Treating in Place: Acute Care for Long-Stay Residents in Nursing Facilities Under a CMS Initiative.

BACKGROUND/OBJECTIVES: Nursing facility (NF) residents are commonly hospitalized, and many of these hospitalizations may be avoidable. A Centers for Medicare & Medicaid Services (CMS) initiative enables participating NFs to bill Medicare for providing on-site acute care to long-stay residents diagnosed with one of six ambulatory care sensitive conditions (pneumonia, congestive heart failure, chronic obstructive pulmonary disease, dehydration, skin infection, and urinary tract infection) that account for many avoidable hospitalizations. This study describes the frequency of initiative-related treatment for the six conditions, both on site and in the hospital, and the health status of residents who were treated. DESIGN: We used the Minimum Data Set V3.0 and Medicare data to identify eligible residents, detect on-site treatment under the initiative as well as in-hospital treatment both before and during the initiative, and measure health status. SETTING: Participating NFs during fiscal years 2017 to 2018. PARTICIPANTS: There were 47,202 long-stay NF residents from 260 facilities in seven states. INTERVENTION: CMS initiative to reduce avoidable hospitalizations among NF residents-payment reform. MEASUREMENTS: Percentage per year who received on-site treatment (2017-2018), and who received in-hospital treatment (2014-2018), for the six conditions. RESULTS: Each year, approximately 20% of residents received treatment on site during 2017 to 2018, and under 10% received treatment in the hospital during 2014 to 2018, with little change over these years. Residents treated on site had less chronic illness than those treated in the hospital. CONCLUSION: Although the initiative sought to reduce hospitalizations, in-hospital treatment for the six conditions did not substantially change after initiative implementation, despite substantial new billing for on-site treatment for those conditions. These findings suggest that many residents treated on site would likely not have been hospitalized even absent the initiative. The residents treated on site tended to have fewer chronic conditions than those treated in the hospital.

Acute and Transient Psychotic Disorders: Newer Understanding.

PURPOSE OF REVIEW: We review the ongoing research in the area of acute and transient psychotic disorders (ATPDs) with regard to their nosology, epidemiology, clinical description, genetics, and neurobiology, examining evidence for distinctiveness or otherwise of ATPDs. We further highlight the lacuna in research in ATPDs. RECENT FINDINGS: Studies on ATPDs as defined in the ICD 10 have been reported from different parts of the world, more so from the developing countries. There is consistent evidence that there exist a group of ATPDs that occur more commonly among females, are often precipitated by stressful life events or exposure to physiological stresses like fever, child birth, are associated with well-adjusted premorbid personality, and show complete recovery in a short period. Although in some cases of ATPDs, there is symptomatic overlap with schizophrenic symptoms in the acute phase, they follow a completely different course and outcome, exhibit genetic distinctiveness, and do not share genetic relationship with schizophrenias or bipolar affective disorder (BPAD). Comparative studies on neurophysiology and neuroimaging in ATPDs and schizophrenias have demonstrated evidence of hyper arousal and hyper metabolism in ATPDs vs hypo arousal and hypo metabolism as noted in the P300 response and on FDG PET studies, respectively. Immune markers such as IL-6, TNF-alpha, and TGF-beta show higher levels in ATPDs as compared to healthy controls. Findings on the neurobiological mechanisms underlying ATPDs, so far, point towards significant differences from those in schizophrenia or BPAD. Although the studies are few and far between, nevertheless, these point towards the possibility of ATPDs as a distinct entity and underscore the need for pursuing alternate hypothesis such as neuro inflammatory or metabolic. Research on ATPDs is limited due to many reasons including lack of harmony between the ICD and DSM diagnostic systems and clinician biases. Available research data supports the validity of ATPDs as a distinct clinical entity. There is also evidence that ATPDs are different from schizophrenias or BPAD on genetic, neuroimaging, neurophysiological, and immunological markers and require further studies.

B cell subset alteration and the expression of tissue homing molecules in dengue infected patients.

BACKGROUND: B cells play an essential role during dengue viral infection. While a major expansion of antibody secreting cells (ASCs) was observed, the importance of these increased frequencies of ASCs remains unclear. The alteration of B cell subsets may result from the expression of tissue specific homing molecules leading to their mobilization and distribution to different target organs during acute dengue viral infection. METHODS: In this study, whole blood samples were obtained from thirty pediatric dengue-infected patients and ten healthy children and then stained with fluorochrome-conjugated monoclonal antibodies against CD3, CD14, CD19, CD20, CD21, CD27, CD38, CD45, CD138 and homing molecules of interest before analyzed by polychromatic flow cytometry. B cell subsets were characterized throughout acute infection period. RESULTS: Data shows that there were no detectable differences in frequencies of resting, activated and tissue memory cells, whereas the frequency of ASCs was significantly increased and associated with the lower frequency of naïve cells. These results were found from patients with both dengue fever and dengue hemorrhagic fever, suggesting that such change or alteration of B cells was not associated with disease severity. Moreover, several homing molecules (e.g., CXCR3 and CCR2) were found in ASCs, indicating that ASCs may distribute to inflamed tissues and various organs. CONCLUSIONS: Findings from this study provide insight into B cell subset distribution. Furthermore, organ mobilization according to homing molecule expression on different B cell subsets during the course of dengue viral infection also suggests they are distributed to inflamed tissues and various organs.

[Patient-related complexity in nursing care - Collective case studies in the acute care hospital]. / Patientenbezogene Komplexität in der Pflege ­ Kollektive Case Studies im Akutspital.

Patient-related complexity in nursing care - Collective case studies in the acute care hospital Abstract. BACKGROUND: Patient-related complexity of nursing is defined by the three characteristics "instability", "uncertainty", and "variability". Complexity increased in the past years, due to reduced hospital length of stay and a growing number of patients with chronic and multiple diseases. AIM: We investigated the phenomenon of patient-related complexity from the point of view of nurses and clinical nurse specialists in an acute care hospital. METHODS: In the context of a collective case study design, nurses and clinical nurse specialists assessed the complexity of nursing situations with a questionnaire. Subsequently, we interviewed nurses and clinical nurse specialists about their evaluation of patient-related complexity. In a within-case-analysis we summarized data inductively to create case narratives. By means of a cross-case-analysis we compared the cases with regard to deductively derived characteristics. RESULTS: The four cases exemplarily showed that the degree of complexity depends on the controllability and predictability of clinical problems. Additionally, complexity increases or decreases, according to patients' individual resources. CONCLUSIONS: Complex patient situations demand professional expertise, experience, communicative competencies and the ability for reflection. Beginner nurses would benefit from support and advice by experienced nurses to develop these skills.

The danish regions pediatric triage model has a limited ability to detect both critically ill children as well as children to be sent home without treatment - a study of diagnostic accuracy.

BACKGROUND: The Danish Regions Pediatric Triage model (DRPT) was introduced in 2012 and subsequent implemented in most Danish acute pediatric departments. The aim was to evaluate the validity of DRPT as a screening tool to detect both the most serious acute conditions and the non-serious conditions in the acute referred patients in a pediatric department. METHOD: The study was prospective observational, with follow-up on all children with acute referral to pediatric department from October to December 2015. The DRPT was evaluated by comparison to a predefined reference standard and to the actual clinical outcomes: critically ill children and children returned to home without any treatment. The sensitivity, specificity, positive predictive value, negative predictive value, accuracy and likelihood for positive and negative test were calculated. RESULTS: Five hundred fifty children were included. The DRPT categorized 7% very urgent, 28% urgent, 29% standard and 36% non-urgent. The DRPT was equal to the reference standard in 31% of the children (CI: 27-35%). DRPT undertriaged 55% of the children (CI: 51-59%) and overtriaged 14% of the children (CI: 11-17%). For the most urgent patients the sensitivity of DRPT was 31% (CI: 20-48%) compared to the reference standard and 20% (CI: 7-41) for critically ill. For children with non-urgent conditions the specificity of DRPT was 66% (CI: 62-71%) compared to the reference standard and 68% (CI: 62-75%) for the children who went home with no treatment. In none of the analyses, the likelihood ratio of the negative test was less than 0.7 and the positive likelihood ratio only reached more than 5 in one of the analyses. DISCUSSION: This study is the first to evaluate the DRPT triage system. From the very limited validity studies of other well-established triage systems, it is difficult to judge whether the DRPT performs better or worse than the alternatives. The DRPT errs to the undertriage side. If the sensitivity is low, a number of the sickest children are undetected and this is a matter of concern. CONCLUSION: The DRPT is a triage tool with limited ability to detect the critically ill children as well as the children who can be returned to home without any treatment. TRIAL REGISTRATION: Not relevant.

Discovery of temporal and disease association patterns in condition-specific hospital utilization rates.

Identifying temporal variation in hospitalization rates may provide insights about disease patterns and thereby inform research, policy, and clinical care. However, the majority of medical conditions have not been studied for their potential seasonal variation. The objective of this study was to apply a data-driven approach to characterize temporal variation in condition-specific hospitalizations. Using a dataset of 34 million inpatient discharges gathered from hospitals in New York State from 2008-2011, we grouped all discharges into 263 clinical conditions based on the principal discharge diagnosis using Clinical Classification Software in order to mitigate the limitation that administrative claims data reflect clinical conditions to varying specificity. After applying Seasonal-Trend Decomposition by LOESS, we estimated the periodicity of the seasonal component using spectral analysis and applied harmonic regression to calculate the amplitude and phase of the condition's seasonal utilization pattern. We also introduced four new indices of temporal variation: mean oscillation width, seasonal coefficient, trend coefficient, and linearity of the trend. Finally, K-means clustering was used to group conditions across these four indices to identify common temporal variation patterns. Of all 263 clinical conditions considered, 164 demonstrated statistically significant seasonality. Notably, we identified conditions for which seasonal variation has not been previously described such as ovarian cancer, tuberculosis, and schizophrenia. Clustering analysis yielded three distinct groups of conditions based on multiple measures of seasonal variation. Our study was limited to New York State and results may not directly apply to other regions with distinct climates and health burden. A substantial proportion of medical conditions, larger than previously described, exhibit seasonal variation in hospital utilization. Moreover, the application of clustering tools yields groups of clinically heterogeneous conditions with similar seasonal phenotypes. Further investigation is necessary to uncover common etiologies underlying these shared seasonal phenotypes.

Disability and functional burden of disease because of mental in comparison to somatic disorders in general practice patients.

BACKGROUND: Severity of illness is not only depending on the symptom load, but also on the burden in life. Mental disorders are among those illnesses, which in particular cause suffering to the individual and society. METHOD: To study burden of disease for mental in comparison to somatic disorders, 2099 patients from 40 general practitioners filled in (a) the Burvill scale which measures acute and chronic illnesses in ten different body systems and (b) the IMET scale which measures impairment in ten different areas of life. RESULTS: Patients were suffering on average from acute and/or chronic illness in 3.5 (SD: 2.0) body systems and 56.6% of patients complained about acute and/or chronic mental disorders. The most significant negative impact on the IMET total score have acute and chronic mental disorders, followed by chronic neurological and musculoskeletal and acute respiratory and gastrointestinal disorders, while cardiovascular, metabolic, urogenital, haematological and ear/eye disorders have no greater impact. Acute as well as chronic mental disorders cause impairment across all areas of life and most burden of disease (functional burden of disease 1.69), followed by musculoskeletal disorders (1.62). CONCLUSION: Mental disorders are among the most frequent health problems with high negative impact across all areas of life. When combining frequency and impairment mental disorders cause most burden of disease in comparison to other illnesses. This should be reflected in the organization of medical care including family medicine.

Stratification of children by medical complexity.

OBJECTIVE: To stratify children using available software, Clinical Risk Groups (CRGs), in a tertiary children's hospital, Seattle Children's Hospital (SCH), and a state's Medicaid claims data, Washington State (WSM), into 3 condition groups: complex chronic disease (C-CD); noncomplex chronic disease (NC-CD), and nonchronic disease (NC). METHODS: A panel of pediatricians developed consensus definitions for children with C-CD, NC-CD, and NC. Using electronic medical record review and expert consensus, a gold standard population of 700 children was identified and placed into 1 the 3 groups: 350 C-CD, 100 NC-CD, and 250 NC. CRGs v1.9 stratified the 700 children into the condition groups using 3 years of WSM and SCH encounter data (2008-2010). WSM data included encounters/claims for all sites of care. SCH data included only inpatient, emergency department, and day surgery claims. RESULTS: A total of 678 of 700 children identified in SCH data were matched in WSM data. CRGs demonstrated good to excellent specificity in correctly classifying all 3 groups in SCH and WSM data; C-CD in SCH (94.3%) and in WSM (91.1%); NC-CD in SCH (88.2%) and in WSM (83.7%); and NC in SCH (84.9%) and in WSM (94.6%). There was good to excellent sensitivity for C-CD in SCH (75.4%) and in WSM (82.1%) and for NC in SCH (98.4%) and in WSM (81.1%). CRGs demonstrated poor sensitivity for NC-CD in SCH (31.0%) and WSM (58.0%). Reasons for poor sensitivity in NC-CD are explored. CONCLUSIONS: CRGs can be used to stratify children receiving care at a tertiary care hospital according to complexity in both hospital and Medicaid administrative data. This method will enhance reporting of health-related outcome data.

The PIRO (predisposition, insult, response, organ dysfunction) model: toward a staging system for acute illness.

Multimodal therapy for diseases like cancer has only become practicable following the development of staging systems like the TNM (tumor, nodes, metastases) system. Staging enables the identification of subgroups of patients with a disease who not only have a differing prognosis, but who are also more likely to benefit from a specific therapeutic modality. Critically ill patients represent a highly heterogeneous population for whom multiple therapeutic options are potentially available, each carrying not only the potential for differential benefit, but also the potential for differential harm. The PIRO system (predisposition, insult, response, organ dysfunction) is a template proposal for a staging system for acute illness that incorporates assessment of pre-morbid baseline susceptibility (predisposition), the specific disorder responsible for acute illness (insult), the response of the host to that insult, and the resulting degree of organ dysfunction. However the creation of a valid, robust, and clinically useful system presents significant challenges arising from the complexity of the disease state, the lack of a clear phenotype, the confounding influence of the effects of therapy and of cultural and socio-economic factors, and the relatively low profile of acute illness with clinicians and the general public. This review summarizes the rationale for such a model of illness stratification and the results of preliminary cohort studies testing the concept. It further proposes two strategies for building a staging system, recognizing that this will be a demanding undertaking that will require decades of work.

The multifactorial presentation of depression in acute care.

Depression is by its very nature a heterogeneous disorder; 2 patients with the same diagnosis (ie, major depressive disorder) may have few symptoms in common. This heterogeneity is evidenced by the fact that depression presents in a wide variety forms related to polarity (unipolar vs bipolar), symptoms (melancholic, atypical, psychotic, or anxious), onset (specific events, seasons, or age), recurrence, and severity. These diagnostic specifiers and subgroups can guide treatment decisions in several ways. For example, recognizing a specific depressive subtype in a patient can help the clinician select an appropriate treatment based on that patient's particular presentation. These subtypes can also guide treatment by helping the clinician and patient to identify and discuss factors that help or hinder the achievement of remission and recovery. Although depression specifiers and subtypes are subject to revision and change, many of them provide helpful information about recognition and treatment.

Using a local early warning scoring system as a model for the introduction of a national system.

BACKGROUND: Chelsea and Westminster Hospital introduced the Chelsea Early Warning Score (CEWS) in 2007 to aid the recognition of acutely unwell patients. The Royal College of Physicians subsequently recommended a National Early Warning Score (NEWS) for implementation across the NHS. The aim of this study was to evaluate local adherence to CEWS to identify potential obstacles to the consistent implementation of NEWS. METHOD: Emergency Department (ED) and Acute Assessment Unit (AAU) notes were retrospectively reviewed for a convenience sample of 102 patients admitted to the AAU. Outcome measures were completeness of documentation of CEWS parameters, documentation and accuracy of aggregate CEWS scores. Aggregate NEWS scores were calculated from the documented observations and the calculated CEWS and NEWS scores were compared. RESULTS: Physiological observations were documented for all patients attending the ED and AAU. Heart rate, blood pressure, respiratory rate, oxygen saturation and conscious level were documented in over 95% of ED and AAU patients. Urine output was recorded for only 48% of ED and 69% of AAU patients. Aggregate CEWS scores were documented for 66% of ED and 84% of AAU patients. These were calculated accurately in 73% of ED and 79% of AAU patients. Calculation errors were eleven times more likely to result in under-scoring than over-scoring. NEWS scores were significantly higher than CEWS for the same observations and would have resulted in a 71% increase in patients requiring escalation of care in the ED and a 116% increase in AAU. CONCLUSION: Concerns highlighted with CEWS were the incomplete and inaccurate recording of aggregate scores, with underscoring resulting in the potential failure to recognise deteriorating patients. It is anticipated that NEWS will be accompanied by standardised documentation and training across the NHS which will support more complete and accurate recording of physiological data. Furthermore, NEWS appears from this study to be more sensitive than CEWS, thereby minimising the chance of missed deterioration.

Reliability of acute pancreatitis diagnosis coding in a National Patient Register: a validation study in Sweden.

AIM: National patient registers are powerful tools in epidemiological research and healthcare administration. As the level of reliability of diagnoses that are partly based on clinical signs, such as acute pancreatitis, may be low, the reliability of discharge diagnoses in these registers needs to be validated. The main aim of this study was to validate the diagnosis coding for acute pancreatitis in the Swedish National Patient Register. METHOD: We randomly sampled 650 admissions of all patients registered in the Swedish National Patient Register with acute pancreatitis or other nonmalignant pancreatic disorders as the main diagnosis in 2007 and 1998, and as the secondary diagnosis in 2007. The medical records for these admissions were reviewed. We analyzed the concordance between the coding of acute pancreatitis in the Swedish National Patient Register and criteria based on internationally accepted diagnostic standards. RESULTS: We received 603 medical records for manual review. Among the 530 patients with a diagnosis of acute pancreatitis in the Swedish National Patient Register, 442 (83%) were, after review, defined as definitive acute pancreatitis, 80 (15%) as probable acute pancreatitis, and 8 (2%) as no acute pancreatitis. There were no significant differences in the reliability of the diagnosis with regard to sex, age, time period or whether the patient had been treated at a county or university hospital. Among the 73 patients registered with a non-malignant pancreatic disorder other than acute pancreatitis, the number of false-negative cases of acute pancreatitis was 23 (32%). They were mainly found among patients registered with a diagnosis of chronic pancreatitis. CONCLUSION: The Swedish National Patient Register is highly reliable as regards correct coding of acute pancreatitis. However, there seems to be a non-negligible share of false-negative cases of acute pancreatitis among patients registered with a diagnosis of chronic pancreatitis.

The value of the Modified Early Warning Score and biochemical parameters as predictors of patient outcome in acute medical admissions a prospective study.

We evaluated the effectiveness of MEWS and biochemical parameters in predicting outcomes for acute medical admissions. Data from consecutive admissions to the Acute Medical Unit (AMU) of National Hospital of Sri Lanka were collected. C-reactive protein (CRP), albumin, white cell count, platelet count and haemoglobin values were collected. Adverse endpoints were HDU/ICU admission,cardio-respiratory emergency/resuscitation and death. A MEWS score of >=5 together with increasing age,pulse rate, respiratory rate, AVPU score, CRP,CRP/Albumin ratio and reduced platelet and albumin levelall increased the odds of reaching "adverse endpoints". Adding a score for biochemical parameters increased the area under the ROC curve for reaching "adverse endpoints" Biochemical parameters better predicted length of hospital stay and adverse outcomes. A combined scoring system improved the sensitivity of prediction.

Prediction of severe acute pancreatitis at admission to hospital using artificial neural networks.

BACKGROUND/AIMS: Artificial neural networks (ANNs) are non-linear pattern recognition techniques, which can be used as a tool in medical decision-making. The aim of this study was to construct and validate an ANN model for early prediction of the severity of acute pancreatitis (AP). METHODS: Patients treated for AP from 2002 to 2005 (n = 139) and from 2007 to 2009 (n = 69) were analyzed to develop and validate the ANN model. Severe AP was defined according to the Atlanta criteria. RESULTS: ANNs selected 6 of 23 potential risk variables as relevant for severity prediction, including duration of pain until arrival at the emergency department, creatinine, hemoglobin, alanine aminotransferase, heart rate, and white blood cell count. The discriminatory power for prediction of progression to a severe course, determined from the area under the receiver-operating characteristic curve, was 0.92 for the ANN model, 0.84 for the logistic regression model (p = 0.030), and 0.63 for the APACHE II score (p < 0.001). The numbers of correctly classified patients for a sensitivity of 50 and 75% were significantly higher for the ANN model than for logistic regression (p = 0.002) and APACHE II (p < 0.001). CONCLUSION: The ANN model identified 6 risk variables available at the time of admission, including duration of pain, a finding not being presented as a risk factor before. The severity classification developed proved to be superior to APACHE II. and IAP.