Emergency department lengths of stay: characteristics favouring a delay to the admission decision as distinct from a delay while awaiting an inpatient bed.

BACKGROUND: A prolonged stay for a patient within the emergency department (ED) can adversely affect the outcome of their ensuing hospital admission. AIMS: To investigate the characteristics of those eventual general medical hospital inpatients who stay in the ED awaiting a decision to be admitted and then await a bed. METHODS: Data from Flinders Medical Centre's patient journey database were analysed. The analysis was carried out on 19 476 patients admitted as an emergency under the General Medicine units. RESULTS: A less urgent Australian Triage Scale category significantly prolonged triage-to-admit time but did not affect boarding time. The decision to admit a patient took 29% longer for patients who presented to the ED outside of working hours. However, a decision to admit taken outside working hours meant the boarding time was over 3 h shorter than if the decision had been taken inside working hours. For every additional patient in the ED at the time of presentation, the admission decision was delayed by about half a minute. Every additional patient in the ED at the time of an admission decision increased boarding time by almost 10 min. CONCLUSION: Outside of working hours, patients presenting to ED have longer triage-to-admit times while patients for admission have shorter boarding times. ED congestion delays admission decisions only slightly and prolongs patients' boarding times to a greater extent. Strategies to reduce the time patients spend in ED should differ depending on whether a decision to admit the patient has been reached.

Relationship between in-hospital location and outcomes of care in patients of a large general medical service.

BACKGROUND: The discrepancy between the number of admissions and the allocation of hospital beds means that many patients admitted under the care of a general medical service can be placed in other departments' wards. These patients are called 'outliers', and their outcomes are unknown. AIMS: To examine the relation between the proportion of time each patient spent in their 'home ward' during an index admission and the outcomes of that hospital stay. METHODS: Data from Flinders Medical Centre's patient journey database were extracted and analysed. The analysis was carried out on the patient journeys of patients admitted under the general medicine units. RESULTS: Outlier patients' length of stay was significantly shorter than that of the inlier patients (110.7 h cf 141.9 h; P < 0.001).They had a reduced risk of readmission within 28 days of discharge from hospital. Outlier patients' discharge summaries were less likely to be completed within a week (64.3% cf 78.0%; P < 0.001). Being an outlier patient increased the risk-adjusted risk of in-hospital mortality by over 40%. Fifty per cent of deaths in the outlier group occurred within 48 h of admission. Outlier patients had spent longer in the emergency department waiting for a bed (6.3 h cf 5.3 h; P < 0.001) but duration of emergency department stay was not an independent predictor of mortality risk. CONCLUSION: Outlier patients had significantly shorter length of stay in hospital but significantly greater in-patient death rates. Surviving outlier patients had lower rates of readmission but lower rates of discharge summary completion.

The significance of reduced kidney function among hospitalized acute general medical patients.

BACKGROUND: Inpatient general medical units often look after older patients who have more complex co-morbidity including renal insufficiency. The consequences of renal insufficiency with respect to length of hospital stay (LOS) and mortality have not been well described in hospitalized general medical patients. AIM: To use a general medical inpatient population to evaluate the impact of reduced kidney function. DESIGN: Retrospective cross-sectional study. METHODS: We studied 504 acute medical admissions through an Acute Assessment Unit between February and November 2007. Patients were classified as having chronic kidney disease (CKD), acute kidney injury (AKI), neither (control) or both. LOS, in-hospital mortality and post-discharge survival were evaluated. RESULTS: Renal impairment was present in 151 patients. Ninety patients had CKD only and 61 had AKI with or without CKD. In-hospital mortality was increased in those with renal impairment compared with controls (9.3 vs. 3.4%; P = 0.006). Within 4 years of admission, 187 (39%) patients had died. Post-discharge mortality was significantly higher in all renal failure populations (hazard ratio: 2.57-4.38; P < 0.01). Adjustment for patient age, gender and Charlson index explained the increased mortality during and after hospital admission but did not explain increased LOS. Only a small proportion (13%) of admitted patients with renal insufficiency had renal disease documented in their discharge summaries. CONCLUSION: Many general medical inpatients (30%) have reduced kidney function at the time of admission. This study provides validation of the Modification of Diet in Renal Disease equation as a predictor of poor outcomes. Reduced renal function was associated with increased hospital LOS and mortality. Mortality rose with AKI and was explicable on the basis of the patients' age and co-morbidities. Renal insufficiency is documented infrequently in discharge summaries.

Quality of resuscitation orders in general medical patients.

BACKGROUND: Documentation of resuscitation status in hospitalized patients has relevance in the management of cardiopulmonary arrest. Its association with mortality, Length Of hospital Stay (LOS) and the patients' primary diagnosis has not been established in general medical inpatients in hospitals in Australia and New Zealand. AIM: To investigate the association of resuscitation orders with in-hospital mortality and LOS in a range of diagnoses, adjusting for severity of illness and other covariates. DESIGN: Retrospective study. METHODS: The admission notes of 1681 medical admissions to four tertiary care teaching hospitals across Australia and New Zealand were reviewed retrospectively for frequency and nature of resuscitation documentation and its association with mortality, LOS and primary diagnosis. RESULTS: Resuscitation orders were documented in 741 patients (44.7%). For the 232 patients with a Not For Resuscitation (NFR) order, the in-hospital mortality rate was higher than in control patients (14% vs. 1.2%, P<0.005). The mortality rate remained significantly higher in the NFR group after propensity matching of the controls for age and co-morbidity (14% vs. 5%, P<0.005). The death-adjusted LOS for the NFR group was also significantly higher compared to the control patients (9.7 days vs. 4.7 days, P<0.005) and this difference remained after propensity matching (9.7 days vs. 7.7 days, P<0.05). Those patients with a primary diagnosis of respiratory tract infection or cardiac failure were more likely to be documented NFR compared to those with cellulitis or urinary tract infection. CONCLUSIONS: The documentation of NFR in a patient's admission notes is associated with increased in-hospital mortality and LOS. This is only partly explicable in terms of these patients' greater age and co-morbidity.

Resuscitation orders and their relevance to patients' clinical status and outcomes.

BACKGROUND: Documented resuscitation orders have relevance in the management of a pulseless, unresponsive patient. Although useful, the frequency of their documentation in the case notes of newly admitted medical patients is not well established. AIM: To investigate the frequency of early clear documentation of resuscitation orders in patients' admission notes. DESIGN: Retrospective audit. METHODS: The admission notes of 618 medical admissions to an Australian tertiary referral teaching hospital between January and December 2007 were reviewed to calculate the frequency of clear resuscitation documentation. Certain outcomes of each admission, such as in-hospital death, were obtained via hospital-based computerized records. RESULTS: Within the first 24 h of admission, discussions regarding resuscitation were not documented for 78% of patients. Of the 482 patients with no documented resuscitation orders, 5 patients died during their index admission. Of the 136 patients with documented resuscitation orders, 24 patients died during their index admission. As age or a measure of clinical debility increased, the absolute number and relative proportion of resuscitation discussions increased significantly (P<0.0001) and the number and proportion of patients deemed not for resuscitation also increased (P<0.0001). CONCLUSION: Those patients apparently targeted for discussion were older, more frail and acutely unwell. We propose widespread use of a clinical scoring system to identify those patients who need their resuscitation status clarified early in their admission prior to clinical deterioration.

Outcome in patients with eating disorders: a 5-year study.

BACKGROUND: Eating disorders are disabling, unpredictable, and difficult to treat. We did a prospective 5-year investigation of a representative sample of patients with eating disorders. Our aim was to identify predictors of outcome and to assess effects of available treatments. METHODS: We prospectively investigated 95 patients with anorexia nervosa, 88 with bulimia nervosa, and 37 with eating disorders not otherwise specified (EDNOS), who sought treatment in Adelaide, South Australia. We divided patients into those who had, and had not, received treatment in specialist units and reached a safe body weight. Individuals were then further classified dependent on intensity of any treatment received. We assessed clinical symptoms, body-related attitudes, and psychosocial function. FINDINGS: 216 (98%) patients were available for follow-up after 5 years. Three patients with anorexia nervosa and two with EDNOS died. 65 (74%) bulimic, 29 (78%) EDNOS, and 53 (56%) anorexic patients had no diagnosable eating disorder. A small proportion of patients in every group had poor Morgan-Russell-Hayward scores at outcome. Final outcome was predicted by extent and intensity, but not duration, of initial symptoms in patients with anorexia nervosa, and by initial body-related attitudes and impaired psychosocial functioning in bulimia patients. We were unable to predict EDNOS outcome. Treatment did not affect outcome for any group. INTERPRETATION: Deaths in the study confirm the serious nature of eating disorders. However, our results suggest that the efficacy of existing interventions is questionable.

Does the body image exist in three dimensions? The study of visual mental representation of a body and a nonbody object.

Do the mental images of 3-dimensional objects recreate the depth characteristics of the original objects? This investigation of the characteristics of mental images utilized a novel boundary-detection task that required participants to relate a pair of crosses to the boundary of an image mentally projected onto a computer screen. 48 female participants with body attitudes within expected normal range were asked to image their own body and a familiar object from the front and the side. When the visual mental image was derived purely from long-term memory, accuracy was better than chance for the front (64%) and side (63%) of the body and also for the front (55%) and side (68%) of the familiar nonbody object. This suggests that mental images containing depth and spatial information may be generated from information held in long-term memory. Pictorial exposure to views of the front or side of the objects was used to investigate the representations from which this 3-dimensional shape and size information is derived. The results are discussed in terms of three possible representational formats and argue that a front-view 2 1/2-dimensional representation mediates the transfer of information from long-term memory when depth information about the body is required.

[Personal behavior and mental state in anorexia nervosa]. / Osobennosti lichnostnogo reagirovaniia i psikhicheskogo sostoianiia pri nervnoi anoreksii.

Personality of the patients with anorexia nervosa is characterised by high neurotization and anxiety that resulted in diffuse anxiety in stress situation. Personal peculiarities included also high total hostility and intrapunitivity, inclination to obsessive-phobic and dysthymic reactions and tendency to somatization of anxiety. Such peculiarities promoted the choice of intrapunitivity type of reaction in situation of frustration. Its manifestation increases with an increase in the disease duration. The range of psychotic disorders in anorexia nervosa is restricted to anxious-depressive, obsessive and asthenic sphere.

Eating disorders revisited. II: Bulimia nervosa and related syndromes.

Bulimia nervosa and related syndromes are common, and occur in up to 5% of women who attend general practitioners. Young women in First World countries, particularly those who "diet", are at increased risk. Behaviours, such as binge eating and induced vomiting, are typically kept well hidden. Only a minority of those with these disorders present for treatment. General practitioners play a key role in primary and secondary prevention. Effective treatments include psychotherapies that focus on the patient's attitudes and relationships, not just the binge eating behaviour. About 50% of patients make a complete recovery, but the long term outcome is unknown.

Eating disorders revisited. I: Anorexia nervosa.

Anorexia nervosa is a serious psychiatric illness with a high morbidity and a significant lifetime mortality. Recurring themes in such patients centre on issues of self-worth and control. Treatment is difficult and prolonged, and may require hospitalisation. Therapy focuses on altering the misperceptions that patients have of themselves, both psychologically and physically. A multi-disciplinary team based in a specialised unit provides the treatment of choice, but if this is not available, a consistent, supportive relationship with an individual therapist familiar with the condition will be beneficial. Successful outcome should be based not simply on body weight but also on the resolution of anorexic thinking.

Recall of the visual body image using a novel boundary detection task.

A new task for eliciting a pictorial mental image of the body or other objects is described. The task involved relating a pair of crosses to the boundary of a mental image 'projected' onto a computer screen. Responses were assessed for accuracy defined as identifying a relationship between a cross and an image that would hold when a photograph (of the same object) was substituted for the mental image. A group of 30 female students achieved between 70 to 80% accuracy when using this task to assess mental images of their own faces, torsos, or a familiar nonbody object. Accuracy was similar for body and nonbody objects. The presence of some kind of quasipictorial representation of the body is confirmed. Its characteristics await further elucidation.

Telepsychiatry: 'tele' yes, but what about the 'psychiatry'?

To investigate what is lost or gained in a psychiatric evaluation when it takes place via telepsychiatry we compared the interrater reliability between two psychiatrists interviewing 63 subjects in an observer/interviewer split configuration in telepsychiatry and same-room settings. The measures used were the BPRS and interviewer ratings from a semi-structured interview. Patients also rated their experience. There were some clear differences between the telepsychiatry and same-room evaluations. Despite these variations, diagnoses were as reliably made by telepsychiatry. Patient acceptance of telepsychiatry was high.

Effects of serotonin reuptake inhibitors on hemostasis.

OBJECTIVE: To examine the hematologic safety profile of the selective serotonin reuptake inhibitors (SSRIs), with particular emphasis on the effects of these drugs on platelet aggregation. METHODS: Platelet aggregation studies were undertaken at baseline, and repeated 2 and 4 weeks after the initiation of treatment with an SSRI. Other investigations undertaken included analysis of serum electrolyte and liver enzyme concentrations, complete blood count, and coagulation studies. Patients were also assessed for clinical signs of bleeding. Eight patients (7 treated with fluoxetine, 1 with paroxetine) completed the study protocol. RESULTS: Repeated ANOVA revealed no abnormalities in platelet aggregation, hematopoiesis, or coagulation profile. No patient developed clinical signs of abnormal hemostasis during the study period. A statistically significant elevation in the mean serum bilirubin concentration was detected, but this was not of clinical significance. CONCLUSIONS: Although the SSRIs may cause abnormal hemostasis, this effect is probably rare. Another possibility is that abnormal hemostasis is more likely to occur when high doses of SSRIs are administered.

Low levels of interrater reliability in a standard measure of outcome in eating disorders (the modified Morgan-Russell Assessment Schedule).

OBJECTIVE: The interrater reliability of the modified version of the widely used Morgan-Russell Assessment Schedule was assessed. METHOD: Sixty-six female patients presenting for treatment for the first time in a general hospital and a community health center were assessed by a treating clinician and a researcher during sequential interviews. Two extra items were added to the Schedule to allow for the assessment of bulimic behaviors. Ratings were analyzed using the Cohen's weighted kappa. RESULTS: Poor to very poor levels of agreement were found between rater pairs assessing the 66 separate patients. DISCUSSION: The necessity for a specific, standardized format in using the Morgan-Russell Schedule is discussed. In its current, unstandardized format the Schedule may not be suitable for comparing outcome in eating disorders across different centers.

Psychiatric and substance abuse disorder diagnoses as predictors of length of hospital stay.

The mental health and substance abuse components of AN-DRG 3 were examined using data from all inpatient separations in two Australian States over a two-year period. Assignment to a mental health or a substance abuse diagnosis related group (DRG) predicted about 20 per cent of the variability in average length of stay of patients treated for such conditions. Assignment to a substance abuse DRG was a much less robust predictor of length of hospital stay than assignment to a mental health DRG. There was little variation between years or States. Day-only intent patients were excluded, as were long-stay outliers identified using an inter-quartile range trimming process. Psychiatric DRGs are similar to a number of other non-surgically focused diagnosis related groups in their capacity to predict length of hospital stay. They are likely to remain an important component of casemix classification systems.