Understanding the contribution of general medical services to acute inpatient care in Victorian public hospitals.

BACKGROUND: General medicine is an integral part of health services, yet there is little data highlighting their contribution to acute hospital care in Australia. AIMS: To utilise the Victorian Department of Health's administrative dataset for hospital admissions to evaluate the relative contribution and trends over time of general medical services to acute multiday inpatient hospital separations in the Victorian public healthcare system. METHODS: A retrospective time-series study of general medical activity compared to other major specialties using hospital-level data provided by the Department of Health: (i) extrapolation from diagnosis-related group (DRG) activity data (2011-2021) and, (ii) directly reported discharge unit-based activity (available from 2018). Acute multiday separations of all patients aged ≥18 years from all metropolitan and rural Victorian public hospitals were included. RESULTS: Using the DRG-based data, general medicine ranked as the largest care provider of all specialties studied, accounting for 12.1% of separations. Despite the largest increase at a rate of 2831 separations/year (0.336%/year of total, P < 0.001) compared to others, mean length of stay declined by 0.08 days/year (P < 0.001). These findings were significant for metropolitan and rural hospitals. The use of directly reported discharge unit-based data also ranked general medicine as the largest care provider accounting for 32.9% of total separations, with rural hospital general medical services contributing nearly 50% of all multiday separations. CONCLUSIONS: Both DRG-based data and discharge unit-based data indicate that general medicine is the largest provider of acute multiday inpatient care in Victorian hospitals. The estimate of contribution of general medicine differed between the two datasets as DRG data likely over-represents the role of other specialties possibly due to assumptions regarding specialty management of varying groups of diagnoses.

Reducing medication errors in hospital discharge summaries: a randomised controlled trial.

OBJECTIVES: To evaluate whether pharmacists completing the medication management plan in the medical discharge summary reduced the rate of medication errors in these summaries. DESIGN: Unblinded, cluster randomised, controlled investigation of medication management plans for patients discharged after an inpatient stay in a general medical unit. SETTING: The Alfred Hospital, an adult major referral hospital in metropolitan Melbourne, with an annual emergency department attendance of about 60000 patients. PARTICIPANTS: The evaluation included patients' discharge summaries for the period 16 March 2015 - 27 July 2015. INTERVENTIONS: Patients randomised to the intervention arm received medication management plans completed by a pharmacist (intervention); those in the control arm received standard medical discharge summaries (control). MAIN OUTCOME MEASURES: The primary outcome variable was a discharge summary including a medication error identified by an independent assessor. RESULTS: At least one medication error was identified in the summaries of 265 of 431 patients (61.5%) in the control arm, compared with 60 of 401 patients (15%) in the intervention arm (P<0.01). The absolute risk reduction was 46.5% (95% CI, 40.7-52.3%); the number needed to treat (NNT) to avoid one error was 2.2 (95% CI, 1.9-2.5). The absolute risk reduction for a high or extreme risk error was 9.6% (95% CI, 6.4-12.8%), with an NNT of 10.4 (95% CI, 7.8-15.5). CONCLUSIONS: Pharmacists completing medication management plans in the discharge summary significantly reduced the rate of medication errors (including errors of high and extreme risk) in medication summaries for general medical patients.Australia New Zealand Clinical Trials Registry number: ACTRN12616001034426.

A feasibility study of the provision of a personalized interdisciplinary audiovisual summary to facilitate care transfer care at hospital discharge: Care Transfer Video (CareTV).

OBJECTIVE: To assess the feasibility and patient acceptance of a personalized interdisciplinary audiovisual record to facilitate effective communication with patients, family, carers and other healthcare workers at hospital discharge. DESIGN: Descriptive pilot study utilizing a study-specific patient feedback questionnaire conducted from October 2013 to June 2014. SETTING AND PARTICIPANTS: Twenty General Medical inpatients being discharged from an Acute General Medical Ward in a metropolitan teaching hospital. INTERVENTION: Audiovisual record of a CareTV filmed at the patient's bedside by a consultant-led interdisciplinary team, within 24 h prior to discharge from the ward, provided immediately for the patient to take home. Patient surveys were completed within 2 weeks of discharge. MAIN OUTCOME MEASURES: Technical quality, utilization, acceptability, patient satisfaction and recall of diagnosis, medication changes and post-discharge review arrangements. RESULTS: All patients had watched their CareTV either alone or in the presence of a variety of others: close family, their GP, a medical specialist, friends or other health personnel. Participating patients had good understanding of the video content and recall of their diagnosis, medication changes and post-discharge plans. Patient feedback was overwhelmingly positive. CONCLUSIONS: In the context of a General Medical Unit with extensive experience in interdisciplinary bedside rounding and teamwork, CareTV is simple to implement, inexpensive, technically feasible, requires minimal staff training and is acceptable to patients. The results of this pilot study will inform and indicate the feasibility of conducting a larger randomized control trial of the impact of CareTV on patient satisfaction, medication adherence and recall of key information, and primary healthcare provider satisfaction.

Prevalence, associations, and risk factors for orthostatic hypotension in medical, surgical, and trauma inpatients: an observational cohort study.

BACKGROUND: Orthostatic hypotension (OH) is prevalent in hospitalized elderly patients. It is defined as a reduction in systolic blood pressure (SBP) of at least 20 mmHg and/or diastolic blood pressure (DBP) of at least 10 mmHg within 3 minutes of standing from a lying position. This observational cohort study describes the prevalence, association with symptoms, and risk factors for OH in medical, surgical, and trauma wards in a tertiary hospital and the differences in hemodynamic behaviors between OH-positive (OHP) and OH-negative (OHN) patients. METHODS: All 76 patients who were hemodynamically stable and able to stand from 4 hospital wards had noninvasive supine and orthostatic blood pressures (BPs) and pulse rates (PRs) measured over 4 days. RESULTS: Mean age of the 76 patients included in the study was 67.8 ± 19.6 years. Overall prevalence of OH was 23.7% (95% CI: 14.7%-34.8%) with 21.2% (95% CI: 9.0%-38.9%) in medical, 31.8% (95% CI: 13.9%-54.9%) in surgical, and 19.0% (95% CI: 5.4%-41.9%) in trauma wards. OH had no association with symptoms (P â€Š=  .53). We found no differences in age, number of comorbidities, and medication use between the OHN and OHP groups. The two groups displayed very different hemodynamic responses. The OHN group demonstrated a statistically significant compensatory rise in BP and PR over time to orthostatic challenge, while the OHP group displayed the opposite effect with BP. There was no statistically significant compensatory increase in PR over time to standing in the OHP group. CONCLUSIONS: OH is common and mostly asymptomatic. Routine measurements are recommended to detect cases in the hospital setting. Our study did not identify any significant risk factors for OH but rather confirmed the previous finding that underlying impairment in autonomic responses in individuals may have instead contributed to the development of OH.

Treatment of intractable painful diabetic neuropathy with intravenous lignocaine.

OBJECTIVE: Lignocaine is a cardiac antiarrhythmic agent occasionally used to treat neuropathic pain. This study was designed to examine the effectiveness of intravenous lignocaine in patients with intractable painful diabetic neuropathy. RESEARCH DESIGN AND METHODS: Fifteen patients with painful diabetic peripheral neuropathy, who had appeared to respond to previous lignocaine infusions, completed a double-blind, placebo-controlled crossover trial of two doses of intravenous lignocaine (5 and 7.5 mg/kg) versus saline. Infusions were administered in random order over 4 h at four weekly intervals. The effect of treatment on pain perception was assessed using the McGill Pain Questionnaire (MPQ), a daily pain diary, hours of sleep, fasting blood glucose, and use of other pain-relieving medication. RESULTS: Both doses of lignocaine significantly (P<.05 to P<.001 for the different measures) reduced the severity of pain compared with placebo. This reduction was present at both 14 and 28 days after the infusion. The qualitative nature of the pain was also significantly (P<.05 to P<.01) modified by lignocaine compared with placebo for up to 28 days. The preceding dose 4 weeks earlier significantly (P<.01 and P<.001) affected the response to the next dose. There were no significant effects of treatment on the other measures of response. There were no significant side effects of the treatment. CONCLUSIONS: This study shows that intravenous lignocaine ameliorates pain in some diabetic participants with intractable neuropathic pain who have failed to respond to or are intolerant of available conventional therapy.