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1.
Medicine (Baltimore) ; 100(3): e23987, 2021 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-33545989

RESUMO

ABSTRACT: The use of beta-blockers (BB) in the context of ST-segment elevation myocardial infarction (STEMI) was a universal practice in the pre-reperfusion era. Since then, evidence of their use for secondary prevention after STEMI is scarce. Our aim is to determine treatment results associated with BB therapy after a STEMI at 1-year follow-up in a contemporary nationwide cohort.A prospective analysis involving 49 national centers, including patients admitted with STEMI, enrolled between October 2010 and September 2019 was conducted. The primary outcome was defined as the composite of all-cause mortality or hospital re-admission for a cardiovascular (CV) cause in the first year after STEMI. The patients were distributed into 2 groups, depending on whether they received therapy with BB at hospital discharge or not (BB and NB group, respectively).A total of 3145 patients were included in the analysis, of which 2526 (80.3%) in the BB group. A total of 12.2% of patients reached the primary outcome. Regarding the univariate Cox regression analysis, the BB group presented lower mortality or re-admission for CV cause at 1-year follow-up [hazard ratio (HR) 0.69, confidence interval (CI) 95% 0.55-0.87, P = .001]. However, after adjustment for significant covariates, this association was lost (HR 0.73, CI 95% 0.51-1.04, P = .081). In patients with preserved (HR 0.73, CI 95% 0.51-1.04, P = .081) and mid-range (HR 1.01, CI 95% 0.64-1.61, P = .959) left ventricular ejection fraction (LVEF), the primary outcome was similar between the 2 groups, while in patients with reduced LVEF, the BB group presented a better prognosis, with fewer patients reaching the primary outcome (HR 0.431, CI 95% 0.262-0.703, P = .001).BB universal therapy after STEMI has not proved useful, but it seems to be beneficial in patients with reduced LVEF.


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Prevenção Secundária/estatística & dados numéricos , Idoso , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Portugal , Estudos Prospectivos , Sistema de Registros , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/prevenção & controle , Resultado do Tratamento
2.
Crit Care ; 25(1): 70, 2021 02 17.
Artigo em Inglês | MEDLINE | ID: mdl-33596975

RESUMO

BACKGROUND: The early months of the COVID-19 pandemic were fraught with much uncertainty and some resource constraint. We assessed the change in survival to hospital discharge over time for intensive care unit patients with COVID-19 during the first 3 months of the pandemic and the presence of any surge effects on patient outcomes. METHODS: Retrospective cohort study using electronic medical record data for all patients with laboratory-confirmed COVID-19 admitted to intensive care units from February 25, 2020, to May 15, 2020, at one of 26 hospitals within an integrated delivery system in the Western USA. Patient demographics, comorbidities, and severity of illness were measured along with medical therapies and hospital outcomes over time. Multivariable logistic regression models were constructed to assess temporal changes in survival to hospital discharge during the study period. RESULTS: Of 620 patients with COVID-19 admitted to the ICU [mean age 63.5 years (SD 15.7) and 69% male], 403 (65%) survived to hospital discharge and 217 (35%) died in the hospital. Survival to hospital discharge increased over time, from 60.0% in the first 2 weeks of the study period to 67.6% in the last 2 weeks. In a multivariable logistic regression analysis, the risk-adjusted odds of survival to hospital discharge increased over time (biweekly change, adjusted odds ratio [aOR] 1.22, 95% CI 1.04-1.40, P = 0.02). Additionally, an a priori-defined explanatory model showed that after adjusting for both hospital occupancy and percent hospital capacity by COVID-19-positive individuals and persons under investigation (PUI), the temporal trend in risk-adjusted patient survival to hospital discharge remained the same (biweekly change, aOR 1.18, 95% CI 1.00-1.38, P = 0.04). The presence of greater rates of COVID-19 positive/PUI as a percentage of hospital capacity was, however, significantly and inversely associated with survival to hospital discharge (aOR 0.95, 95% CI 0.92-0.98, P < 0.01). CONCLUSIONS: During the early COVID-19 pandemic, risk-adjusted survival to hospital discharge increased over time for critical care patients. An association was also seen between a greater COVID-19-positive/PUI percentage of hospital capacity and a lower survival rate to hospital discharge.


Assuntos
/epidemiologia , Pandemias , Alta do Paciente/estatística & dados numéricos , Idoso , Cuidados Críticos , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de Sobrevida , Estados Unidos/epidemiologia
3.
Pediatr Emerg Care ; 37(2): 126-130, 2021 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-33512892

RESUMO

OBJECTIVE: We hypothesized that a paper documentation and discharge bundle can expedite patient care during an influenza-related surge. METHODS: Retrospective cohort study of low-acuity patients younger than 21 years surging into a pediatric emergency department between January and March 2018 with influenza-like illness. Patient visits documented using a paper bundle were compared with those documented in the electronic medical record on the same date of visit. The primary outcome of interest was time from physician evaluation to discharge for patient visits documented using the paper bundle compared with those documented in the electronic medical record. Secondary outcome was difference in return visits within 72 hours. We identified patient and visit level factors associated with emergency department length of stay. RESULTS: A total of 1591 patient visits were included, 1187 documented in the electronic health record and 404 documented using the paper bundle. Patient visits documented using the paper bundle had a 21% shortened median time from physician evaluation to discharge (41 minutes; interquartile range, 27-62.8 minutes) as compared with patient visits documented in the electronic health record (52 minutes; interquartile range, 35-61 minutes; P < 0.001). There was no difference in return visits (odds ratio, 0.7; 95% confidence interval, 0.2, 2.2). CONCLUSIONS: Implementation of paper charting during an influenza-related surge was associated with shorter physician to discharge times when compared with patient visits documented in the electronic health record. A paper bundle may improve patient throughput and decrease emergency department overcrowding during influenza or coronavirus disease-related surge.


Assuntos
Documentação/métodos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Influenza Humana/terapia , Registros Médicos/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Criança , Pré-Escolar , Registros Eletrônicos de Saúde/estatística & dados numéricos , Feminino , Humanos , Lactente , Recém-Nascido , Tempo de Internação/estatística & dados numéricos , Masculino , Papel , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos
4.
Arq Bras Cir Dig ; 33(3): e1544, 2021.
Artigo em Inglês, Português | MEDLINE | ID: mdl-33470374

RESUMO

BACKGROUND: In Brazil, the goal-based approach was named Project ACERTO and has obtained good results when applied in elective surgeries with shorter hospitalization time, earlier return to activities without increased morbidity and mortality. AIM: To analyze the impact of ACERTO on emergency surgery care. METHODS: An intervention study was performed at a trauma hospital. Were compared 452 patients undergoing emergency surgery and followed up by the general surgery service from October to December 2018 (pre-ACERTO, n=243) and from March to June 2019 (post-ACERTO, n=209). Dietary reintroduction, volume of infused postoperative venous hydration, duration of use of catheters, probes and drains, postoperative analgesia, prevention of postoperative vomiting, early mobilization and physiotherapy were evaluated. RESULTS: After the ACERTO implantation there was earlier reintroduction of the diet, the earlier optimal caloric intake, earlier venous hydration withdrawal, higher postoperative analgesia prescription, postoperative vomiting prophylaxis and higher physiotherapy and mobilization prescription were achieved early in all (p<0.01); in the multivariate analysis there was no change in the complication rates observed before and after ACERTO (10.7% vs. 7.7% (p=0.268) and there was a decrease in the length of hospitalization after ACERTO (8,5 vs. 6,1 dias (p=0.008). CONCLUSION: The implementation of the ACERTO project decreased the length of hospital stay, improved medical care provided without increasing the rates of complications evaluated.


Assuntos
Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Operatórios/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil , Protocolos Clínicos , Feminino , Hospitais Públicos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Recuperação de Função Fisiológica , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
5.
Sci Rep ; 11(1): 1233, 2021 01 13.
Artigo em Inglês | MEDLINE | ID: mdl-33441900

RESUMO

To determine factors associated with delayed discharge of hospitalized patients with coronavirus disease (COVID-19). This retrospective cohort study included 47 patients with COVID-19 admitted to three hospitals in Quanzhou City, Fujian Province, China, between January 21, 2020 and March 6, 2020. Univariate and multivariate logistic regression analyses were conducted to identify factors associated with delayed discharge. The median length of hospital stay was 22 days. Patients in the delayed discharge group (length of hospital stay ≥ 21 days, n = 27) were more likely to have diarrhea, anorexia, decreased white blood cell counts, increased complement C3 and C-reactive protein levels, air bronchograms, undergo thymalfasin treatment, and take significantly longer to convert to a severe acute respiratory syndrome coronavirus (SARS-CoV-2) RNA-negative status than those in the control group (length of hospital stay, < 21 days; n = 20). In multivariate logistic regression analysis, the time to SARS-CoV-2 RNA-negative conversion (odds ratio [OR]: 1.48, 95% confidence interval [CI] 1.09-2.04, P = 0.01) and complement C3 levels (OR 1.14 95% CI 1.02-1.27, P = 0.03) were the only risk factors independently associated with delayed discharge from the hospital. Dynamic monitoring of complement C3 and SARS-CoV-2 RNA levels is useful for predicting delayed discharge of patients.


Assuntos
/metabolismo , Complemento C3/metabolismo , Alta do Paciente/estatística & dados numéricos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , RNA Viral/metabolismo
7.
J Surg Res ; 257: 278-284, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32866668

RESUMO

BACKGROUND: Emergency general surgery has higher adverse outcomes than elective surgery. Patients leaving the hospital against medical advice (AMA) have a greater risk for readmission and complications. We sought to identify clinical and demographic characteristics along with hospital factors associated with leaving AMA after EGS operations. METHODS: A retrospective review of the Nationwide Inpatient Sample was performed. All patients who underwent an EGS procedure accounting for >80% of the burden of EGS-related inpatient resources were identified. 4:1 propensity score analysis was conducted. Regression analyses determined predictive factors for leaving AMA. RESULTS: 546,856 patients were identified. 1085 (0.2%) patients who underwent EGS left AMA. They were more likely to be men (59% versus 42%), younger (median age 51 y, IQR [37.61] versus 54, IQR [38.69]), qualify for Medicaid (26% versus 13%) or be self-pay (17% versus 9%), and be within the lowest quartile median household income (40% versus 28%) (all P < 0.05). After applying 4:1 propensity score matching, individuals who were self-pay (OR 3.15, 95% CI 2.44-4.06) or insured through Medicare (OR 2.75, 95% CI 2.11-3.57) and Medicaid (OR 3.58, 95% CI 2.83-4.52) had increased odds of leaving AMA compared with privately insured patients. In addition, history of alcohol (OR 2.21, 95% CI 1.65-2.98), drug abuse (OR 4.54, 95% CI 3.23-6.38), and psychosis (OR 2.31, 95% CI 1.65-3.23) were associated with higher likelihood for leaving AMA. CONCLUSIONS: Patients undergoing EGS have a high risk of complications, and leaving AMA further increases this risk. Interventions to encourage safe discharge encompassing surgical, psychiatric, and socioeconomic factors are warranted to prevent a two-hit effect and compound postoperative risk.


Assuntos
Tratamento de Emergência/efeitos adversos , Cooperação do Paciente/estatística & dados numéricos , Alta do Paciente/normas , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adulto , Fatores Etários , Idoso , Feminino , Humanos , Renda/estatística & dados numéricos , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Cooperação do Paciente/psicologia , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Estados Unidos/epidemiologia
8.
Bone Joint J ; 103-B(1): 164-169, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33380184

RESUMO

AIMS: Patients who sustain neck of femur fractures are at high risk of malnutrition. Our intention was to assess to what extent malnutrition was associated with worse patient outcomes. METHODS: A total of 1,199 patients with femoral neck fractures presented to a large UK teaching hospital over a three-year period. All patients had nutritional assessments performed using the Malnutrition Universal Screening Tool (MUST). Malnutrition risk was compared to mortality, length of hospital stay, and discharge destination using logistic regression. Adjustments were made for covariates to identify whether malnutrition risk independently affected these outcomes. RESULTS: Inpatient mortality was 5.2% (35/678) in the group at low risk of malnutrition, 11.3% (46/408) in the medium-risk group, and 17.7% (20/113) in the high-risk group. Multivariate analysis showed each categorical increase in malnutrition risk independently predicted inpatient mortality with an odds ratio (OR) of 1.59 (95% confidence interval (CI) 1.14 to 2.21; p = 0.006). An increased mortality rate persisted at 120 days post-injury (OR 1.64, 95% CI 1.20 to 2.22; p = 0.002). There was a stepwise increase in the proportion of patients discharged to a residence offering a greater level of supported living. Multivariate analysis produced an OR of 1.34 (95% CI 1.03 to 1.75; p = 0.030) for each category of MUST score. Median length of hospital stay increased with a worse MUST score: 13.9 days (interquartile range (IQR) 8.2 to 23.8) in the low-risk group; 16.6 days (IQR 9.0 to 31.5) in the medium-risk group; and 22.8 days (IQR 10.1 to 41.1) in the high-risk group. Adjustment for covariates revealed a partial correlation coefficient of 0.072 (p = 0.008). CONCLUSION: A higher risk of malnutrition independently predicted increased mortality, length of hospital stay, and discharge to a residence offering greater supported living after femoral neck fracture. Cite this article: Bone Joint J 2021;103-B(1):164-169.


Assuntos
Fraturas do Colo Femoral/mortalidade , Fraturas do Colo Femoral/cirurgia , Desnutrição/epidemiologia , Estado Nutricional , Complicações Pós-Operatórias/mortalidade , Idoso , Estudos Transversais , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Estudos Prospectivos , Fatores de Risco , Reino Unido/epidemiologia
9.
J Surg Res ; 257: 118-127, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32823009

RESUMO

BACKGROUND: As the population ages, the incidence of traumatic falls has been increasing. We hypothesize that a machine learning algorithm can more accurately predict mortality after a fall compared with a standard logistic regression (LR) model based on immediately available admission data. Secondary objectives were to predict who would be discharged home and determine which variables had the largest effect on prediction. METHODS: All patients who were admitted for fall between 2012 and 2017 at our level 1 trauma center were reviewed. Fourteen variables describing patient demographics, injury characteristics, and physiology were collected at the time of admission and were used for prediction modeling. Algorithms assessed included LR, decision tree classifier (DTC), and random forest classifier (RFC). Area under the receiver operating characteristic curve (AUC) values were calculated for each algorithm for mortality and discharge to home. RESULTS: About 4725 patients met inclusion criteria. The mean age was 61 ± 20.5 y, Injury Severity Score 8 ± 7, length of stay 5.8 ± 7.6 d, intensive care unit length of stay 1.8± 5.2 d, and ventilator days 0.7 ± 4.2 d. The mortality rate was 3% and three times greater for elderly (aged 65 y and older) patients (5.0% versus 1.6%, P < 0.001). The AUC for predicting mortality for LR, DTC, and RFC was 0.78, 0.64, and 0.86, respectively. The AUC for predicting discharge to home for LR, DTC, and RFC was 0.72, 0.61, and 0.74, respectively. The top five variables that contribute to the prediction of mortality in descending order of importance are the Glasgow Coma Score (GCS) motor, GCS verbal, respiratory rate, GCS eye, and temperature. CONCLUSIONS: RFC can accurately predict mortality and discharge home after a fall. This predictive model can be implemented at the time of patient arrival and may help identify candidates for targeted intervention as well as improve prognostication and resource utilization.


Assuntos
Acidentes por Quedas/mortalidade , Acidentes por Quedas/estatística & dados numéricos , Aprendizado de Máquina , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Árvores de Decisões , Feminino , Escala de Coma de Glasgow , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Curva ROC , Estudos Retrospectivos , Centros de Traumatologia
10.
J Surg Res ; 257: 135-141, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32828996

RESUMO

BACKGROUND: Clinical practice guidelines (CPGs) have been associated with improved patient outcomes. We aimed to evaluate institutional CPG adherence and hypothesized that adherence would be associated with fewer complications in pediatric appendicitis. METHODS: A retrospective review was conducted of pediatric (<18 y) appendicitis patients who underwent appendectomy (6/1/2017-5/30/2018). Patients were managed using an institutional pediatric appendicitis CPG. The primary outcome was CPG adherence, defined as receipt of preoperative antibiotics at diagnosis, surgical prophylaxis before incision, and, in perforated/gangrenous appendicitis, continued postoperative antibiotics, and prescription for discharge antibiotics. Univariate and multivariate analyzes were performed. RESULTS: Among 399 patients, the baseline characteristics were similar between CPG-adherent and nonadherent patients. Overall CPG adherence was low at 55% (n = 221). Only 58% of patients received preoperative antibiotics per protocol (n = 233). Patients with simple appendicitis were more likely to proceed to surgery without receiving any preoperative antibiotics (35% vs. 21%, P = 0.004). Surgical prophylaxis compliance was high at 97% (n = 389). CPG violation was associated with reoperation (n = 5 versus 0, P = 0.02). After adjusting for age and admission white blood cell count, the association between CPG adherence and postoperative surgical site infection or intra-abdominal abscess remained nonsignificant (OR: 1.2, 95% CI: 0.5-2.5). CONCLUSIONS: Despite a long-standing pediatric appendicitis CPG, adherence with antibiotic components of the CPG was poor. CPG violation was significantly associated with reoperation, but was not associated with other postoperative complications. Regular audits of CPG adherence are necessary to ascertain reasons for noncompliance and identify ways to improve adherence.


Assuntos
Antibacterianos/uso terapêutico , Apendicectomia/efeitos adversos , Apendicite/cirurgia , Fidelidade a Diretrizes/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Antibioticoprofilaxia/métodos , Apendicectomia/métodos , Criança , Feminino , Humanos , Contagem de Leucócitos , Masculino , Alta do Paciente/estatística & dados numéricos , Cuidados Pós-Operatórios/métodos , Cuidados Pré-Operatórios/métodos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos
11.
Healthc (Amst) ; 9(1): 100512, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33383393

RESUMO

Little is known about the follow-up healthcare needs of patients hospitalized with coronavirus disease 2019 (COVID-19) after hospital discharge. Due to the unique circumstances of providing transitional care in a pandemic, post-discharge providers must adapt to specific needs and limitations identified for the care of COVID-19 patients. In this study, we conducted a retrospective chart review of all hospitalized COVID-19 patients discharged from an Emory Healthcare Hospital in Atlanta, GA from March 26 to April 21, 2020 to characterize their post-discharge care plans. A total of 310 patients were included in the study (median age 58, range: 23-99; 51.0% female; 69.0% African American). The most common presenting comorbidities were hypertension (200, 64.5%), obesity (BMI≥30) (138, 44.5%), and diabetes mellitus (112, 36.1%). The median length of hospitalization was 5 days (range: 0-33). Sixty-seven patients (21.6%) were admitted to the intensive care unit and 42 patients (13.5%) received invasive mechanical ventilation. The most common complications recorded at discharge were electrolyte abnormalities (124, 40.0%), acute kidney injury (86, 27.7%) and sepsis (55, 17.7%). The majority of patients were discharged directly home (281, 90.6%). Seventy-five patients (24.2%) required any home service including home health and home oxygen therapy. The most common follow-up need was an appointment with a primary care provider (258, 83.2%). Twenty-four patients (7.7%) had one or more visit to an ED after discharge and 16 patients (5.2%) were readmitted. To our knowledge, this is the first large study to report on post-discharge medical care for COVID-19 patients.


Assuntos
/terapia , Hospitalização/tendências , Alta do Paciente/normas , Transferência de Pacientes/normas , Adulto , Idoso , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Transferência de Pacientes/métodos , Transferência de Pacientes/estatística & dados numéricos
12.
Medicine (Baltimore) ; 99(51): e23776, 2020 Dec 18.
Artigo em Inglês | MEDLINE | ID: mdl-33371146

RESUMO

ABSTRACT: Whereas handover of pertinent information between hospital and primary care is necessary to ensure continuity of care and patient safety, both quality of content and timeliness of discharge summary need to be improved. This study aims to assess the impact of a quality improvement program on the quality and timeliness of the discharge summary/letter (DS/DL) in a University hospital with approximatively 40 clinical units using an Electronic medical record (EMR).A discharge documents (DD) quality improvement program including revision of the EMR, educational program, audit (using scoring of DD) and feedback with a ranking of clinical units, was conducted in our hospital between October 2016 and November 2018. Main outcome measures were the proportion of the DD given to the patient at discharge and the mean of the national score assessing the quality of the discharge documents (QDD score) with 95% confidence interval.Intermediate evaluation (2017) showed a significant improvement as the proportion of DD given to patients increased from 63% to 85% (P < .001) and mean QDD score rose from 41 (95%CI [36-46]) to 74/100 (95%CI [71-77]). In the final evaluation (2018), the proportion of DD given to the patient has reached 95% and the mean QDD score was 82/100 (95% CI [80-85]). The areas of the data for admission and discharge treatments remained the lowest level of compliance (44%).The involvement of doctors in the program and the challenge of participating units have fostered the improvement in the quality of the DD. However, the level of appropriation varied widely among clinical units and completeness of important information, such as discharge medications, remains in need of improvement.


Assuntos
Documentação/normas , Alta do Paciente/normas , Avaliação de Programas e Projetos de Saúde/métodos , Fatores de Tempo , Estudos Controlados Antes e Depois , Documentação/métodos , Documentação/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Paris , Alta do Paciente/estatística & dados numéricos , Melhoria de Qualidade
13.
Artigo em Inglês | MEDLINE | ID: mdl-33352913

RESUMO

Discharge planning is important to prevent surgical site infections, reduce costs, and improve the hospitalization experience. The identification of early variables that can predict a longer-than-expected length of stay or the need for a discharge with additional needs can improve this process. A cohort study was conducted in the largest hospital of Northern Italy, collecting discharge records from January 2017 to January 2020 and pre-admission visits in the last three months. Socio-demographic and clinical data were collected. Linear and logistic regression models were fitted. The main outcomes were the length of stay (LOS) and discharge destination. The main predictors of a longer LOS were the need for additional care at discharge (+10.76 days), hospitalization from the emergency department (ED) (+5.21 days), and age (+0.04 days per year), accounting for clinical variables (p < 0.001 for all variables). Each year of age and hospitalization from the ED were associated with a higher probability of needing additional care at discharge (OR 1.02 and 1.77, respectively, p < 0.001). No additional findings came from pre-admission forms. Discharge difficulties seem to be related mainly to age and hospitalization procedures: those factors are probably masking underlying social risk factors that do not show up in patients with planned admissions.


Assuntos
Serviço Hospitalar de Emergência , Hospitalização , Tempo de Internação/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Estudos de Coortes , Feminino , Humanos , Itália , Masculino , Estudos Retrospectivos
14.
Artigo em Inglês | MEDLINE | ID: mdl-33322234

RESUMO

With increasing survival rates of children born extremely preterm (EPT), before gestational week 28, the post-discharge life of these families has gained significant research interest. Quantitative studies of parental experiences post-discharge have previously reported elevated levels depressive symptoms, posttraumatic stress-disorder and anxiety among the parents. The current investigation aims to qualitatively explore the situation for parents of children born EPT in Sweden during the first year at home. Semi-structured interviews were performed with 17 parents of 14 children born EPT; eight parents were from an early intervention group and nine parents from a group that received treatment as usual, with extended follow-up procedures. Three main themes were identified using a thematic analytic approach: child-related concerns, the inner state of the parent, and changed family dynamics. Parents in the intervention group also expressed themes related to the intervention, as a sense of security and knowledgeable interventionists. The results are discussed in relation to different concepts of health, parent-child interaction and attachment, and models of the recovery processes. In conclusion, parents describe the first year at home as a time of prolonged parental worries for the child as well as concerns regarding the parent's own emotional state.


Assuntos
Assistência ao Convalescente , Lactente Extremamente Prematuro , Solidão , Pais , Alta do Paciente , Assistência ao Convalescente/estatística & dados numéricos , Humanos , Lactente , Pais/psicologia , Alta do Paciente/estatística & dados numéricos , Suécia
15.
JAMA Netw Open ; 3(12): e2028328, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-33346847

RESUMO

Importance: Hip and knee arthroplasty are the most common inpatient surgical procedures for Medicare beneficiaries in the US, with substantial variation in cost and quality. Whether remote monitoring incorporating insights from behavioral science might help improve outcomes and increase value of care remains unknown. Objective: To evaluate the effect of activity monitoring and bidirectional text messaging on the rate of discharge to home and clinical outcomes in patients receiving hip or knee arthroplasty. Design, Setting, and Participants: Randomized clinical trial conducted between February 7, 2018, and April 15, 2019. The setting was 2 urban hospitals at an academic health system. Participants were patients aged 18 to 85 years scheduled to undergo hip or knee arthroplasty with a Risk Assessment and Prediction Tool score of 6 to 8. Interventions: Eligible patients were randomized evenly to receive usual care (n = 153) or remote monitoring (n = 147). Those in the intervention arm who agreed received a wearable activity monitor to track step count, messaging about postoperative goals and milestones, pain score tracking, and connection to clinicians as needed. Patients assigned to receive monitoring were further randomized evenly to remote monitoring alone or remote monitoring with gamification and social support. Remote monitoring was offered before surgery, began at hospital discharge, and continued for 45 days postdischarge. Main Outcomes and Measures: The primary outcome was discharge status (home vs skilled nursing facility or inpatient rehabilitation). Prespecified secondary outcomes included change in average daily step count and rehospitalizations. Results: A total of 242 patients were analyzed (124 usual care, 118 intervention); median age was 66 years (interquartile range, 58-73 years); 78.1% were women, 45.5% were White, 43.4% were Black; and 81.4% in the intervention arm agreed to receive monitoring. There was no significant difference in the rate of discharge to home between the usual care arm (57.3%; 95% CI, 48.5%-65.9%) and the intervention arm (56.8%; 95% CI, 47.9%-65.7%) and no significant increase in step count in those receiving remote monitoring plus gamification and social support compared with remote monitoring alone. There was a statistically significant reduction in rehospitalization rate in the intervention arm (3.4%; 95% CI, 0.1%-6.7%) compared with the usual care arm (12.2%; 95% CI, 6.4%-18.0%) (P = .01). Conclusions and Relevance: In this study, the remote monitoring program did not increase rate of discharge to home after hip or knee arthroplasty, and gamification and social support did not increase activity levels. There was a significant reduction in rehospitalizations among those receiving the intervention, which may have resulted from goal setting and connection to the care team. Trial Registration: ClinicalTrials.gov Identifier: NCT03435549.


Assuntos
Artroplastia do Joelho/reabilitação , Monitorização Fisiológica/métodos , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Telerreabilitação/métodos , Idoso , Feminino , Humanos , Masculino , Osteoartrite do Joelho/cirurgia , Avaliação de Resultados em Cuidados de Saúde , Recuperação de Função Fisiológica , Medição de Risco/métodos , Apoio Social , Resultado do Tratamento
16.
JAMA Netw Open ; 3(12): e2030905, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-33355677

RESUMO

Importance: Little is known about the natural course of oxygen desaturation in acute bronchiolitis. Information on risk factors associated with desaturation as well as the time to desaturation in infants with bronchiolitis could help physicians better treat these infants before deciding whether to hospitalize them. Objective: To prospectively determine the frequency of desaturation in infants with bronchiolitis, along with the time to desaturation and risk factors associated with desaturation, and to compare infants who were hospitalized with those discharged home and evaluate risk factors for rehospitalization. Design, Setting, and Participants: This cohort study was conducted during the 2017 to 2018 and 2018 to 2019 respiratory syncytial virus seasons in a tertiary care pediatric emergency department in Switzerland. Included individuals were 239 otherwise-healthy infants aged younger than 1 year, diagnosed with acute bronchiolitis and oxygen saturation of 90% or more on arrival. Data were analyzed from July 2019 to October 2020. Exposures: After receiving triage care, study participants admitted to the emergency department were equipped with a pulse oximeter to continuously record oxygen saturation (Spo2 levels), regardless of subsequent hospitalization or discharge home. Main Outcomes and Measures: The primary outcome was desaturation (ie, Spo2 < 90%) during the first 36 hours. Results: Of 239 infants enrolled, with a median (interquartile range [IQR]) age of 3.9 (1.5-6.5) months, 116 (48.5%) were boys and desaturation occurred in 165 infants (69.0%). Median (IQR) time to desaturation was 3.6 (1.8-9.4) hours. The rate of desaturation was similar between infants hospitalized and those discharged home (137 of 200 infants [68.5%] vs 28 of 39 infants [71.8%]; difference, -3.3%; 95% CI, -18.8% to 12.2%; P = .85). A more severe initial clinical presentation with moderate or severe retractions was the only independent risk factor associated with desaturation (odds ratio, 2.73; 95% CI, 1.49 to 5.02; P = .001). Of 39 infants discharged home, 22 infants (56.4%) experienced major desaturations. However, infants with desaturations, including those with major desaturations, had rates of rehospitalization similar to those of infants without desaturations (8 of 28 infants [28.5%] vs 3 of 11 infants [27.3%]; difference, 1.2%; 95% CI, -29.9% to 32.5; P > .99). Conclusions and Relevance: These findings suggest that rates of desaturation in infants with acute bronchiolitis were high and similar between infants who were hospitalized and those discharged home. A more severe initial clinical presentation was the only risk factor associated with desaturation. However, for infants discharged home, desaturation was not a risk factor associated with rehospitalization.


Assuntos
Bronquiolite/fisiopatologia , Oximetria/estatística & dados numéricos , Consumo de Oxigênio/fisiologia , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Doença Aguda , Serviço Hospitalar de Emergência , Feminino , Humanos , Lactente , Masculino , Estudos Prospectivos , Fatores de Risco , Suíça , Fatores de Tempo
17.
J Nurs Adm ; 50(12): 642-648, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33186003

RESUMO

OBJECTIVE: The purpose of this study was to analyze if patient race and the presence of insurance predict the odds of admission from the emergency department (ED) for patients diagnosed with congestive heart failure (CHF). BACKGROUND: Excessive hospital readmissions for patients with CHF are considered a quality-of-care issue. Previous studies have not considered race and insurance in conjunction with quality measures in predicting hospital admission from the ED for these patients. METHODS: A secondary data analysis was conducted from cross-sectional archival data from the 2015 National Hospital Ambulatory Medical Care Survey using cross-tabulations with χ followed by multiple logistic regression analysis. RESULTS: Race and the presence of insurance were not significant in predicting the odds of admission from the ED for patients with CHF. CONCLUSIONS: Being seen in the ED within the last 72 hours and seen by provider types consulting physician and nurse practitioner were significant (P ≤ .05) in predicting the odds of admission related to a diagnosis of CHF.


Assuntos
Grupos de Populações Continentais/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Insuficiência Cardíaca/diagnóstico , Revisão da Utilização de Seguros/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Idoso , Estudos Transversais , Feminino , Humanos , Masculino , Medicare , Alta do Paciente/estatística & dados numéricos , Inquéritos e Questionários , Estados Unidos
18.
MMWR Morb Mortal Wkly Rep ; 69(45): 1695-1699, 2020 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-33180754

RESUMO

Coronavirus disease 2019 (COVID-19) is a complex clinical illness with potential complications that might require ongoing clinical care (1-3). Few studies have investigated discharge patterns and hospital readmissions among large groups of patients after an initial COVID-19 hospitalization (4-7). Using electronic health record and administrative data from the Premier Healthcare Database,* CDC assessed patterns of hospital discharge, readmission, and demographic and clinical characteristics associated with hospital readmission after a patient's initial COVID-19 hospitalization (index hospitalization). Among 126,137 unique patients with an index COVID-19 admission during March-July 2020, 15% died during the index hospitalization. Among the 106,543 (85%) surviving patients, 9% (9,504) were readmitted to the same hospital within 2 months of discharge through August 2020. More than a single readmission occurred among 1.6% of patients discharged after the index hospitalization. Readmissions occurred more often among patients discharged to a skilled nursing facility (SNF) (15%) or those needing home health care (12%) than among patients discharged to home or self-care (7%). The odds of hospital readmission increased with age among persons aged ≥65 years, presence of certain chronic conditions, hospitalization within the 3 months preceding the index hospitalization, and if discharge from the index hospitalization was to a SNF or to home with health care assistance. These results support recent analyses that found chronic conditions to be significantly associated with hospital readmission (6,7) and could be explained by the complications of underlying conditions in the presence of COVID-19 (8), COVID-19 sequelae (3), or indirect effects of the COVID-19 pandemic (9). Understanding the frequency of, and risk factors for, readmission can inform clinical practice, discharge disposition decisions, and public health priorities such as health care planning to ensure availability of resources needed for acute and follow-up care of COVID-19 patients. With the recent increases in cases nationwide, hospital planning can account for these increasing numbers along with the potential for at least 9% of patients to be readmitted, requiring additional beds and resources.


Assuntos
Infecções por Coronavirus/terapia , Hospitalização/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Pneumonia Viral/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções por Coronavirus/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/epidemiologia , Fatores de Risco , Estados Unidos/epidemiologia , Adulto Jovem
19.
J Nurs Adm ; 50(12): 649-654, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33181525

RESUMO

OBJECTIVE: The aim of this study was to examine the effect of nurses' mobility plan use on patients' length of stay, discharge destination, falls, physical therapy consults, and nurses' knowledge, attitudes, and beliefs regarding patient mobility. BACKGROUND: Functional decline due to decreased mobility during hospitalization results in diminished quality of life. Sixty-five percent of older inpatients lose the ability to ambulate during hospitalization and 30% do not regain that capability. METHODS: Using a quasi-experimental design, nurses' use of a mobility assessment on 4 patient outcome variables was examined before (n = 2,259) and after (n = 3,649) use. Nurses' attitudes, knowledge, and beliefs regarding mobility were also examined. RESULTS: Positive changes in patient variables occurred. Limited change occurred relative to nurses' knowledge, attitudes, and beliefs. CONCLUSIONS: Implementing a nurse-led mobility plan enhances therapy resource utilization through identification of appropriate consults and improves patients' discharge home. In addition, nurses' knowledge, attitudes, and beliefs toward patient mobility planning can be positively influenced.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Serviços de Assistência Domiciliar , Pacientes Internados/estatística & dados numéricos , Recursos Humanos de Enfermagem no Hospital/organização & administração , Caminhada/estatística & dados numéricos , Idoso , Feminino , Humanos , Masculino , Alta do Paciente/estatística & dados numéricos , Qualidade de Vida/psicologia , Inquéritos e Questionários , Estados Unidos
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