC removed 100% 2-NSA (100 mg/l) from tannery wastewater at an empty bed contact time of 22 min for a minimum of 120 d without the need for GAC reconditioning or replacement. This suggests that small volume GAC bioreactors could be used for tannery wastewater recycling.

Heparin-induced thrombocytopenia: recent experience in a large teaching hospital

Background: Heparin-induced thrombocytopenia (HIT) is a potentially serious adverse reaction caused by platelet-activating antibodies. Aim: To describe experience with HIT. Methods: Twenty-two patients identified by laboratory records of heparin-associated antibodies with a 50% or greater decrease in platelet count were reviewed in our 600-bed metropolitan teaching hospital from 1999 to April 2005. Results: There was an increase in the frequency of HIT diagnosed during the review period, which was associated with a rise in the number of requests for HIT antibodies. Thrombotic complications were identified in 14 of 22 patients with HIT. Mean age was 65 years, and 11 patients were men. Seven patients died and HIT was considered contributory in four. One patient required mid-forearm amputation. Unfractionated heparin was used in all cases and five patients also received enoxaparin. Mean time to HIT screen, reflecting when the diagnosis was first suspected, was 14 days. Platelet nadir ranged from 6 x 10(9)/L to 88 x 10(9)/L, with a percentage drop in platelet count of 67-96%. Alternative anticoagulation (danaparoid) was not used in three patients, two of whom died. Conclusions: HIT is a potentially life-threatening complication of heparin therapy, associated with a fall in platelet count and a high incidence of thromboembolic complications. It is most frequently seen using unfractionated heparin therapy. The increase in frequency of HIT diagnosed in our hospital appears to be associated with a greater awareness of the entity, although detection is often delayed. Platelet count should be monitored in patients on heparin and the presence of antiplatelet antibodies determined if HIT is suspected. Treatment involves both discontinuation of heparin and the use of an alternative anticoagulant such as danaparoid because of the persisting risk of thrombosis.

Bed shear stress measurements in dam break and swash flows

A novel shear plate was used to make direct bed shear stress measurements in laboratory dam break and swash flows on smooth, fixed, impermeable beds. The pressure gradient due to the slope of the fluid free-surface across the plate was measured using pressure transducers. Surface elevation was measured at five locations using acoustic displacement sensors. Flow velocity was measured using an Acoustic-Doppler Velocimeter and calculated using the ANUGA inundation model. The measured bed shear stress at the dam break fluid tip for an initially dry, horizontal bed was close to twice that estimated using steady flow theory. The temporal variation of swash bed shear stress showed a large peak in landward directed stress at the uprush tip, followed by a rapid decay throughout the uprush flow interior. The peak seaward directed stress during the backwash phase was less than half that measured in the uprush. Close to the still water line, in the region of bore collapse and at the time of initial uprush, favourable pressure gradients were measured. In the lower swash region predominately weak adverse pressure gradients were measured.

Standing wave bed forms at Plage de la Grande Roche, le Verdelet, Pléneuf-Val-André, Cote d’Armor (France)

Coastal Photograph by Hubert Chanson This photograph of standing wave bed forms was taken at very low tide. The tidal range was 10 m. The bed forms were located on the island of Le Verdelet, in a channel between Le Grande Jaune and Le Verdelet. It is likely that these standing wave bed forms were formed during transcritical shallow water flows at the end of ebb tide. The author’s watch is in the foreground for scale. (Coastal Photograph by Hubert Chanson, Division of Civil Engineering, the University of Queensland, Brisbane, Queensland 4072, Australia.)

Family orientated delivery of routine nursing care in hospital

Hospital nursing may be better deployed to acute clinical patient care. The recruitment of family assistance will facilitate this process in patients in hospital awaiting placement and without acute care issues.

Enzyme deactivation in fixed bed reactors with michaelis-menten kinetics

Rate expression for enzyme poisoning which are consistent with a Michaelis-Menten main reaction are used to analyze the performance of a fixed bed reactor containing immobilized enzyme. When enzyme deactivation results from the irreversible bonding of a product molecule to an existing substrate-enzyme complex, it is shown that minimum enzyme activity can occur in the interior of the bed, well away from the ends. This suggests that bed sectioning techniques may enable direct evaluation of fundamental poisoning mechanisms.

Fixed bed reactors with catalyst poisoning - first order kinetics.

The long performance of an isothermal fixed bed reactor undergoing catalyst poisoning is theoretically analyzed using the dispersion model. First order reaction with dth order deactivation is assumed and the model equations are solved by matched asymptotic expansions for large Peclet number. Simple closed-form solutions, uniformly valid in time, are obtained.