Reglas de decisión clínica en los pacientes con tromboembolismo pulmonar agudo / Clinical Decision Rules and Patients With Acute Pulmonary Embolism

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Treatment of elderly patients with uncomplicated diverticulitis, even with comorbidity, at home.

BACKGROUND: Elderly patients with uncomplicated diverticulitis are usually hospitalized. The aim of this study is to compare the outcomes of elderly patients with uncomplicated diverticulitis who were treated at home versus traditional Hospitalization. METHODS: Prospective study from March 2011 to September 2012 including patients over 70 years with uncomplicated diverticulitis admitted to Hospital at Home Unit and to Conventional Hospitalization from the Emergency Department. Patients with ß-lactam allergy or who required admission to Conventional Hospitalization for other pathology were excluded. All patients were given intravenous antibiotic. Patients transferred to Hospital at Home stayed 24h in the Observation Ward within the Emergency Department prior to discharge. Characteristics and outcomes of patients are analyzed. RESULTS: 34 patients were treated at home and 18 in hospital. Mean age was similar in both groups (77 vs 79). The oldest patient treated at home was 90 years old. 64% of patients treated in Hospital at Home had comorbidity vs 68% in Conventional Hospitalization. 11% of patients treated at home were diabetic. Thickening colonic wall was present in 100% of patients. 38% of patients treated at home had free fluid vs 42% treated in Hospital. All patients had a good clinical evolution. None of the patients treated at home was transferred to Hospital. Home treatment was associated with a cost reduction of 1368 euros per patient. CONCLUSIONS: Treatment at home of elderly patients with uncomplicated diverticulitis is as safe and effective as treatment in Hospital, even if patient has comorbidity.

Implementation of a quality management system according to 9001 standard in a hospital in the home unit: changes and achievements.

PURPOSE: The purpose of this paper is to describe changes and results obtained after implementation of a quality management system (QMS) according to ISO standards in a Hospital in the Home (HIH) Unit. DESIGN/METHODOLOGY/APPROACH: The paper describes changes made and outcomes achieved. This took part in the HiH Unit, Clinico Hospital, Madrid, Spain, and looked at admissions, mean stay, patient satisfaction, adverse events, returns to hospital, no admitted referrals, complaints, compliance to protocols, equipment failures and resolution of urgent consultations. FINDINGS: In June 2008, HiH Unit, Clinico Hospital obtained ISO certification. The main results achieved are as follows. There was an increase in patients' satisfaction--in June 2008, assessment of the quality of care provided by staff was scored at 4.7 (on a scale of 1 to 5); in 2010 it has been scored at 4.96. Patient satisfaction rate has increased from 92 percent to 98.8 percent. No complaints from patients were received. Unscheduled returns to hospital have decreased from 7 percent to 3 percent. There were no medical equipment failures. External suppliers' performance has improved. Material and medication needed by staff was available when necessary. The number of admissions has increased. Compliance to protocols has reached 97 percent. Inappropriate referrals have decreased by 8 percent. Six medications-related incidents were detected; in two cases the incident was not due to an error. In the other four cases error could have been detected before reaching the patient. ORIGINALITY/VALUE: Implementations of an ISO quality management system allow improved quality of care and patient satisfaction in a HIH Unit.

Home treatment of patients with acute cholecystitis.

BACKGROUND: Patients with acute cholecystitis are treated in Hospital. The aim of the study was to analyze the security and efficacy of treating not-operated-on patients with acute cholecystitis in Hospital in the Home (HIH). METHODS: Prospective study from January 2010 to May 2011 including all patients diagnosed with acute cholecystitis, not operated on and without comorbidities admitted to HIH Unit from the Emergency Department Short Stay Unit and Observation Unit. Patients were treated with ertapenem for at least one week. Intravenous treatment was followed by oral therapy to complete 14 days of antibiotic treatment. Patient characteristics, clinical course, need for return to hospital during admission to HIH, and admission to hospital in the month after discharge from HIH are analyzed. RESULTS: 25 patients were included. Mean age was 59 years (34-82). Upon arrival to the Emergency Department, all patients suffered abdominal pain, 60% had fever, and 32% vomiting. 48% of patients had a leukocyte count over 13,000 cells/µl. All patients had cholelithiasis and a distended gallbladder. 56% showed thickening of the gallbladder wall. Fluid accumulation around the gallbladder was noted in 16% of the cases. Murphy's sign proved positive in 44%. All patients showed a favorable course. No patient required hospital readmission during stay in HIH or in the month after discharge. All patients expressed their satisfaction with treatment at home. CONCLUSIONS: Patients with acute cholecystitis and without comorbidities can be safely and effectively treated in HIH after a short monitoring period in hospital.

Patients with uncomplicated diverticulitis and comorbidity can be treated at home.

BACKGROUND: Patients with uncomplicated diverticulitis and comorbidity are usually hospitalized. We analyze the efficacy and safety of treating these patients in Hospital at Home. METHODS: Prospective study since January 2007 to December 2009. Patients were transferred to the Hospital at Home after 12-24h at Emergency Department Observation Ward. All patients were treated with intravenous antibiotic until clinical condition improved. RESULTS: 176 patients were diagnosed with uncomplicated diverticulitis at the Emergency Department. 18% of them (33) had comorbidity. Twenty four patients were transferred to the Hospital at Home (seventeen patients had cardiopathy, four diabetes mellitus and three chronic renal failure). Mean age was 73.4 years. All patients had abdominal pain and 29.1% fever; 45.8% presented with leucocytosis. 20.8% had a previous history of diverticulitis. Mean stay of patients was 9 days. All patients had a favorable course. The home treatment was successfully completed in 100% of patients. 95% of the patients expressed their satisfaction with this type of treatment. CONCLUSIONS: Treatment of patients with uncomplicated diverticulitis and comorbidity at home after a short period of observation in Hospital is safe and effective.

A prospective study of the management of non-massive pulmonary embolism in the home.

BACKGROUND: The objective of this study is to compare the characteristics, outcomes, and clinical complications of patients with pulmonary embolism (PE) who were treated at home as outpatients versus traditional hospitalization. METHODS: Prospective study from January 2006 to June 2007. Selected patients diagnosed at the Emergency Department with stable non-massive pulmonary embolism that met standard inclusion criteria of Hospital at Home (HH) were treated at home. Patients that did not meet these criteria were admitted to Conventional Hospitalization (CH). Major and minor bleeding, re-thrombosis, clinical course, unexpected returns to hospital, and need for hospital re-admission in the following 3 months were recorded. RESULTS: 61 patients with PE were included (30 HH and 31 CH). Mean age 66.8 and 66.7 years in HH and CH, respectively. A history of neoplasm was found to be present in 13.3% and 9.7% of HH and CH patients. In the CH group, 19.3% of patients had prior thromboembolic disease. Concomitant DVT was seen in 40% and 29% of HH and CH patient. Pulmonary embolism was bilateral in 30% and 38.7% of HH and CH patients. No major bleeding, re-thrombosis, or death occurred. The home treatment was successfully completed in 100% of the patients. Three patients in the CH group had hospital-acquired infections. CONCLUSIONS: Patients with stable non-massive pulmonary embolism may be safely treated under conditions of home hospitalization.

High prevalence of secondary hypertension and insulin resistance in patients with refractory hypertension.

OBJECTIVE: To determine causes of treatment resistance in patients with refractory hypertension, and to estimate the prevalence of true resistant hypertension. METHODS: We studied 50 consecutive patients referred with refractory hypertension after exclusion of hypokalemia and stenosis of the renal artery. Ambulatory blood pressure monitoring was performed in all patients to detect white-coat effect. The patients were hospitalized, antihypertensive drugs were withdrawn and a screening for secondary hypertension was performed. In addition, these patients, and a control group of essential hypertensives controlled with three antihypertensive drugs, underwent a OGTT with 75 g of glucose. RESULTS: Primary normokalemic hyperaldosteronism was diagnosed in seven patients. Two patients had a pheochromocytoma and six had white-coat effect. The 35 remaining patients with true resistant hypertension shown significant differences in serum insulin and HOMA IR when compared with the control group. CONCLUSIONS: These findings show that among normokalemic treatment-resistant hypertension, the presence of hyperaldosteronism and pheochromocytoma is quite high. Moreover, treatment resistance in hypertensive patients appears to be associated with insulin resistance.