Associations between characteristics of the patients at municipal acute bed unit admission and further transfer to hospital: a prospective observational study.

BACKGROUND: As an alternative to acute hospitalisations, all communities in Norway are required to provide inpatient care in municipal acute bed units (MAUs) for patients who can be treated at the primary care level. Patient selection is challenging, and some patients need transfer from MAUs to hospitals. The aim of this study was to examine associations between characteristics of the patient at admission to MAU and further transfer to hospital. METHODS: In a prospective observational study on all admissions to a large MAU, March 2016-August 2017, information was obtained on patient age, gender, comorbidities, drug use, reason for stay and Triage Early Warning Score (TEWS) on admission and at discharge, and length of stay. Comparison between admissions resulting in discharge to hospital, nursing home or own home were performed with chi-square and ANOVA tests. Estimated relative risks (RR) with 95% confidence interval for transfer to hospital versus being retained at primary care level was estimated for age, gender, comorbidity and TEWS in generalized linear models, crude and adjusted. RESULTS: Two thousand seven hundred forty-four admissions were included. Mean age of the patients was 69.5 years (SD 21.9), 65.2% were women. In 646 admissions (23.6%), the patients were transferred to hospital. Male gender and TEWS > 2 were associated with transfer to hospital. Most transfers to hospital occurred within 24 h, and these patients had unchanged or increasing TEWS during their stay at MAU. When transferred to hospital 41.5% of the patients had the same reason for stay as on MAU admission, 14.9% had another reason for stay, 25.2% had a medical condition outside the treatment scope of MAU, and 18.4% needed further diagnostic clarification in hospital. CONCLUSIONS: Likelihood of transfer to hospital increased with male gender and higher TEWS on admission. Main reasons for transfer to hospital were lack of improvement and identification of clinical conditions that needed hospital care. TEWS > 2 at admission should make physicians alert to the need of close monitoring for lack of improvement.

First four years of operation of a municipal acute bed unit in rural Norway.

OBJECTIVE: To evaluate the use of a small municipality acute bed unit (MAU) in rural Norway resulting from the Coordination reform regarding occupancy-rate, patient characteristics and healthcare provided during the first four years of operation. Further, to investigate whether implementation of the new municipal service avoided acute hospital admissions. DESIGN: Observational study. SETTING: A two-bed municipal acute bed unit. SUBJECTS: All patients admitted to the unit between 2013 and 2016. MAIN OUTCOME MEASURES: Demographics, comorbidity, main diagnoses and level of municipal care on admission and discharge, diagnostic and therapeutic initiatives, MAU occupancy rate, and acute hospital admission rate. RESULTS: Altogether, 389 admissions occurred, 215 first-time admissions and 174 readmissions. The mean MAU bed occupancy rate doubled from of 0.26 in 2013 to 0.50 in 2016, while acute hospital admission rates declined. The patients (median age 84.0 years, 48.9% women at first time admission) were most commonly admitted for infections (28.0%), observation (22.1%) or musculoskeletal symptoms (16.2%). Some 52.7% of the patients admitted from home were discharged to a higher care level; musculoskeletal problems as admission diagnosis predicted this (RR =1.43, 95% CI 1.20-1.71, adjusted for age and sex). CONCLUSION: Admission rates to MAU increased during the first years of operation. In the same period, there was a reduction in acute hospital admissions. Patient selection was largely in accordance with national and local criteria, including observational stays. Half the patients admitted from home were discharged to nursing home, suggesting that the unit was used as pathway to a higher municipal care level. Key Points Evaluation of the first four years of operation of a municipality acute bed unit (MAU) in rural Norway revealed: • Admission rates to MAU increased, timely coinciding with decreased acute admission rates to hospital medical wards. • Most patients were old and had complex health problems. • Only half the patients were discharged back home; musculoskeletal symptoms were associated with discharge to a higher care level.

The impact of health care settings on survival time of patients with chronic myeloid leukemia.

With the introduction of tyrosine kinase inhibitors, the treatment of chronic myeloid leukemia (CML) patients has migrated extensively to municipal hospitals (MHs) and office-based physicians (OBPs). Thus, we wanted to check whether the health care setting has an impact on outcome. Based on 1491 patients of the German CML Study IV, we compared the outcomes of patients from teaching hospitals (THs) with those from MHs and OBPs. Adjusting for age, European Treatment and Outcome Study (EUTOS) score, Karnofsky performance status, year of diagnosis, and experience with CML, a significant survival advantage for TH patients (hazard ratio: 0.632 respectively 0.609) was found. In particular, when treated in THs, patients with blast crisis showed a superior outcome (2-year survival rate: 47.7% vs 22.3% vs 25.0%). Because the impact of the health care setting on the outcome of CML patients has not been reported before, these findings need confirmation by other study groups. This trial was registered at www.clinicaltrials.gov as #NCT00055874.

[Alcohol-related mortality in the assessments of hospital unit physicians and pathologists: analysis of accounting medical documents].

AIM: To make a comparative analysis of the data available in the accounting medical documents drawn up at a multidisciplinary hospital on the level and structure of alcohol-related mortality (ARM) and to evaluate the efficiency of its accounting. MATERIALS AND METHODS: Accounting medical documents, such as 453 inpatient cards (Form 003/y), 453 postmortem protocols (cards) (Form 013/H-80), and 453 death certificates (Form 106/y-08), were chosen as the basis for the study. The data of the final clinical and postmortem diagnoses in the patients who had died at hospital and their primary cause of death were comparatively analyzed. RESULTS: According to Form 003/y, ARM was 5.5%; the detection rate of alcohol-related disease (ARD) was 11% (95% confidence interval (CI), 8.3 to 14.3%); according to Form 013/H-80, ARM was 7.1% (95% CI, 4.9 to 9.8%) and the detection rate of ARD was 12.6% (95% CI, 9.7 to 16%). The consistency of the diagnoses of ARD as a main cause of death, made by hospital unit physicians and pathologists, is estimated as the mean--the Cohen's kappa coefficient (kappa) is 0.570) (p < 0.001). CONCLUSION: The results of the investigation suggest that there are 3 types of ARM, which differ in its level and structure: ARM in the assessments of hospital unit physicians; that in the assessments of pathologists, and that according to the death certificates drawn up. The consistency index for the diagnosis of ARD as a main cause of death indicates that the hospital unit physicians only determine the etiology of alcohol-related cause of death, without identifying it specifically.

The objective and subjective outcome of orthodontic care in one municipal health center.

OBJECTIVE: The aim of this study was to assess the outcome of orthodontic care in one municipal health center. MATERIALS AND METHODS: The material consisted of one age-cohort of 15-16 year-old adolescents (n = 67). Of them, 97% participated in a clinical examination. The final group included in the study consisted of 61 adolescents (91% of the whole age cohort). The occlusions were evaluated applying the Occlusal Morphology and Function Index (OMFI), the Dental Health Component (DHC) and the Aesthetic Component (AC) of the Index of Orthodontic Treatment Need (IOTN). Moreover, all adolescents filled in a semi-structured questionnaire enquiring about their satisfaction with the function and appearance of their own dentition and self-perceived orthodontic treatment need. They also scored their own dental appearance on a Visual Analog Scale (VAS). RESULTS: Of the adolescents, 42% had received orthodontic treatment, while 58% were untreated. All morphological criteria of the OMFI were met by 58% of orthodontically treated and 49% of untreated adolescents and all functional criteria by 67% and 57%, respectively. Treatment need was registered in two of the treated adolescents (7%) and five of the untreated adolescents (14%). Treated adolescents were more often satisfied with their dental appearance than untreated adolescents (p = 0.034). In both groups, satisfaction with the function was high (93%). CONCLUSIONS: Orthodontic treatment seems to improve both occlusal morphology and function. The high satisfaction with one's own dental appearance among the treated adolescents is worth noting.

Predicting outcomes in emergency medical admissions - role of laboratory data and co-morbidity.

BACKGROUND: The utility of risk stratification following an emergency medical admission has been debated. We have examined the predictability of outcomes, from a database of all emergency admissions to St James' Hospital, Dublin, over a six year period (2005-2010). METHODS: Analysis was performed using the hospital in-patient enquiry system, linked to the patient administration system and laboratory data. The utility of a fractional polynomial laboratory only model to predict 30-day in-hospital mortality was determined. RESULTS: The AUROC for the laboratory parameters to predict a 30 day death was 0.90 ( 95% CI 0.89, 0.90) in the 2002 - 2010 derivation dataset and was 0.88 (95% CI 0.86, 0.90) in the 2011 validation set. The addition of co-morbidity measures did not improve the model prediction (0.89 : 95% CI 0.88 - 0.89). CONCLUSION: A fractional polynomial laboratory only model can reliably predict 30-day hospital mortality following an emergency medical admission, potentially allowing resources to be risk focused and patients to be prioritised.

[Regional differences and costs of physical therapy procedures in Brazil's Unified Health System, 1995 to 2008]. / Diferenças regionais e custos dos procedimentos de fisioterapia no Sistema Único de Saúde do Brasil, 1995 a 2008.

OBJECTIVE: Describe the ambulatory physical therapy treatments provided by the Unified Health System (SUS) in Brazil with regard to their geographical distribution, costs, types of procedure, and types of provider. METHODS: Data from the SUS Information Technology Department (DATASUS) were utilized, drawing from the period from 1995 to 2008, which included the quantity and the value of the procedures approved for payment by the Secretariats of Health and the quantity and value of the procedures presented for payment. The treatment coefficients (CoA) were calculated by dividing the number of treatments in a particular year and region by the estimated population of that region in that year. RESULTS: The CoA in Brazil in 2008 was 0.19 and the North and Center-West regions presented the lowest coefficients (0.13 and 0.10, respectively). Between 1995 and 2007 there was an increase in the national treatment coefficient of 33.7%, with the North region showing the largest increase, 143.8%; the Center-West 62.1%, and the Northeast 56.1%. Treatment for motor disorders was the most widely performed procedure (61.8%), and the values of payments approved were lower than those presented by the managers of the services in 2008 (10.4%). Private for-profit establishments provided 44.5% of the physical therapy treatments paid for by the SUS in 2008. Municipal establishments accounted for 26.6% of the treatments, and federal establishments for only 0.9%. Between 1995 and 2007, the quantity of treatments offered by municipal establishments increased 278.7%. CONCLUSIONS: It was observed that the provision of ambulatory physical therapy treatment by the SUS remains small and geographically unequal, although less developed regions showed a larger increase in the CoA. The SUS remunerates inadequately the physical therapy services provided and continues to do so, in large part, by means of agreements with private establishments.

[Observing migration and deficiencies in health care - STD center at the Cologne Municipal Health Department]. / Seismograf für Migration und Versorgungsdefizite - STD-Sprechstunde im Gesundheitsamt Köln.

BACKGROUND: In spite of the compulsory health insurance in Germany, many people only have limited access to medical services. This has serious consequences, especially in the field of sexual health. The affected people are not only undocumented migrants, but also many people from the new European Union countries who are temporarily living in Germany. Many of these people, especially in larger cities, frequent STD counselling centers. METHOD: Since 2002, in addition to basic socio-demographic data, other anonymous data have been recorded for all consultations in the STD offices of the Cologne Health Department. These data include the patients' country of origin, rea-son for consultation, whether the patients are medically insured, as well as the medical services provided and the diagnoses. The data is evaluated with the help of EpiInfo. RESULTS: During the study period, between 608 and 883 people visited the STD Counselling Centre per year. During this period, 4 235 people received in total medical help. The proportion of patients with a migration history rose from 65% in 2002 to 83% in 2010. The proportion of patients without health insurance rose from 45% (2002) to 67% (2010).About half of the counselled migrants were, at least for a short time, involved in professional sexwork. The number of counselled patients from the sub-Saharan region decreased from 123 (2002) to 72 (2010). The number of patients from Central Europe increased from 112 to 364 in this period.Migrants were over-represented in the group of patients who were diagnosed with gonorrhea and trichomoniasis, as well as among women with a conspicuous cytological swab. Chlamydia infections were, in contrast, more frequent among German clients.Gender, sexual orientation, age and the proportion of people involved in sexwork are, however, more important predictive factors than having an immigration status. CONCLUSION: The client spectrum has changed considerably during the study period.These changes are related to economic and political developments, as well as to the consequences of immigration laws. For the majority of patients with a migration history, the STD centre is the primary means of access to medical care in Germany. The rapid change in the client spectrum, the patients' limited access to information and to medical care and the resulting changes in epidemiology represent a major challenge for the public health services.

[Parameters of bed occupancy of intensive care units in Hungary]. / A magyarországi intenzív osztályok kihasználtságának néhány paramétere.

According to the Semmelweis Plan for Saving Health Care, "the capacity of the national network of intensive care units in Hungary is one but not the only bottleneck of emergency care at present". Author shows on the basis of data reported to the health insurance that not on a single calendar day more than 75% of beds in intensive care units were occupied. There were about 15 to 20 thousand sick days which could be considered unnecessary because patients occupying these beds were discharged to their homes directly from the intensive care unit. The data indicate that on the whole bed capacity is not low, only in some institutions insufficient. Thus, in order to improve emergency care in Hungary, the rearrangement of existing beds, rather than an increase of bed capacity is needed.

[Practice of treatment restriction in Hungarian intensive care units]. / A kezeléskorlátozás gyakorlata a hazai intenzív osztályokon.

UNLABELLED: End of life decisions affect most of patients in intensive care units, thus, it is important to know both local and international practice in accordance with law and ethical principles for intensive care physicians. AIM: To search for local customs of end of life decisions (withholding or withdrawing the therapy, shortening of the dying process), and to compare the data with the international literature. METHODS: In 2007-2008 the first Hungarian survey was performed with the purpose to learn more about local practice of end of life decisions. Questionnaires were sent out electronically to 743 registered members of Hungarian Society of Anesthesiology and Intensive Care. Respecting anonymity, 103 replies were statistically evaluated (response rate was 13.8%) and compared with data from other European countries. RESULTS: As expected, it turned out from replies that the practice of domestic intensive care physicians is very paternal and this is promoted by legal regulations that share a similar character. Intensive care physicians generally make their decisions alone (3.75/5 point) without respecting the opinion of the patient (2.57/5 point) the relatives (2.14/5 point) or other medical personnel (2.37/5 point). Furthermore, they prefer not to start a therapy rather than withdraw an ongoing treatment. Nevertheless, the frequency of end of life decisions (3-9% of ICU patients) is smaller than other European countries. CONCLUSIONS: There is a need for the expansion of patients' right in our country. For end of life decisions, self determinations must be supported and a dialogue must be established between lawmakers and physicians, in order to improve the legal support of this medical practice.

[Diagnosis of thromboembolism of the pulmonary artery branches according to autopsy data in Tomsk hospitals in 2003-2007].

AIM: To study the frequency and structure of new cases of thromboembolism of the pulmonary artery branches among those who died at Tomsk hospitals in 2003 to 2007. MATERIALS AND METHODS: The autopsy protocols and case histories of all patients (n = 442) with the lifetime and/or postmortem diagnosis of pulmonary thromboembolism (PTE) who had died at Tomsk hospitals on January 1, 2003 to December 31, 2007 were analyzed. A systemic postmortem study applied the complete organ evacuation method (complete evisceration after Shore). The variance analysis was employed to calculate variability in all values; the correlation analysis was used to estimate statistical correlations. RESULTS: Out of the 442 patients, 217 (50.9%) patients had thromboembolism as being a direct cause of death and it worsened the course of the underlying disease in 225 (49.1%) patients. According to the number of dead patients with PTE, therapeutic (60.6%), surgical (26.6%), and cancer (9.1%) ones ranked first, second, and third, respectively. In addition to the most common inferior vena cava thrombosis (65.1%), right cardiac thrombosis was the main source of PTE in 25.6% of cases. CONCLUSION: The detected specific features of the occurrence of new cases of PTE at Tomsk hospitals in 2003-2007 may become the basis for planning measures by health administrators to improve the diagnosis of PTE and to improve medical and preventive care to patients with this condition in therapeutic-and-prophylactic institutions.

Continuation Rate, Safety and Efficacy of Hydroxychloroquine Treatment in a Retrospective Cohort of Systemic Lupus Erythematosus in a Japanese Municipal Hospital.

Objective We investigated the continuation rate, safety and efficacy of treatment with hydroxychloroquine (HCQ) in a retrospective cohort of systemic lupus erythematosus (SLE) in a Japanese municipal hospital. Methods All of the patients with SLE who started treatment with HCQ were included in this study. A retrospective chart review was performed. Our primary outcomes were the continuation rate of HCQ treatment for 1 year and adverse events (AEs) during the treatment. We also investigated the efficacy of HCQ treatment in cases in which treatment with immunosuppressive therapies remained unchanged for the preceding six months. Results Forty-seven patients with SLE were included in this study. Twenty-five patients (53.2%) had AEs. Eleven (64.7%) of the 17 patients who tried the readministration of HCQ could continue HCQ treatment. The continuation rate of HCQ for a period of 1 year was 78.3% (36 of 46 patients). The development of cutaneous lesions was the most frequent adverse event (25.5%) followed by gastrointestinal symptoms (8.5%). In the 16 cases in which the immunosuppressive therapies remained unchanged for at least six months prior to starting HCQ treatment, the SLE disease activity index, anti-DNA antibody, immune complex, and serum complement activity significantly decreased over a period of 1 year, while the prednisolone dose significantly decreased. Conclusion The continuation rate of HCQ treatment was high in an SLE cohort of a Japanese municipal hospital. Although more than half of the patients experienced AEs, the readministration of HCQ was often successful. HCQ treatment provided benefits regarding the clinical and immunological findings in Japanese patients with SLE, which would likely lead to glucocorticoid tapering.

COVID-19 autopsy reports from the Ga-East Municipal and the 37 Military Hospitals in Accra, Ghana.

INTRODUCTION: Since the declaration of COVID-19 by the World Health Organisation (WHO) as a global pandemic on 11th March 2020, the number of deaths continue to increase worldwide. Reports on its pathologic manifestations have been published with very few from the Sub-Saharan African region. This article reports autopsies on COVID-19 patients from the Ga-East and the 37 Military Hospitals to provide pathological evidence for better understanding of COVID-19 in Ghana. METHODS: Under conditions required for carrying out autopsies on bodies infected with category three infectious agents, with few modifications, complete autopsies were performed on twenty patients with ante-mortem and/or postmortem RT -PCR confirmed positive COVID-19 results, between April and June, 2020. RESULTS: There were equal proportion of males and females. Thirteen (65%) of the patients were 55years or older with the same percentage (65%) having Type II diabetes and/or hypertension. The most significant pathological feature found at autopsy was diffuse alveolar damage. Seventy per cent (14/20) had associated thromboemboli in the lungs, kidneys and the heart. Forty per cent (6/15) of the patients that had negative results for COVID-19 by the nasopharyngeal swab test before death had positive results during postmortem using bronchopulmonary specimen. At autopsy all patients were identified to have pre-existing medical conditions. CONCLUSION: Diffuse alveolar damage was a key pathological feature of deaths caused by COVID-19 in all cases studied with hypertension and diabetes mellitus being major risk factors. Individuals without co-morbidities were less likely to die or suffer severe disease from SARS-CoV-2. FUNDING: None declared.

[Characteristics of elderly patients with acute myelogenous leukemia].

The average life span of our country is the longest in the world, and rapid aging is taking place, besides. Therefore the elderly patients with acute myelogenous leukemia (EAML) is increasing. The biological characteristic of EAML is deteriorating internal organs function, and high ratios having the complication of the patient. Leukemic cells in the elderly has the biologic characteristic that non-usual case, for example hypoplastic leukemia, is many, and a case having abnormal chromosomal aberration is also. A social characteristic of EAML is that they are treated at a general hospital such as the municipal hospital not a university hospital, and in many cases the only family is the elderly spouse. Enough understanding of the nation is necessary to overcome such a disadvantageous point and to improve treatment results of EAML.

Erlang could have told you so-A case study of health policy without maths.

Little consideration is given to the operational reality of implementing national policy at local scale. Using a case study from Norway, we examine how simple mathematical models may offer powerful insights to policy makers when planning policies. Our case study refers to a national initiative requiring Norwegian municipalities to establish acute community beds (municipal acute units or MAUs) to avoid hospital admissions. We use Erlang loss queueing models to estimate the total number of MAU beds required nationally to achieve the original policy aim. We demonstrate the effect of unit size and patient demand on anticipated utilisation. The results of our model imply that both the average demand for beds and the current number of MAU beds would have to be increased by 34% to achieve the original policy goal of transferring 240 000 patient days to MAUs. Increasing average demand or bed capacity alone would be insufficient to reach the policy goal. Day-to-day variation and uncertainty in the numbers of patients arriving or leaving the system can profoundly affect health service delivery at the local level. Health policy makers need to account for these effects when estimating capacity implications of policy. We demonstrate how a simple, easily reproducible, mathematical model could assist policy makers in understanding the impact of national policy implemented at the local level.

Local hospital networks for STEMI treatment for a population of half a million inhabitants increase the use of invasive treatment of acute coronary syndromes to the European recommended level. The Malopolska Registry of Acute Coronary Syndromes 2005-2006.

BACKGROUND: According to the European Society of Cardiology (ESC) consensus, over 75% of patients with ST-elevation myocardial infarction (STEMI) should receive reperfusion therapy. An early invasive strategy is also advocated for high-risk non-ST elevation acute coronary syndromes (NSTE ACS). Until 2005, a single high-volume percutaneous coronary intervention (PCI) centre provided 24-hour service for the population of 3.2 million inhabitants in the Krakow Hospital Network Region. In August 2005 and December 2005 two additional round-the-clock duty PCI centres were launched in remote municipal hospitals (Tarnow and Nowy Sacz). METHODS: 29 non-PCI centres participated in the Registry of ACS in February-March 2005 (Period 1) and in December 2005-January 2006 (Period 2), so while Period 2 was conducted, three PCI centres provided 24-hour service for the Malopolska Region. RESULTS: A total of 1404 patients with ACS were enrolled - 695 during Period 1 and 709 in Period 2. In comparison to Period 1, a non-significant trend towards more frequent mechanical reperfusion of STEMI patients with chest pain onset <12 hours was observed in Period 2 (54 vs. 60%; p=NS). A steep and significant rise was observed particularly among STEMI patients treated in non-PCI centres outside of the Krakow City Network (51 vs. 78%; p=0.001). In the newly established Tarnow and Nowy Sacz (eastern Malopolska) PCI networks the reperfusion rates for STEMI patients with chest pain <12 hours were 78% and 88%, respectively, in comparison to 55% in western Malopolska (p=0.001). The transfer rate for invasive treatment of NSTE ACS has increased from 13.8% in Period 1 to 19% in Period 2 (p=0.031) in the entire region. The in-hospital mortality for patients receiving conservative treatment in community hospitals has decreased among NSTE ACS patients (6.8 vs. 3.9%; p=0.045) and remained unchanged in STEMI (21.3 vs. 19%; p=NS). CONCLUSIONS: Opening of new PCI centres, based on population magnitude and structure, improves local adherence to the guideline-recommended invasive approach in high-risk ACS patients. The Malopolska Programme model showed that one high-volume 24-hour duty PCI centre with a network of cooperating non-PCI centres for a population of 0.5 million might be sufficient to provide invasive treatment according to the ESC guidelines for eligible patients.

[Thrombolytic therapy of myocardial infarction in municipal hospital in years 1999-2005]. / Trombolityczne leczenie zawalu serca w szpitalu bez pracowni hemodynamicznej w latach 1999-2005.

UNLABELLED: The aim of the work was to assess the treatment of patients in whom acute myocardial infarction with ST elevation (STEMI) was diagnosed. MATERIAL AND METHODS: Among 889 patients with STEMI 302 persons (34%) were transferred to hospitals with possibility of making primary percutaneous coronary intervention (PCI) without thrombolytic therapy, in 132 persons (15%) thrombolytic therapy was done and in 455 patients (51%) such treatment was not done for the lack of indications or existing contraindications. RESULTS AND CONCLUSIONS: The increasing number of patients transferred to primary PCI immediately from Emergency Ward and the decreasing number of patients qualified to thrombolytic therapy was observed. It is the effect of wider access to primary PCI as the method of choice for treatment and the common application of the ESC standards by the doctors. Abolishment of age criterion as the contraindication to thrombolytic therapy made that average of patients age cured with thrombolysis still increases. The time exceeding 12 hours from the beginning of pain to the admittance to hospital is the main reason (59%) of rejection from thrombolytic therapy. The analysis of complications after the treatment does not show them to be multiple. The stroke as the most serious one did not take place. Two cases of serious bleeding from digestive tract in older ladies have been observed. The hypotony after streptokinase was observed in 14% of patients. This is only side effect, efficiently treated either with 100-200 mg of hydrocortisonum i.v. or/and the partial stopping of dosing medicament.

Impact on and use of an inner-city London Infectious Diseases Department by international migrants: a questionnaire survey.

BACKGROUND: The UK has witnessed a considerable increase in immigration in the past decade. Migrant may face barriers to accessing appropriate health care on arrival and the current focus on screening certain migrants for tuberculosis on arrival is considered inadequate. We assessed the implications for an inner-city London Infectious Diseases Department in a high migrant area. METHODS: We administered an anonymous 20-point questionnaire survey to all admitted patients during a 6 week period. Questions related to sociodemographic characteristics and clinical presentation. Analysis was by migration status (UK born vs overseas born). RESULTS: 111 of 133 patients completed the survey (response rate 83.4%). 58 (52.2%) were born in the UK; 53 (47.7%) of the cohort were overseas born. Overseas-born were over-represented in comparison to Census data for this survey site (47.7% vs 33.6%; proportional difference 0.142 [95% CI 0.049-0.235]; p = 0.002): overseas born reported 33 different countries of birth, most (73.6%) of whom arrived in the UK pre-1975 and self-reported their nationality as British. A smaller number (26.4%) were new migrants to the UK (< or =10 years), mostly refugees/asylum seekers. Overseas-born patients presented with a broad range and more severe spectrum of infections, differing from the UK-born population, resulting in two deaths in this group only. Presentation with a primary infection was associated with refugee/asylum status (n = 8; OR 6.35 [95% CI 1.28-31.50]; p = 0.023), being a new migrant (12; 10.62 [2.24-50.23]; p = 0.003), and being overseas born (31; 3.69 [1.67-8.18]; p = 0.001). Not having registered with a primary-care physician was associated with being overseas born, being a refugee/asylum seeker, being a new migrant, not having English as a first language, and being in the UK for < or =5 years. No significant differences were found between groups in terms of duration of illness prior to presentation or duration of hospitalisation (mean 11.74 days [SD 12.69]). CONCLUSION: Migrants presented with a range of more severe infections, which suggests they face barriers to accessing appropriate health care and screening both on arrival and once settled through primary care services. A more organised and holistic approach to migrant health care is required.

Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls prevention program.

BACKGROUND: Patient falls in hospitals are common and may lead to negative outcomes such as injuries, prolonged hospitalization and legal liability. Consequently, various hospital falls prevention programs have been implemented in the last decades. However, most of the programs had no sustained effects on falls reduction over extended periods of time. METHODS: This study used a serial survey design to examine in-patient fall rates and consequent injuries before and after the implementation of an interdisciplinary falls prevention program (IFP) in a 300-bed urban public hospital. The population under study included adult patients, hospitalized in the departments of internal medicine, geriatrics, and surgery. Administrative patient data and fall incident report data from 1999 to 2003 were examined and summarized using frequencies, proportions, means and standard deviations and were analyzed accordingly. RESULTS: A total of 34,972 hospitalized patients (mean age: 67.3, SD +/- 19.3 years; female 53.6%, mean length of stay: 11.9 +/- 13.2 days, mean nursing care time per day: 3.5 +/- 1.4 hours) were observed during the study period. Overall, a total of 3,842 falls affected 2,512 (7.2%) of the hospitalized patients. From these falls, 2,552 (66.4%) were without injuries, while 1,142 (29.7%) falls resulted in minor injuries, and 148 (3.9%) falls resulted in major injuries. The overall fall rate in the hospitals' patient population was 8.9 falls per 1,000 patient days. The fall rates fluctuated slightly from 9.1 falls in 1999 to 8.6 falls in 2003. After the implementation of the IFP, in 2001 a slight decrease to 7.8 falls per 1,000 patient days was observed (p = 0.086). The annual proportion of minor and major injuries did not decrease after the implementation of the IFP. From 1999 to 2003, patient characteristics changed in terms of slight increases (female gender, age, consumed nursing care time) or decreases (length of hospital stay), as well as the prevalence of fall risk factors increased up to 46.8% in those patients who fell. CONCLUSION: Following the implementation of an interdisciplinary falls prevention program, neither the frequencies of falls nor consequent injuries decreased substantially. Future studies need to incorporate strategies to maximize and evaluate ongoing adherence to interventions in hospital falls prevention programs.

Impact on and use of health services by international migrants: questionnaire survey of inner city London A&E attenders.

BACKGROUND: Changing immigration trends pose new challenges for the UK's open access health service and there is considerable speculation that migrants from resource-poor countries place a disproportionate burden on services. Data are needed to inform provision of services to migrant groups and to ensure their access to appropriate health care. We compared sociodemographic characteristics and impact of migrant groups and UK-born patients presenting to a hospital A&E/Walk-In Centre and prior use of community-based General Practitioner (GP) services. METHODS: We administered an anonymous questionnaire survey of all presenting patients at an A&E/Walk-In Centre at an inner-city London hospital during a 1 month period. Questions related to nationality, immigration status, time in the UK, registration and use of GP services. We compared differences between groups using two-way tables by Chi-Square and Fisher's exact test. We used logistic regression modelling to quantify associations of explanatory variables and outcomes. RESULTS: 1611 of 3262 patients completed the survey (response rate 49.4%). 720 (44.7%) were overseas born, representing 87 nationalities, of whom 532 (73.9%) were new migrants to the UK (< or =10 years). Overseas born were over-represented in comparison to local estimates (44.7% vs 33.6%; p < 0.001; proportional difference 0.111 [95% CI 0.087-0.136]). Dominant immigration status' were: work permit (24.4%), EU citizens (21.5%), with only 21 (1.3%) political asylum seekers/refugees. 178 (11%) reported nationalities from refugee-generating countries (RGCs), eg, Somalia, who were less likely to speak English. Compared with RGCs, and after adjusting for age and sex, the Australians, New Zealanders, and South Africans (ANS group; OR 0.28 [95% CI 0.11 to 0.71]; p = 0.008) and the Other Migrant (OM) group comprising mainly Europeans (0.13 [0.06 to 0.30]; p = 0.000) were less likely to have GP registration and to have made prior contact with GPs, yet this did not affect mode of access to hospital services across groups nor delay access to care. CONCLUSION: Recently arrived migrants are a diverse and substantial group, of whom migrants from refugee-generating countries and asylum seekers comprise only a minority group. Service reorganisation to ensure improved access to community-based GPs and delivery of more appropriate care may lessen their impact on acute services.