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1.
J Surg Res ; 245: 492-499, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31446191

RESUMO

BACKGROUND: Older adults with isolated rib fractures are often admitted to an intensive care unit (ICU) because of presumedly increased morbidity and mortality. However, evidence-based guidelines are limited. We sought to identify characteristics of these patients that predict the need for ICU care. MATERIALS AND METHODS: We analyzed patients ≥50 y old at our center during 2013-2017 whose only indication for ICU admission, if any, was isolated rib fractures. The primary outcome was any critical care intervention (e.g., intubation) or adverse event (e.g., hypoxemia) (CCIE) based on accepted critical care guidelines. We used stepwise logistic regression to identify characteristics that predict CCIEs. RESULTS: Among 401 patients, 251 (63%) were admitted to an ICU. Eighty-three patients (33%) admitted to an ICU and 7 (5%) admitted to the ward experienced a CCIE. The most common CCIEs were hypotension (10%), frequent respiratory therapy (9%), and oxygen desaturation (8%). Predictors of CCIEs included incentive spirometry <1 L (OR 4.72, 95% CI 2.14-10.45); use of a walker (OR 2.86, 95% CI 1.29-6.34); increased chest Abbreviated Injury Scale score (AIS 3 OR 5.83, 95% CI 2.34-14.50); age ≥72 y (OR 2.68, 95% CI 1.48-4.86); and active smoking (OR 2.11, 95% CI 1.06-4.20). CONCLUSIONS: Routine ICU admission is not necessary for most older adults with isolated rib fractures. The predictors we identified warrant prospective evaluation for development of a clinical decision rule to preclude unnecessary ICU admissions.


Assuntos
Hipotensão/epidemiologia , Unidades de Terapia Intensiva/normas , Admissão do Paciente/normas , Fraturas das Costelas/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/normas , Cuidados Críticos/estatística & dados numéricos , Feminino , Humanos , Hipotensão/etiologia , Hipotensão/terapia , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Fraturas das Costelas/complicações , Medição de Risco , Centros de Traumatologia/normas , Centros de Traumatologia/estatística & dados numéricos
2.
Pediatrics ; 144(4)2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31488695

RESUMO

This is an executive summary of the 2019 update of the 2004 guidelines and levels of care for PICU. Since previous guidelines, there has been a tremendous transformation of Pediatric Critical Care Medicine with advancements in pediatric cardiovascular medicine, transplant, neurology, trauma, and oncology as well as improvements of care in general PICUs. This has led to the evolution of resources and training in the provision of care through the PICU. Outcome and quality research related to admission, transfer, and discharge criteria as well as literature regarding PICU levels of care to include volume, staffing, and structure were reviewed and included in this statement as appropriate. Consequently, the purposes of this significant update are to address the transformation of the field and codify a revised set of guidelines that will enable hospitals, institutions, and individuals in developing the appropriate PICU for their community needs. The target audiences of the practice statement and guidance are broad and include critical care professionals; pediatricians; pediatric subspecialists; pediatric surgeons; pediatric surgical subspecialists; pediatric imaging physicians; and other members of the patient care team such as nurses, therapists, dieticians, pharmacists, social workers, care coordinators, and hospital administrators who make daily administrative and clinical decisions in all PICU levels of care.


Assuntos
Cuidados Críticos/normas , Unidades de Terapia Intensiva Pediátrica , Admissão do Paciente/normas , Alta do Paciente/normas , Pediatria/normas , Triagem/normas , Comitês Consultivos , Criança , Cuidados Críticos/tendências , Técnica Delfos , Humanos , Lactente , Pediatria/tendências
3.
Rev Assoc Med Bras (1992) ; 65(7): 1015-1020, 2019 Aug 05.
Artigo em Inglês | MEDLINE | ID: mdl-31389516

RESUMO

OBJECTIVE: To review systematically the influence of admission criteria on the mortality of elderly patients under intensive therapy. METHODS: We performed a search on the PUBMED and BIREME databases by using the MeSH and DeCS terms "intensive care units", "patient admission", and "aged" in Portuguese, English, and Spanish. Only prospective and retrospective cohort studies were included. We analyzed the severity score, type of hospital admission, quality of life, co-morbidities, functionality, and elderly institutionalization. RESULTS: Of the 1,276 articles found, thirteen were selected after evaluation of the inclusion and exclusion criteria. It was observed that the severity score, functionality, and co-morbidities had an impact on mortality. It was not possible to determine which severity score was more suitable. CONCLUSION: We suggest that analysis of functionality, co-morbidities, and severity scores should be conducted to estimate the elderly mortality in relation to the admission to intensive care units.


Assuntos
Mortalidade Hospitalar , Unidades de Terapia Intensiva/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Admissão do Paciente/normas , Fatores Etários , Comorbidade , Humanos , Qualidade de Vida , Índice de Gravidade de Doença
5.
J Stroke Cerebrovasc Dis ; 28(9): 2488-2495, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31277995

RESUMO

BACKGROUND AND OBJECTIVE: Current standard practice guidelines recommend ICU admission for ischemic stroke patients treated with intravenous tissue plasminogen activator (IV-tPA). More recently, the trend in stroke care is to broaden eligibility for IV thrombolysis. Two examples are a more liberal inclusion criteria known as SMART criteria (sIV-tPA), and the transfer of patients to comprehensive stroke centers (CSC). The present study characterizes ICU interventions in these patients. Understanding which stroke patients that require ICU-level care may allow for placement of patients in the appropriate level of care at hospital admission. METHODS: We performed a retrospective review of consecutive transfer and nontransfer sIV-tPA-treated patients admitted to the ICU at a CSC. We evaluated the frequency, timing, and nature of ICU interventions. RESULTS: Three hundred and thirty one patients were treated with sIV-tPA and 42% required ICU interventions during ICU admission. Of patients requiring ICU interventions, 98% had an ICU intervention performed in triage, prior to admission. National Institute of Health Stroke Scale score only had a moderate association to requirement of ICU interventions. Neither transferring patients to a CSC nor the number of standard IV-tPA contraindications increased ICU interventions. CONCLUSIONS: Liberalized IV-tPA administration did not increase ICU interventions. Nearly all patients that required ICU interventions declared this need in triage, prior to ICU admission. This timing of ICU intervention use during triage is highly sensitive for whether a patient will require ongoing ICU-level care during hospital admission. Identifying ICU intervention use in triage may allow for more effective placement of post-IV-tPA patients in the appropriate inpatient care setting, leading to better utilization of scarce ICU resources.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Unidades de Terapia Intensiva , Admissão do Paciente , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Triagem , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Tomada de Decisão Clínica , Bases de Dados Factuais , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Infusões Intravenosas , Unidades de Terapia Intensiva/normas , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/normas , Seleção de Pacientes , Transferência de Pacientes , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/normas , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento , Triagem/normas
6.
Am Surg ; 85(6): 611-619, 2019 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-31267902

RESUMO

The Medicare Severity Diagnosis Related Group (MS-DRG) weight, as derived from the MS-DRG assigned at discharge, is in part determined by the physician-documented diagnoses. However, the terminology associated with MS-DRG determination is often not aligned with typical physician language, leading to inaccurate coding and decreased hospital reimbursements. The goal of this study was to evaluate the impact of a diagnosis picklist within a paper-based history and physical examination (H&P) on the average MS-DRG weight and the Case-mix index (CMI). Our trauma center implemented a paper H&P form for trauma patients featuring picklist diagnoses aligned with the MS-DRG terminology and arranged by the physiologic system. To evaluate its impact, we conducted a cohort study using data from our trauma registry between July 2015 and November 2017. Our cohort included 442 (26.0%) paper and 1,261 (74.0%) dictated H&Ps. Average CMI (2.56 vs 2.15) and expected patients ($25,057 vs $19,825) were higher for the paper group (P < 0.001, P = 0.002). Adjusted regression models demonstrated paper coding to be associated with 0.265 CMI points, translating to an average increase in expected payment of 6.5 per cent per patient. Utilization of a standardized, paper-based H&P template with picklist diagnoses was associated with a higher trauma service CMI and higher expected payments. Preprinted diagnoses that align with the MS-DRG terminology lead to clinical documentation improvement.


Assuntos
Grupos Diagnósticos Relacionados/tendências , Documentação/tendências , Alta do Paciente/tendências , Melhoria de Qualidade , Centros de Traumatologia/organização & administração , Ferimentos e Lesões/diagnóstico , Centros Médicos Acadêmicos/organização & administração , Arizona , Intervalos de Confiança , Bases de Dados Factuais , Grupos Diagnósticos Relacionados/normas , Documentação/métodos , Feminino , Humanos , Masculino , Medicare/economia , Admissão do Paciente/normas , Admissão do Paciente/tendências , Alta do Paciente/normas , Alta do Paciente/estatística & dados numéricos , Exame Físico/normas , Exame Físico/tendências , Sistema de Pagamento Prospectivo/normas , Sistema de Pagamento Prospectivo/tendências , Análise de Regressão , Estudos Retrospectivos , Estados Unidos , Ferimentos e Lesões/classificação
7.
Hosp Top ; 97(2): 60-65, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31050309

RESUMO

The objective of study was to evaluate the prevalence of malnutrition and associated factors in cardiac patients in the north of Iran. This cross-sectional study was done on 430 cardiac patients, who were admitted to the only heart hospital in the north of Iran. The malnutrition status was assessed based on "Malnutrition Universal Screening Tool" (MUST). The data was analyzed using SPSS software. The mean age of patients was 63.5 ± 12.67 years. The commonest cause of hospitalization was acute coronary syndrome. 31.4% patients had history of admission in the past 12 months. The prevalence of malnutrition was 14%, 7.7%, and 6.3% had medium and high risk of malnutrition, respectively. Patients with history of one time admission were 2.7 times more likely to be malnourished. The odds ratio for more than one time of hospital admission was 3.54. Malnutrition is likely to be present when the cardiac patients are admitted to hospital in Gilan province, in northern Iran.


Assuntos
Cardiopatias/complicações , Desnutrição/classificação , Idoso , Estudos Transversais , Feminino , Humanos , Irã (Geográfico) , Masculino , Desnutrição/etiologia , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Estado Nutricional , Razão de Chances , Admissão do Paciente/normas , Admissão do Paciente/estatística & dados numéricos , Prevalência , Fatores de Risco
9.
Tidsskr Nor Laegeforen ; 139(9)2019 May 28.
Artigo em Norueguês, Inglês | MEDLINE | ID: mdl-31140252

RESUMO

BACKGROUND: Chronic pain is a widespread health problem. The four regional interdisciplinary pain management centres in Norway receive approximately 5 000 referrals from GPs and the specialist health service annually. Equality in service provision requires referrals to be identically assessed. The objective of the study was to evaluate the degree of correspondence between the admission teams in the pain management centres in their assessment of the quality of the referrals received and in their assessment of the patients' right to necessary health care. MATERIAL AND METHOD: Each admission team assessed 40 referrals. They undertook a 'primary assessment' of 10 referrals received in the regular manner and a 'secondary assessment' of 30 referrals sent in the regular manner to the other centres. Each referral was assessed for quality and rights in each centre. The proportion of agreement and the intra-class correlation coefficient (ICC) were used to assess correspondence between the admission teams. RESULTS: The quality of the referrals was deemed 'not good' in 45 % of the primary assessments and 43 % of the secondary assessments. The degree of correspondence varied from low (ICC = 0.19) to moderate (ICC = 0.74). The primary and secondary assessments both granted 63 % of the patients 'the legal right to health care'. The overall degree of correspondence was 69 %, i.e. lower than what is considered 'acceptable agreement' (75 %). INTERPRETATION: The study shows that there is a need for structured referrals, and for the admission teams to harmonise their assessments to a greater degree in order to ensure equality in service provision across the health regions.


Assuntos
Clínicas de Dor , Admissão do Paciente/normas , Encaminhamento e Consulta/normas , Dor Crônica/terapia , Humanos , Noruega , Manejo da Dor , Direitos do Paciente
10.
Comput Inform Nurs ; 37(5): 260-265, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31094915

RESUMO

The objective of this quality improvement study was to evaluate whether electronic health record system timers and event logs can measure the efficiency and quality of a clinical process in an electronic health record. Using an experimental pre- and post-nonrandomized prospective cohort design, the researchers introduced a newly defined admission patient history essential data set and examined the electronic health record event files and timers to analyze the nursing experience from an efficiency and quality perspective. The researchers evaluated efficiency by measuring the time and clicks required to complete an admission history. The average active time spent documenting the admission patient history decreased by 72% from the preintervention measure (mean = 9.30 minutes) to the postintervention measure (mean = 2.55 minutes). The number of clicks decreased by 76% from the preintervention number of clicks (mean = 151.5) to the postintervention number of clicks (mean = 35.93). The quality of documentation was measured as the proportion of completed essential items and the frequency of completing an assessment in one sequence. The capture of essential data elements improved by almost 6%, and admission patient history data completed in one sequence increased by 24%. These study results demonstrate that system timers and event logs can measure the preintervention and postintervention changes in efficiency and quality of a defined clinical workflow into an electronic health record.


Assuntos
Documentação/normas , Registros Eletrônicos de Saúde , Anamnese/métodos , Enfermeiras e Enfermeiros/normas , Conjuntos de Dados como Assunto , Documentação/métodos , Humanos , Anamnese/normas , Enfermeiras e Enfermeiros/estatística & dados numéricos , Admissão do Paciente/normas , Melhoria de Qualidade
11.
World J Surg ; 43(9): 2186-2193, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31089767

RESUMO

BACKGROUND: Classical medical teaching has made a clear distinction between signs and symptoms, and diagnosis. However, at the time of ward admission, a diagnosis may remain unclear. We propose administrative pressures during the admission process may have reduced the ability for pathological diagnosis. This may result in increased hospitalisation for investigation of signs and symptoms, rather than for treatment of clear diagnoses. We sought to further clarify this hypothesis and investigate changes in the nature of admissions during the last two decades in an adult emergency general surgery service. METHODS: A retrospective analysis of emergency general surgical admissions during four six-month time periods, between 2000 and 2018, was conducted. The six-month periods were spaced evenly during the 18-year study. Demographic information, emergency department length of stay, incidence of a pathological diagnosis on ward admission and accuracy of admission diagnosis were analysed. RESULTS: 2763 patients were admitted in the four six-month time periods. A significant reduction in number of patients admitted with a pathological diagnosis was noted between the 2012 and 2018 study periods (p < 0.05), with 21.2% of patients admitted in 2018 for investigation of signs and symptoms. The incidence of an accurate admission diagnosis (as assessed by the discharge diagnosis) ranged from 62.3 to 63.6% and did not differ significantly by year. CONCLUSION: Between 2012 and 2018, there was a significant increase in the number of emergency general surgical patients admitted for investigation of signs and symptoms. However, accuracy of admission diagnosis was unchanged during the study period.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Cirurgia Geral/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Diagnóstico , Serviço Hospitalar de Emergência/organização & administração , Feminino , Cirurgia Geral/organização & administração , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Lactente , Recém-Nascido , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/normas , Estudos Retrospectivos , Centros de Atenção Terciária/organização & administração , Centros de Atenção Terciária/estatística & dados numéricos , Austrália Ocidental , Adulto Jovem
12.
Pediatrics ; 143(5)2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30944154

RESUMO

OBJECTIVES: Frequent hospitalizations for sickle cell disease (SCD) vaso-occlusive crises (VOCs) are associated with school absenteeism, emotional distress, and financial hardships. Our goal was to decrease hospital days for VOC admissions by 40% over a 5-year period. METHODS: From October 2011 to September 2016, a multidisciplinary quality-improvement project was conducted with a plan-do-study-act methodology. Five key drivers were identified and 9 interventions implemented. Interventions included individualized home pain plans, emergency department and inpatient order sets, an inpatient daily schedule, psychoeducation, and a biofeedback program. High users (≥4 admissions per year) received an individualized SCD plan and assigned mental health provider. We expanded the high-use group to include at-risk patients (3 admissions per year). Data were analyzed for patients ages 0 to 21 years admitted for VOC. Hospital days were the primary measure; the 30-day readmission rate was the balancing measure. RESULTS: A total of 216 SCD pediatric patients were managed in 2011 with a 14% increase over 5 years. A total of 122 patients were admitted for VOC. Hospital days decreased by 61% from 59.6 days per month in the preintervention period to 23.2 days per month in the postintervention period (P < .0001). Length of stay decreased from 4.78 (SD = 4.08) to 3.84 days (SD = 2.10; P = .02). Among high users, hospital days decreased from 35.4 to 15.5 days per month. The thirty-day readmission rate decreased from 33.9% to 19.4%. Overall savings in direct hospital costs per year were $555 120. CONCLUSIONS: A dedicated team effort with simple interventions can have a significant impact on the well-being of a patient population and hospital costs.


Assuntos
Anemia Falciforme/terapia , Manejo da Dor/normas , Admissão do Paciente/normas , Equipe de Assistência ao Paciente/normas , Melhoria de Qualidade/normas , Adolescente , Anemia Falciforme/diagnóstico , Anemia Falciforme/epidemiologia , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Dor/diagnóstico , Dor/epidemiologia , Manejo da Dor/métodos
13.
N Z Med J ; 132(1490): 10-16, 2019 02 22.
Artigo em Inglês | MEDLINE | ID: mdl-30789884

RESUMO

BACKGROUND: Electronic whiteboards have largely replaced the use of traditional whiteboards in many hospital departments. They are used to electronically record and display a variety of patient information to streamline the admission process and the quality of handover between relevant staff. We assessed the impact of such a system upon the patient admission process in a busy general surgery department. METHODS: A survey of 12 qualitative questions was completed by surgical registrars working within a general surgery department in 2013 prior to the introduction of electronic whiteboards and again in 2016 after introduction. The questions compared the satisfaction of the admission process before and after its introduction. RESULTS: There was an improvement in staff satisfaction with the admissions process after the introduction of electronic whiteboards (78% vs 9% high level of satisfaction, p<0.05). A statistically non-significant rise was also seen in individual areas of the admissions and handover process. No change was seen in staff attitude to security of patient details (50% vs 42% high level of satisfaction, p=0.671). CONCLUSION: Electronic whiteboards assist in the process of admitting patients to a general surgical department. This strengthens the case for the introduction of electronic whiteboards across a range of hospital departments.


Assuntos
Eficiência Organizacional/estatística & dados numéricos , Registros Eletrônicos de Saúde/organização & administração , Admissão do Paciente/normas , Centro Cirúrgico Hospitalar , Atitude do Pessoal de Saúde , Sistemas de Informação Hospitalar/normas , Humanos , Comunicação Interdisciplinar , Nova Zelândia , Melhoria de Qualidade , Centro Cirúrgico Hospitalar/organização & administração , Centro Cirúrgico Hospitalar/normas , Inquéritos e Questionários
14.
J Gerontol Nurs ; 45(3): 7-11, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30789984

RESUMO

The CARE Act, law in 40 states and territories in the United States, requires hospitals to identify and include family caregivers during admission and in preparation for discharge. Although the number of family caregivers has been steadily increasing, health care providers are ill-prepared to address their needs, and caregiving remains a neglected topic in health care providers' education. A market analysis was performed to explore the availability of and interest in interprofessional courses and programs focused on preparing health professionals to support family caregivers. Although nurses and chief nursing officers agreed on the importance of supporting caregivers, they were less likely to endorse formal educational preparation for this complex role. The current study elucidates a gap between what caregivers report they need and the preparation of health care professionals to advance family-centered approaches to care. [Journal of Gerontological Nursing, 45(3), 7-11.].


Assuntos
Cuidadores/educação , Cuidadores/legislação & jurisprudência , Pessoal de Saúde/educação , Admissão do Paciente/legislação & jurisprudência , Admissão do Paciente/normas , Alta do Paciente/legislação & jurisprudência , Alta do Paciente/normas , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
17.
Gac. sanit. (Barc., Ed. impr.) ; 33(1): 60-65, ene.-feb. 2019. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-183628

RESUMO

Objetivo: Comparar la concordancia de los pesos de complejidad entre los estratificadores Clinical Risk Groups (CRG) y los grupos de morbilidad ajustada (GMA), determinar cuál de ellos es el mejor predictor de ingreso hospitalario y optimizar el método para seleccionar el 0,5% de pacientes de más alta complejidad que se incluirán en un protocolo de intervención. Método: Estudio analítico transversal en 18 zonas de salud de Canarias, con una población a estudio de 385.049 personas, usando variables sociodemográficas procedentes de la tarjeta sanitaria, los diagnósticos y el uso de los recursos asistenciales obtenidos de la historia electrónica de salud de atención primaria (HSAP) y del conjunto mínimo básico de datos hospitalario, el estado funcional registrado en la HSAP y los fármacos prescritos en el sistema de receta electrónica. A partir de esos datos se estimó la concordancia entre estratificadores, se evaluó la capacidad de cada estratificador para predecir ingresos y se construyeron modelos para optimizar la predicción. Resultados: La concordancia entre los pesos de complejidad de los estratificadores fue fuerte (rho = 0,735) y la concordancia entre categorías de complejidad fue moderada (Kappa ponderado = 0,515). El peso de complejidad GMA predice el ingreso hospitalario mejor que el del CRG (área bajo la curva [AUC]: 0,696 [0,695-0,697] vs. 0,692 [0,691-0,693]). Se añadieron otras variables predictivas al peso GMA, obteniendo la mejor AUC (0,708 [0,707-0,708]) el modelo compuesto por GMA, sexo, edad, escalas de Pfeiffer y Barthel, existencia de reingreso y número de grupos terapéuticos prescritos. Conclusiones: Se constató una fuerte concordancia entre estratificadores y una mayor capacidad predictiva de los ingresos por parte de los GMA, que puede aumentarse añadiendo otras dimensiones


Objective: To compare the concordance of complexity weights between Clinical Risk Groups (CRG) and Adjusted Morbidity Groups (AMG). To determine which one is the best predictor of patient admission. To optimise the method used to select the 0.5% of patients of higher complexity that will be included in an intervention protocol. Method: Cross-sectional analytical study in 18 Canary Island health areas, 385,049 citizens were enrolled, using sociodemographic variables from health cards; diagnoses and use of healthcare resources obtained from primary health care electronic records (PCHR) and the basic minimum set of hospital data; the functional status recorded in the PCHR, and the drugs prescribed through the electronic prescription system. The correlation between stratifiers was estimated from these data. The ability of each stratifier to predict patient admissions was evaluated and prediction optimisation models were constructed. Results: Concordance between weights complexity stratifiers was strong (rho = 0.735) and the correlation between categories of complexity was moderate (weighted kappa = 0.515). AMG complexity weight predicts better patient admission than CRG (AUC: 0.696 [0.695-0.697] versus 0.692 [0.691-0.693]). Other predictive variables were added to the AMG weight, obtaining the best AUC (0.708 [0.707-0.708]) the model composed by AMG, sex, age, Pfeiffer and Barthel scales, re-admissions and number of prescribed therapeutic groups. Conclusions: strong concordance was found between stratifiers, and higher predictive capacity for admission from AMG, which can be increased by adding other dimensions


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Seleção de Pacientes , Alocação de Recursos para a Atenção à Saúde/métodos , Risco Ajustado/métodos , Doença Crônica/classificação , Estudos Transversais , Índice de Gravidade de Doença , Hospitalização/estatística & dados numéricos , Admissão do Paciente/normas
18.
BMC Geriatr ; 19(1): 20, 2019 01 23.
Artigo em Inglês | MEDLINE | ID: mdl-30674278

RESUMO

BACKGROUND: Mobility is a key indicator of physical functioning in older people, but there is limited evidence of the reliability of mobility measures in older people with cognitive impairment. This study aimed to examine the test-retest reliability and measurement error of common measurement instruments of mobility and physical functioning in older patients with dementia, delirium or other cognitive impairment. METHODS: A cross-sectional study was performed in a geriatric hospital. Older acute medical patients with cognitive impairment, indicated by a Mini-Mental State Examination (MMSE) score of ≤24 points, were assessed twice within 1 day by a trained physiotherapist. The following instruments were applied: de Morton Mobility Index, Hierarchical Assessment of Balance and Mobility, Performance-Oriented Mobility Assessment, Short Physical Performance Battery, 4-m gait speed, 5-times chair rise test, 2-min walk test, timed up and go test, Barthel Index mobility subscale and Functional Ambulation Categories. As appropriate, the intraclass correlation coefficient (ICC), Cohen's kappa, standard error of measurement, limits of agreement and minimal detectable change (MDC) values were estimated. RESULTS: Sixty-five older acute medical patients with cognitive impairment participated in the study (mean age: 82 ± 7 years; mean MMSE: 20 ± 4, range: 10 to 24 points). Some participants were physically or cognitively unable to perform the gait speed (46%), 2-min walk (46%), timed up and go (51%) and chair rise (75%) tests. ICC and kappa values were above 0.9 in all instruments except for the gait speed (ICC = 0.86) and chair rise (ICC = 0.72) measures. Measurement error is reported for each instrument. The absolute limits of agreement ranged from 11% (de Morton Mobility Index and Hierarchical Assessment of Balance and Mobility) to 35% (chair rise test). CONCLUSIONS: The test-retest reliability is sufficient (> 0.7) for group-comparisons in all examined instruments. Most mobility measurements have limited use for individual monitoring of mobility over time in older hospital patients with cognitive impairment because of the large measurement error (> 20% of scale width), even though relative reliability estimations seem sufficient (> 0.9) for this purpose. TRIAL REGISTRATION: German Clinical Trials Register ( DRKS00005591 ). Registered 2 February 2015.


Assuntos
Disfunção Cognitiva/diagnóstico , Serviços de Saúde para Idosos/normas , Limitação da Mobilidade , Velocidade de Caminhada/fisiologia , Caminhada/fisiologia , Caminhada/normas , Idoso , Idoso de 80 Anos ou mais , Disfunção Cognitiva/psicologia , Estudos Transversais , Feminino , Serviços de Saúde para Idosos/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/normas , Admissão do Paciente/tendências , Modalidades de Fisioterapia/normas , Modalidades de Fisioterapia/tendências , Equilíbrio Postural/fisiologia , Reprodutibilidade dos Testes
19.
Int J Clin Pharm ; 41(1): 65-73, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30610543

RESUMO

Background Medication communication and prescribing on the post-take ward round following patient admission to hospital can be suboptimal leading to worse patient outcomes. Objective To evaluate the impact of clinical pharmacist participation on the post-take ward round on the appropriateness of medication prescribing, medication communication, and overall patient health care outcomes. Setting Tertiary referral teaching hospital, Brisbane, Australia. Method A pre-post intervention study was undertaken that compared the addition of a senior clinical pharmacist attending the post-take ward was compared to usual wardbase pharmacist service, with no pharmacist present of the post-take ward round. We assessed the proportion of patients with an improvement in medication appropriateness from admission to discharge, using the START/STOPP checklists. Medication communication was assessed by the mean number of brief and in-depth discussions, with health care outcomes measured by comparing length of stay and 28-day readmission rates. Main outcome measures: Medication appropriateness according to the START/STOPP list, number and type of discussions with team members and length of stay and readmission rate. Results Two hundred and sixty patients were recruited (130 pre- and 130-post-intervention), across 23 and 20 post-take ward rounds, respectively. Post-intervention, there was increase in the proportion of patients who had an improvement medication appropriateness (pre-intervention 25.4%, post-intervention 36.9%; p = 0.004), the number of in-depth discussions about patients' medication (1.9 ± 1.7 per patient pre-intervention, 2.7 ± 1.7 per patient post-, p < 0.001), and the number relating to high-risk medications (0.71 ± 1.1 per patient pre-intervention, to 1.2 ± 1.2 per patient post-, p < 0.05). Length of stay and 28-day mortality were unchanged. Conclusion Clinical pharmacist participation on the post-take ward round leads to improved medication-related communication and improved medication appropriateness but did not significantly improve health care outcomes.


Assuntos
Prescrições de Medicamentos/normas , Equipe de Assistência ao Paciente/normas , Farmacêuticos/normas , Lista de Medicamentos Potencialmente Inapropriados/normas , Papel Profissional , Visitas com Preceptor/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Erros de Medicação/prevenção & controle , Pessoa de Meia-Idade , Admissão do Paciente/normas , Serviço de Farmácia Hospitalar/métodos , Serviço de Farmácia Hospitalar/normas , Visitas com Preceptor/métodos
20.
Int J Clin Pharm ; 41(1): 159-166, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30478496

RESUMO

Background Successful deprescribing practices are required to address issues associated with polypharmacy but are hindered by minimal interprofessional collaboration, time constraints, concern for negative outcomes, and absence of a systematic and evidence-based approach. Objective Determine the impact of pharmacist-led deprescribing rounds within a clinical teaching unit (CTU) the number of home medications discontinued upon hospital discharge. Setting Canadian tertiary care hospital. Methods Prospective, dual-arm, interventional study conducted in a single centre, from November 23rd, 2015 to August 30th, 2016. All patients ≥ 19 years old admitted under the CTU were considered for enrolment if on medication(s) prior to admission and patients were excluded if not taking any medications. Study arm allocation alternated daily between the two teams. The control arm operated as per standard whereas the intervention arm's pharmacist used a deprescribing guide and medication review to identify medications eligible for discontinuation prior to discussing during daily rounds. Discharge documents communicated medication changes to patient and primary healthcare providers. The study was sufficiently powered. Main outcome measure The difference of number of home medications discontinued at discharge between the intervention and control groups. Results 171 and 187 patients were allocated to the intervention and control arms, respectively. No significant differences of baseline characteristics existed between groups. Main outcome measure results showed that deprescribing rounds resulted in significantly more medications deprescribed compared to control (65% vs. 38%; p = 0.001). The rates of readmission and emergency department visits were reduced in the intervention arm. Conclusions Incorporating deprescribing rounds into routine care led to significantly greater discontinuation of medications without increasing rate of emergency department visits or hospital admissions.Trial registration ISRCTN11751440.


Assuntos
Desprescrições , Alta do Paciente/normas , Farmacêuticos/normas , Polimedicação , Medicamentos sob Prescrição/normas , Visitas com Preceptor/normas , Adulto , Idoso , Feminino , Seguimentos , Humanos , Medicina Interna/métodos , Medicina Interna/normas , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/normas , Medicamentos sob Prescrição/efeitos adversos , Papel Profissional , Estudos Prospectivos
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