Utilisation of beds on the general medical unit by 'non-acute medical' patients: a retrospective study of incidence and cost in two Tasmanian regional medical hospital units.

BACKGROUND: Demand for healthcare services threatens to overwhelm the Australian healthcare system. Public hospitals have the largest component of expenditure growth and as such represent the largest opportunity for efficiency gains. Utilisation of inpatient hospital beds and in particular those on general medical units has not been studied in Australia. AIM: To undertake a retrospective patient medical record review of 200 sequential admissions to the medical wards in two regional Tasmanian hospitals to determine the incidence of non-acute medical patient admission to the medical unit, and the subsequent days in hospital that were not required for medical reasons. The cost of these days was estimated. RESULTS: Sixteen patient admissions (8%) could not be justified on medical grounds. Forty-eight (24%) patient admissions had at least one day hospital day that could not be justified on medical grounds. Of the 1438 total bed days, 475 (33%) were for non-medical reasons. The estimated cost of those non-medical bed days for this cohort was $764 800. CONCLUSIONS: The incidence of non-acute medical admissions and non-acute medical bed days to the medical unit and associated cost was significant. Further research is needed to design alternative care provision for such patients particularly in regional Australia. The potential savings to the Australian healthcare system could be significant.

Erythromycin improves gastric emptying in critically ill patients intolerant of nasogastric feeding.

OBJECTIVE: To evaluate the effect of intravenous erythromycin on gastric emptying and the success of enteral feeding in mechanically ventilated, critically ill patients with large volume gastric aspirates. DESIGN: Prospective, double-blind, randomized, and placebo-controlled trial. SETTING: General intensive care unit in a university hospital. PATIENTS: Twenty critically ill, mechanically ventilated patients intolerant of nasogastric feeding (indicated by a residual gastric volume of > or =250 mL during feed administration at > or =40 mL/hr). INTERVENTIONS: After a gastric aspirate of > or =250 mL, which was discarded, the enteral feeding was continued at the previous rate for 3 hrs. Intravenous erythromycin (200 mg) or placebo was then administered over 20 mins. The residual gastric contents were again aspirated and the volume was recorded 1 hr after the infusion began. MEASUREMENTS AND MAIN RESULTS: Gastric emptying was calculated as volume of feed infused into the stomach over 4 hrs minus the residual volume aspirated. Mean gastric emptying was 139+/-37 (+/-SEM) mL after erythromycin and -2+/-46 mL after placebo (p = .027). Nasogastric feeding was successful in nine of ten patients treated with erythromycin and five of ten who received placebo 1 hr after infusion (chi-square p = .05). CONCLUSION: In critically ill patients who have large volumes of gastric aspirates indicating a failure to tolerate nasogastric feeding, a single small dose of intravenous erythromycin allows continuation of feed in the short term.

Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary-care hospital.

OBJECTIVE: To investigate the nature and duration of clinical instability (i.e., abnormalities in simple physical observations or laboratory test results) in hospital patients before a "critical event" (i.e., a cardiac arrest or an unplanned admission to intensive care). DESIGN: Retrospective survey of medical records of all patients having critical events (CEs) over 12 months. Data on hospital and Intensive Care Unit (ICU) patients were obtained for comparison with the study population. SETTING: A 300-bed metropolitan teaching hospital with a seven-bed ICU. PATIENTS: All patients having CEs over a 12-month period (January to December 1997). MAIN OUTCOME MEASURES: Number of patients with clinical instability before a CE; duration of clinical instability before a CE; number of medical reviews of each patient before a CE; mortality rate and length of hospital stay for all patients. RESULTS: There were 122 CEs in 112 patients (median, 1; range, 1-4). Of the CEs, 79 were unplanned ICU admissions (14 subsequent to cardiac arrest calls), and 43 were cardiac arrest calls not resulting in ICU admission. Each CE was preceded by a median of two (range, 0-9) criteria for clinical instability. The median duration of instability before a CE was 6.5 hours (range, 0-432 hours), and in that time a median of two (range, 0-13) medical reviews took place. The incidence of CEs in the total hospital population (122 CEs/19,853 admissions) and in ICU patients (79 unplanned admissions/515 admissions) was 0.6% and 15%, respectively. There were 70 deaths (62%) among the 112 patients, compared with a total of 392 deaths (2% of admissions) in the hospital, of which 107 were in ICU. CONCLUSIONS: Very few patients suffer a CE while in hospital. However, those who do frequently manifest abnormalities in simple physical observations and laboratory test results before the CE. More rapid intervention in response to warning signs might provide a better outcome for these patients.

A severe, late reaction to radiological contrast media mimicking a sepsis syndrome.

An unusual, severe delayed reaction to non-ionic intravenous contrast media was observed. A 44-year-old man underwent a computed tomography scan with non-ionic contrast media. Four hours later the patient collapsed with hypotension and cardiovascular shock. Aggressive management (including inotropic support and fluid resuscitation) was instituted in the intensive care unit. Rigorous imaging and biochemical and microbiological investigation failed to identify a source of this man's circulatory collapse. A rapid recovery ensued and at 3 months follow-up the patient was suffering no residual effects from this event. To our knowledge, this is only the second report of a severe delayed reaction to radiological contrast media and the first that manifested as a prolonged hypotensive syndrome.

Fulminant desquamative interstitial pneumonitis.

A previously well, 48-year-old female presented with a short history of respiratory distress and fever for which no cause could be found. Open lung biopsy was not contributory. She died within nine days of presentation of hypoxia and multi-organ failure. Post mortem examination revealed the pattern of desquamative interstitial pneumonitis.

Intraabdominal pressure and gastric intramucosal pH: is there an association?

This study evaluated the potential association between increased intraabdominal pressure (IAP) and abnormally low gastric intramucosal pH (pHi) (/= 20 mmHg and a pHi of

Prospective study of intra-abdominal hypertension and renal function after laparotomy.

The value of postoperative monitoring of intra-abdominal pressure (IAP) in surgical patients has not been established. This study prospectively evaluated the occurrence of increased IAP and its association with renal impairment and outcome in surgical patients admitted to an intensive care unit. One hundred consecutive patients after laparotomy were studied, 88 of whom had complete IAP measurements. IAP was measured using an intravesical catheter and was considered increased when equal to 20 mmHg or above. Renal impairment was defined as a postoperative serum creatinine concentration of greater than 130 mumol/l, or an increase in serum creatinine of greater than 100 mumol/l within 72 h of surgery. The median (range) APACHE (Acute Physiology And Chronic Health Evaluation) II score of the patients was 13.5 (4-43). The incidence of raised IAP was 29 of 88 (33 per cent). Renal impairment was present in 29 of 88 (33 per cent), of whom 20 of 29 (69 per cent) had raised IAP (P < 0.01). The odds ratios (95 per cent confidence interval) for the development of renal impairment and death in patients with increased IAP were 12.4 (3.8-41.7) and 11.2 (2.8-47.9) respectively. There is a clinically significant association between increased IAP and renal impairment in patients admitted to an intensive care unit after laparotomy.

Intra-abdominal pressure measurement using a modified nasogastric tube: description and validation of a new technique.

OBJECTIVE: This study assessed the accuracy of an intragastric method of measuring intra-abdominal pressure (IAP). DESIGN: Prospective sequential study with simultaneous paired measurement of gastric and urinary bladder pressures. SETTING: Operating theatre, University Teaching Hospital. PATIENTS: 9 patients undergoing laparoscopic cholecystectomy were studied. INTERVENTIONS: Intraperitoneal pressures were monitored during peritoneal insufflation at laparoscopy up to a pressure of 20 mmHg. MEASUREMENTS AND RESULTS: Intra-abdominal pressure measurements were recorded simultaneously using a gastric balloon and urinary catheter. Gastric pressure may be up to 4 mmHg higher or 3 mmHg lower than urinary bladder pressure. CONCLUSIONS: Intra-abdominal pressure can be measured easily in this new fashion, allowing a continuous pressure trend to be obtained without interfering with urinary output estimation.

Severe meningococcal septicaemia associated with splenic rupture.

OBJECTIVE: To present the first report of ruptured spleen associated with meningococcal septicaemia. CLINICAL FEATURES: A 13-year-old girl presented with an acute abdomen and clinical signs of meningococcal septicaemia. Features of her illness placed her in a high mortality group. INTERVENTION AND OUTCOME: She required cardiovascular and respiratory support in the Intensive Care Unit. Failure to initially identify the organism led to percutaneous fine-needle aspiration of fluid in the lesser sac. A laparotomy revealed free intraperitoneal blood and a ruptured spleen. During the course of her illness she was given penicillin and methylprednisolone, and required haemodialysis. She made a complete recovery. CONCLUSION: Ruptured spleen does occur with severe meningococcaemia, and may complicate management.