Factors influencing inpatient mortality of medical patients

OBJECTIVE: To investigate factors influencing inpatient mortality and length of stay among medical patients at a public hospital. METHODS: A case-control study involving a 10 percent sample of medical admissions who died (n=109) was done at the Kingston Regional Hospital during 1998. These were matched for age, gender and admission date to 2 controls (n=180) where death did not occur. Trained personnel abstracted information from personnel records. RESULTS: The sample comprised 147 men and 139 women of mean/Standard Deviation (SD) age 61.3ñ18.1 years and range of 12 to 94 years. The mean/SD length of stay was 6.3ñ6.0 days with a median of 5 days. Length of stay did not differ by gender (p=0.69) or mortality (p=0.86). Re-admission accounted for 34.3 percent of admissions occuring at a median of 174 days. There was 70 percent agreement between the provisional diagnosis at admission and the primary discharge diagnosis. The commonest primary diagnoses were diabetes mellitus and hypertension (14 percent each). Stroke, pneumonia and cancer each accounted for over 5 percent of primary diagnoses. Risk of death was greater in women who were alone (single or widowed/divorced/separated) than in those in a union - odds ratio (OR) and 95 percent confidence interval (95 percent CI) 3.63 (1.36, 9.67). In men the OR (95 percent CI) was 0.94 (0.38-2.31). Cancer, stroke chronic renal failure and pneumonia were associated with an increased risk of in-hospital mortality and so was documentation of examination by a consultant. There was an inverse association between the number of entries per day in patients' notes and the risk of death. Less than 2 percent of admissions had a record of patient satisfaction. Nurses notes were judged to be adequate in 76.5 percent of admissions but only 19.2 percent of patient records were rated as good overall. Good quality records were not associated with better survival or shorter hospitalization. CONCLUSION: The relationship between process of care and inpatient mortality is complex and clear associations were not demonstrated for overall mortality. Cause-specific mortality may be a more informative outcome for quality of care studies. (AU)

The challenge of designing a database for auditing surgical in-patients

Surgical audit is imperative in modern practice, particularly in the developing world where resources are limited and efficient allocation important. The structure, process and outcome of surgical care can be determined for quality assurance or for research. Improved efficiency and reduction of morbidity and mortality are additional goals which may be accomplished. However, computerization, medical staff cooperation and the availability of dedicated staff are among the hurdles which may be encountered. We report the challenge of designing and establishing a database for auditing surgical inpatients in a developing country and the difficuties which were encountered.(AU)

Significance of polymicrobic bacteriuria in a teaching hospital in Trinidad

OBJECTIVE: To compare microbial prevalence (mixed versus pure), define microbial combination in mixed urine cultures among inpatients and outpatients to identify factors that might allow a more objective interpretation of polymicrobic urine cultures. DESIGN: Case series. SETTING: The study involved inpatients (hospitalized) and outpatients (those attending outpatient clinics and the accident and emergency department) of the San Fernando General Hospital in southern Trinidad. MAIN OUTCOME MEASURES: Prevalence rates of bacterial isolates in mixed and pure cultures of urine specimens were determined using standard techniques and Kirby-Bauer disc diffusion methodology. RESULTS: The results showed that of 5,089 urine specimens, 1,491 (29.3 percent) yielded positive cultures. Of these positive cultures, 524 (35.1 percent) revealed significant polymicrobic bacteriuria. Eighty five percent yielded two organisms 13.2 percent had three organisms and 1.8 percent had four organisms. Repeat cultures 157 patients revealed the same organisms in only 57.3 percent of them. Almost all of the repeat cultures were from patients with in-dwelling Foley catheters. E. coli was the most common single isolate (42.8 percent), while Klebsiella, Enterobacter and Proteus organisms were most often encountered in mixed cultures. All isolates were relatively sensitive to routinely used antibiotics for urinary pathogens. CONCLUSION: The prevalence rate of polymicrobic bacteriuria at our institution was 10.2 percent. More than 65 percent of positive cultures were from patients with Foley catheters on open drainage (inpatients) and closed drainage (outpatients). Most were men with out-flow obstruction who either refused surgery, were unfit for surgery, or had to wait long periods to be booked for surgery. No cases developed bacteremia secondary to bacteriuria. All urinary isolates were susceptible to routinely used antimicrobial agents.(Au)

The pattern of in-patient psychiatric referrals in a general hospital

All patients referred for a psychiatric consultation from the adult wards of a General Hospital over a 10-month period were examined. The referral rate was 1.4 percent. Twice as many female patients were referred as male pateints. Parasuicide accounted for 68 percent of referrals. The most common psychiatric diagnoses were adjustment reaction (41 percent), depression (23 percent), alcohol dependence (5 percent). In 30 percent of referrals, no psychiatric treatment was necessary; 26 percent were transferred to the psychiatric unit and 17 percent were discharged to the out-patients' psychiatric clinic. Explanations are offered for the "hidden" psychiatric morbidity in General Hospitals and the high percentage of referrals who did not need psychiatric follow-up. Suggestions are made for a better liaison between physicians and psychiatrists (AU)

Psychiatric referrals in the University Hospital of the West Indies

The creation in 1965 of a Department of Psychiatry at the University of the West Indies and the introduction of an inpatient psychiatric service at the University Hospital, marked an important step in the development of community psychiatry services in Jamaica. This study examines two important areas of the Psychiatric Unit's activities which have not been reported on to date: referrals to psychiatry from the Hospital's Casualty Department and referrals from general hospital wards. The very fact of providing a twenty-four hour emergency referral service for Casualty attenders is an important factor in encouraging the use of Casualty as a first point of medical contact for psychiatric disorders, even though it serves in practice as a walk-in facility rather than a true emergency service. The judgement of the casualty officers both in diagnosis and disposal is shown to be good. Day Hospital is probably under-used by the duty psychiatrist as a disposal option for persons seen in Casualty. There is a high incidence of cannabis use among males aged 20-29 and the findings agree with earlier reports of the association between cannabis and schizophrenic disturbance. Inpatient referrals to the consultation service show a low rate compared to that reported for other hospitals. With more than a quarter of these referrals originating from complications of medical condition and medical treatment, the consultation-liaison service is well justified. The fact that less than one in ten of these patients needed transfer to the psychiatric unit for management of their disorder should encourage a community-based approach to mental health in the minds of all practitioners. The author's view is that a consultation-liaison service assists the teaching of psychiatry by encouraging an awareness of the relationship between physical and psychological medicine (AU)