Methods and preliminary results for a data linkage project to determine long-term survival after intensive care unit admission

Aims: To describe a local data linkage project to match hospital data with the Australian Institute of Health and Welfare (AIHW) National Death Index (NDI) to assess longterm outcomes of intensive care unit patients. Methods: Data were obtained from hospital intensive care and cardiac surgery databases on all patients aged 18 years and over admitted to either of two intensive care units at a tertiary-referral hospital between 1 January 1994 and 31 December 2005. Date of death was obtained from the AIHW NDI by probabilistic software matching, in addition to manual checking through hospital databases and other sources. Survival was calculated from time of ICU admission, with a censoring date of 14 February 2007. Data for patients with multiple hospital admissions requiring intensive care were analysed only from the first admission. Summary and descriptive statistics were used for preliminary data analysis. Kaplan-Meier survival analysis was used to analyse factors determining long-term survival. Results: During the study period, 21 415 unique patients had 22 552 hospital admissions that included an ICU admission; 19 058 surgical procedures were performed with a total of 20 092 ICU admissions. There were 4936 deaths. Median follow-up was 6.2 years, totalling 134 203 patient years. The casemix was predominantly cardiac surgery (80%), followed by cardiac medical (6%), and other medical (4%). The unadjusted survival at 1, 5 and 10 years was 97%, 84% and 70%, respectively. The 1-year survival ranged from 97% for cardiac surgery to 36% for cardiac arrest. An APACHE II score was available for 16 877 patients. In those discharged alive from hospital, the 1, 5 and 10-year survival varied with discharge location. Conclusions: ICU-based linkage projects are feasible to determine long-term outcomes of ICU patients

Implementing an emergency department patient admission predictive tool : insights from practice

Purpose: This paper aims to show that identification of expectations and software functional requirements via consultation with potential users is an integral component of the development of an emergency department patient admissions prediction tool. ---------- Design/methodology/approach: Thematic analysis of semi-structured interviews with 14 key health staff delivered rich data regarding existing practice and future needs. Participants included emergency department staff, bed managers, nurse unit managers, directors of nursing, and personnel from health administration. ---------- Findings: Participants contributed contextual insights on the current system of admissions, revealing a culture of crisis, imbued with misplayed communication. Their expectations and requirements of a potential predictive tool provided strategic data that moderated the development of the Emergency Department Patient Admissions Prediction Tool, based on their insistence that it feature availability, reliability and relevance. In order to deliver these stipulations, participants stressed that it should be incorporated, validated, defined and timely. ---------- Research limitations/implications: Participants were envisaging a concept and use of a tool that was somewhat hypothetical. However, further research will evaluate the tool in practice. ---------- Practical implications: Participants' unsolicited recommendations regarding implementation will not only inform a subsequent phase of the tool evaluation, but are eminently applicable to any process of implementation in a healthcare setting. ---------- Originality/value: The consultative process engaged clinicians and the paper delivers an insider view of an overburdened system, rather than an outsider's observations.

Pre-Admission and Post-Hospital Management of Heart Failure in Patients not Enrolled in Specialist Programs

Aim: To review the management of heart failure in patients not enrolled in specialist multidisciplinary programs. Method: A prospective clinical audit of patients admitted to hospital with either a current or past diagnosis of heart failure and not enrolled in a specialist heart failure program or under the direct care of the cardiology unit. Results: 81 eligible patients were enrolled (1 August to 1 October 2008). The median age was 81 9.4 years and 48% were male. Most patients (63%) were in New York Heart Association Class II or Class III heart failure. On discharge, 59% of patients were prescribed angiotensin converting enzyme inhibitors and 43% were prescribed beta-blockers. During hospitalisation, 8.6% of patients with a past diagnosis of heart failure were started on an angiotensin converting enzyme inhibitor and 4.9% on a beta-blocker. There was evidence of suboptimal dosage on admission and discharge for angiotensin converting enzyme inhibitors (19% and 7.4%) and beta-blockers (29% and 17%). The results compared well with international reports regarding the under-treatment of heart failure. Conclusion: The demonstrated practice gap provides excellent opportunities for the involvement of pharmacists to improve the continuation of care for heart failure patients discharged from hospital in the areas of medication management review, dose titration and monitoring.

Prevalence of malnutrition risk and its relationship with risk factors of hospital re-admission in older adults

Background: Risk of malnutrition in older people continues to be a global problem. Malnutrition is often unrecognized and under-treated across health care settings and may result in undesirable health consequences, impaired recovery from illness and a poorer quality of life. Aim: This study aimed to determine the prevalence of malnutrition risk in a sample of older people at high risk of hospital re-admission. The association between risk factors of hospital re-admission and risk of malnutrition were also explored. Methods: One hundred and twenty five hospitalised patients aged 65 years and older at risk of hospital readmission (24% male, 76% female, mean age 77 ± 6 years) were recruited from a tertiary metropolitan hospital in Australia. The valid and reliable Malnutrition Screen Tool (MST) was employed to screen for malnutrition risk. It consists of two questions related to recent weight loss and appetite. Results: Prevalence of older adults at risk of malnutrition was 27.4%. Risk of malnutrition was not associated with age, gender and living arrangement. However, among risk factors of hospital readmission, lack of social support (χ2 = 4.18, N = 125, p = 0.028), and fair –poor self-rating of health (χ2 = 4.13, N = 125, p = 0.042) were statistically significant associated with risk of malnutrition. Conclusion: Risk of malnutrition in older people continues to be a concern in health care, and increasing psycho social support may help shed light on reducing risk of malnutrition.

Observed family interaction and outcome in patients with first-admission psychoses

Families of 52 first-admission patients diagnosed with a severe psychiatric disorder were videotaped interacting with the patient. Behavioral coding was used to derive several indices of interaction: base rates of positive and negative behavior by patients and relatives, cumulative affect of patients and relatives (the difference between the rates of positive and negative behaviors), and classification of families as affect-regulated or unregulated. Family-affect regulation reflects positive cumulative affect by both people in a given interaction. Six months after hospital discharge patients were assessed on occurrence of relapse, global functioning, severity of psychiatric symptoms, and quality of life. Relative to affect-unregulated family interaction, affect-regulated interaction predicted significantly fewer relapses, better global functioning, fewer positive and negative psychiatric symptoms, and higher patient quality of life. Most of the predictions by family-affect regulation were independent of

Admission as a lawyer : the fearful spectre of academic misconduct

Notwithstanding a cultural critique of the concepts that underpin the values of academic integrity, both the university, as a community of scholarship, and the legal profession, as a vocation self-defined by integrity, retain traditional values. Despite the lack of direct relevance of plagiarism to legal practice, courts now demonstrate little tolerance for applicants for admission against whom findings of academic misconduct have been made. Yet this lack of tolerance is neither fatal nor absolute, with the most egregious forms of academic misconduct, coupled with less than complete candour, resulting in no more than a deferral of an application for admission for six months. Where allegations are of a less serious nature, law schools deal with allegations in a less formal or punitive fashion, regarding it as an educative function of the university, assisting students to understand the cultural practices of scholarship. For law students seeking admission to practice, applicants are under an obligation of complete candour in disclosing any matters that bear on their suitability, including any finding of academic misconduct. Individual legal academics, naturally adhering to standards of academic integrity, often have only a general understanding of the admissions process. Applying appropriate standards of academic integrity, legal academics can create difficulties for students seeking admission by not recognising a pastoral obligation to ensure that students have a clear understanding of the impact adverse findings will have on admission. Failure to fulfil this obligation deprives students of the opportunity to take prompt remedial action as well as presenting practical problems for the practitioner who moves their admission.

Prevalence of undiagnosed urinary tract infections on admission to a rehabilitation unit

Background Through clinical observation nursing staff of an inpatient rehabilitation unit identified a link between incontinence and undiagnosed urinary tract infections (UTIs). Further, clinical observation and structured continence management led to the realisation that urinary incontinence often improved, or resolved completely, after treatment with antibiotics. In 2009 a small study found that 30% of admitted rehabilitation patients had an undiagnosed UTI, with the majority admitted post-orthopaedic fracture. We suspected that the frequent use of indwelling urinary catheters (IDCs) in the orthopaedic environment may have been a contributing factor. Therefore, a second, more thorough, study was commenced in 2010 and completed in 2011. Aim The aim of this study was to identify what proportion of patients were admitted to one rehabilitation unit with an undiagnosed UTI over a 12-month period. We wanted to identify and highlight the presence of known risk factors associated with UTI and determine whether urinary incontinence was associated with the presence of UTI. Methods Data were collected from every patient that was admitted over a 12-month period (n=140). The majority of patients were over the age of 65 and had an orthopaedic fracture (36.4%) or stroke (27.1%). Mid-stream urine (MSU) samples, routinely collected and sent for culture and sensitivity as part of standard admission procedure, were used by the treating medical officer to detect the presence of UTI. A data collection sheet was developed, reviewed and trialled, before official data collection commenced. Data were collected as part of usual practice and collated by a research assistant. Inferential statistics were used to analyse the data. Results This study found that 25 (17.9%) of the 140 patients admitted to rehabilitation had an undiagnosed UTI, with a statistically significant association between prior presence of an IDC and the diagnosis of UTI. Urinary incontinence improved after the completion of treatment with antibiotics. Results further demonstrated a significant association between the confirmation of a UTI on culture and sensitivity and the absence of symptoms usually associated with UTI, such as burning or stinging on urination. Overall, this study suggests careful monitoring of urinary symptoms in patients admitted to rehabilitation, especially in patients with a prior IDC, is warranted.

Limitation of Actions - effect of admission of liability

The decision in Simpson v Lenton [2002] QDC 214 applied the decisions of the Court of Appeal in Lindsay v Smith [2002] 1 Qd R 610 and Morris v FAI General Insurance Co Ltd [1996] 1 QDR 495 in finding the second defendant, having admitted liability, was estopped from relying on the expiration of the limitation period.

Pharmacist prescribing of venous thromboembolism prophylaxis in a surgical pre-admission clinic

Venous thromboembolism (VTE) is the term used to describe the disease process which presents as either deep vein thrombosis or pulmonary embolism. It is a major cause of death and disability worldwide and places a large financial burden on healthcare systems. Multiple risk factors have been identified for the development of VTE, including hospitalisation for acute medical illness and surgery. Documentation of VTE risk assessment is a critical part of any patient admission, driven by evidence that a risk assessment is a trigger for VTE prophylaxis to be considered. In the United Kingdom, healthcare services have set targets for VTE risk assessment documentation and financial incentives are linked to targets being met...

A pilot study to assess the appropriateness of prescribing from a collaborative pharmacist prescribing study in a surgical pre admission clinic

Background Current evidence to support non-medical prescribing is predominantly qualitative, with little evaluation of appropriateness. This study aims to evaluate the appropriateness of prescribing, and significance of omissions, from a doctor pharmacist collaborative prescribing model in an elective surgery pre admission clinic (PAC). Method A modified version of the Medication Appropriate Index (MAI) was developed, piloted and subsequently used by an expert panel, comprised of a surgeon, anaesthetist, clinical pharmacologist, pharmacist, resident medical officer (RMO) and clinical nurse. The tool was used to rate the appropriateness of prescribing of medications, and the significance of omissions in a 5% sample (N=19) of the total cohort from a randomised, controlled two arm trial of doctor-pharmacist collaborative prescribing. Results When reviewer assessments were combined, 32 out of 294 (10.9%) medications assessed for appropriateness in the control arm were classed as inappropriate, compared to 13 of 266 (4.9%) in the intervention arm. Out of 89 regular medications in the control arm, 25 (28%) were omitted from the medication charts, compared to 1 out of 55 (2%) in the intervention arm (p<0.001, fishers exact) On average, 52% of omissions in the control arm were judged to have potential for patient harm or ward inconvenience. Conclusion For the appropriateness of prescribing, overall results were similar between arms, as judged by individual panel members. Medication charts in the control arm contained significantly more omissions than in the intervention arm, a number of which were rated by the panel members as having the potential for patient harm or ward inconvenience.

Delirium in advanced cancer : screening for the incidence on admission to an inpatient hospice unit

Background Delirium is a common underdiagnosed condition in advanced cancer leading to increased distress, morbidity, and mortality. Screening improves detection but there is no consensus as to the best screening tool to use with patients with advanced cancer. Objective To determine the incidence of delirium in patients with advanced cancer within 72 hours of admission to an acute inpatient hospice using clinical judgement and validated screening tools. Method One hundred consecutive patients with advanced cancer were invited to be screened for delirium within 72 hours of admission to an acute inpatient hospice unit. Two validated tools were used, the Delirium Rating Scale-Revised 98 (DRS-R-98) and the Confusion Assessment Method (CAM) shortened diagnostic algorithm. These results were compared with clinical assessment by review of medical charts. Results Of 100 consecutive admissions 51 participated and of these 22 (43.1%) screened positive for delirium with CAM and/or DRS-R-98 compared to 15 (29.4%) by clinical assessment. Eleven (21.6%) were identified as hypoactive delirium and 5 (9.8%) as subsyndromal delirium. Conclusion This study confirms that delirium is a common condition in patients with advanced cancer.While there remains a lack of consensus regarding the choice of delirium screening tool this study supports theCAMas being appropriate. Further research may determine the optimal screening tool for delirium enabling the development of best practice clinical guidelines for routinemedical practice.

Patients Undergoing Subacute Physical Rehabilitation following an Acute Hospital Admission Demonstrated Improvement in Cognitive Functional Task Independence

Objective. This study investigated cognitive functioning among older adults with physical debility not attributable to an acute injury or neurological condition who were receiving subacute inpatient physical rehabilitation. Design. A cohort investigation with assessments at admission and discharge. Setting. Three geriatric rehabilitation hospital wards. Participants. Consecutive rehabilitation admissions () following acute hospitalization (study criteria excluded orthopaedic, neurological, or amputation admissions). Intervention. Usual rehabilitation care. Measurements. The Functional Independence Measure (FIM) Cognitive and Motor items. Results. A total of 704 (86.5%) participants (mean age = 76.5 years) completed both assessments. Significant improvement in FIM Cognitive items (-score range 3.93–8.74, all ) and FIM Cognitive total score (-score = 9.12, ) occurred, in addition to improvement in FIM Motor performance. A moderate positive correlation existed between change in Motor and Cognitive scores (Spearman’s rho = 0.41). Generalized linear modelling indicated that better cognition at admission (coefficient = 0.398, ) and younger age (coefficient = −0.280, ) were predictive of improvement in Motor performance. Younger age (coefficient = −0.049, ) was predictive of improvement in FIM Cognitive score. Conclusions. Improvement in cognitive functioning was observed in addition to motor function improvement among this population. Causal links cannot be drawn without further research.