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1.
J Surg Res ; 246: 457-463, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31706537

RESUMO

BACKGROUND: Readmissions after colorectal operations adversely impact patient recovery and are associated with about $300 million in additional health care expenditure in the United States alone. The present study aimed to characterize nonelective, short-term readmissions of colorectal surgery patients who underwent colostomy. METHODS: The Nationwide Readmissions Database was used to identify patients who received a colostomy from 2010 to 2015. Patients were stratified by discharge-to-readmission interval: immediate (within 7 d) and delayed (7-30 d). Nonparametric trend analysis and multivariable regression were performed to identify predictors of immediate and delayed readmission. RESULTS: Of an estimated 376,693 operations requiring colostomies during the study, in-hospital survival was 92.3%, with higher rates after elective compared with nonelective operations (96.5 versus 90.8%, P < 0.001). Overall, 15.3% patients undergoing elective and nonelective colostomy creation returned to the hospital within 30 d, with 41.6% of these readmissions occurring by the first week of discharge (immediate). Readmission rates and proportion of immediate and delayed groups did not significantly change over the 6-year study period. Nonhome discharge increased the odds of immediate (AOR 1.25, 95% CI 1.17-1.34) and delayed readmission (AOR 1.44, 95% CI 1.35-1.54). Annually, immediate and delayed rehospitalizations after colostomy creation were responsible for $64 and 82 million in excess costs, respectively. CONCLUSIONS: Colostomy creation is associated with a steady and high rate of rehospitalization. Nonhome discharge, in addition to several patient comorbidities, is associated with higher odds of readmission. Programs aimed at reduction of immediate readmission are warranted.


Assuntos
Colostomia/efeitos adversos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Transferência de Pacientes/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia
2.
J Surg Res ; 245: 593-599, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31499365

RESUMO

BACKGROUND: After traumatic arrest, resuscitative thoracotomy is lifesaving in appropriately selected patients, yet data are limited regarding hospital course after intensive care unit (ICU) admission. The objective of this study was to describe the natural history of resuscitative thoracotomy survivors admitted to the ICU. MATERIALS AND METHODS: We conducted a retrospective review (January 1, 2012-June 30, 2017) of all adult trauma patients who underwent resuscitative thoracotomy after traumatic arrest at two adult level 1 trauma centers. Data evaluated include demographics, injury characteristics, hospital course, and outcome. RESULTS: Over 66 mo, there were 52,624 trauma activations. Two hundred ninety-eight patients underwent resuscitative thoracotomy and 96 (32%) survived to ICU admission. At ICU admission, mean age was 35.8 ± 14.5 y, 79 (82%) were male, 36 (38%) sustained blunt trauma, and the mean injury severity score was 32.3 ± 13.7. Eight blunt and 20 penetrating patients (22% and 34% of ICU admissions, respectively) survived to discharge. 67% of deaths in the ICU occurred within the first 24 h, whereas 90% of those alive at day 21 survived to discharge. For the 28 survivors, mean ICU length of stay was 24.1 ± 17.9 d and mean hospital length of stay was 43.9 ± 32.1 d. Survivors averaged 1.9 ± 1.5 complications. Twenty-four patients (86% of hospital survivors) went home or to a rehabilitation center. CONCLUSIONS: After resuscitative thoracotomy and subsequent ICU admission, 29% of patients survived to hospital discharge. Complications and a long hospital stay should be expected, but the functional outcome for survivors is not as bleak as previously reported.


Assuntos
Parada Cardíaca/cirurgia , Complicações Pós-Operatórias/epidemiologia , Ressuscitação/efeitos adversos , Toracotomia/efeitos adversos , Ferimentos não Penetrantes/complicações , Ferimentos Penetrantes/complicações , Adulto , Feminino , Parada Cardíaca/etiologia , Parada Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Centros de Reabilitação/estatística & dados numéricos , Ressuscitação/métodos , Estudos Retrospectivos , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/cirurgia , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/cirurgia , Adulto Jovem
4.
Medicine (Baltimore) ; 98(43): e17715, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31651903

RESUMO

A few studies have compared patients who were directly admitted with patients who were transferred to a tertiary facility for an appendectomy. However, there have been no reports of an association between the time to transfer and outcome in patients who underwent an appendectomy. As the only tertiary military hospital in South Korea, we occasionally encountered patients who were delayed for transfer due to the military environment. We hypothesize that patients with a longer time to transfer have a worse outcome. This study aimed to evaluate the relationship between the time to transfer and the outcome of patients who underwent an appendectomy.Patients who underwent appendectomy in the tertiary military hospital in South Korea from May 2015 to April 2017 were analyzed retrospectively. The groups were divided by the time for the transfer. Four hours was used as the cut-off point to divide the early and delayed transfer groups. Time from symptom onset to hospitalization, time from diagnosis to surgery, and time from hospitalization to surgery were also analyzed to assess the effect of time for the transfer.A total of 449 patients were analyzed: 293 with direct admission, 110 with early transfer, and 46 with delayed transfer. The time required for transfer was more critical for delaying appendectomy than the time from hospital admission to surgery. There was no difference in outcomes among the groups. When patients were compared according to the perforation, no differences were found in time from hospitalization to surgery, time from diagnosis to surgery, and presence of transfer. Multivariate analysis showed that a greater than 72 hours delay from symptom onset to hospitalization was associated with perforation (odds ratio = 12.61; 95% confidence interval: 3.84-41.40; P < .001).Even if a long transfer time is necessary, an appendectomy can be performed safely if patients were administered antibiotics immediately after diagnosis.


Assuntos
Apendicite/cirurgia , Hospitais Militares , Transferência de Pacientes/estatística & dados numéricos , Tempo para o Tratamento , Apendicectomia , Progressão da Doença , Feminino , Humanos , Masculino , República da Coreia , Estudos Retrospectivos , Centros de Atenção Terciária , Resultado do Tratamento , Adulto Jovem
5.
Health Serv Res ; 54(6): 1335-1345, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31602639

RESUMO

OBJECTIVE: To assess whether an electronic health record (EHR) portal to enable health information exchange (HIE) between a hospital and three skilled nursing facilities (SNFs) reduced likelihood of patient readmission. SETTING/DATA: Secondary data; all discharges from a large academic medical center to SNFs between July 2013 and March 2017, combined with portal usage records from SNFs with HIE access. DESIGN: We use difference-in-differences to determine whether portal implementation reduced likelihood of readmission over time for patients discharged to HIE-enabled SNFs, relative to those discharged to nonenabled facilities. Additional descriptive analyses of audit log data characterize portal use within enabled facilities. DATA COLLECTION: Encounter-level clinical EHR data were merged with EHR audit log data that captured portal usage in the timeframe associated with a patient transition from hospital to SNF. PRINCIPAL FINDINGS: Declines in likelihood of 30-day readmission were not significantly different for patients in HIE-enabled vs control SNFs (diff-in-diff = 0.022; P = .431). We observe similar null effects with shorter readmission windows. The portal was used for 46 percent of discharges, with significant usage pattern variation within/across facilities. CONCLUSIONS: Implementation of a hospital-SNF EHR portal did not reduce readmissions from enabled SNFs. Emergent HIE use cases need to be better defined and leveraged for design and implementation that generates value in the context of postacute transitions.


Assuntos
Continuidade da Assistência ao Paciente/estatística & dados numéricos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Troca de Informação em Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos
6.
BMJ ; 367: l5678, 2019 10 16.
Artigo em Inglês | MEDLINE | ID: mdl-31619384

RESUMO

OBJECTIVE: To determine if postnatal transfer or birth in a non-tertiary hospital is associated with adverse outcomes. DESIGN: Observational cohort study with propensity score matching. SETTING: National health service neonatal care in England; population data held in the National Neonatal Research Database. PARTICIPANTS: Extremely preterm infants born at less than 28 gestational weeks between 2008 and 2015 (n=17 577) grouped based on birth hospital and transfer within 48 hours of birth: upward transfer (non-tertiary to tertiary hospital, n=2158), non-tertiary care (born in non-tertiary hospital; not transferred, n=2668), and controls (born in tertiary hospital; not transferred, n=10 866). Infants were matched on propensity scores and predefined background variables to form subgroups with near identical distributions of confounders. Infants transferred between tertiary hospitals (horizontal transfer) were separately matched to controls in a 1:5 ratio. MAIN OUTCOME MEASURES: Death, severe brain injury, and survival without severe brain injury. RESULTS: 2181 infants, 727 from each group (upward transfer, non-tertiary care, and control) were well matched. Compared with controls, infants in the upward transfer group had no significant difference in the odds of death before discharge (odds ratio 1.22, 95% confidence interval 0.92 to 1.61) but significantly higher odds of severe brain injury (2.32, 1.78 to 3.06; number needed to treat (NNT) 8) and significantly lower odds of survival without severe brain injury (0.60, 0.47 to 0.76; NNT 9). Compared with controls, infants in the non-tertiary care group had significantly higher odds of death (1.34, 1.02 to 1.77; NNT 20) but no significant difference in the odds of severe brain injury (0.95, 0.70 to 1.30) or survival without severe brain injury (0.82, 0.64 to 1.05). Compared with infants in the upward transfer group, infants in the non-tertiary care group had no significant difference in death before discharge (1.10, 0.84 to 1.44) but significantly lower odds of severe brain injury (0.41, 0.31 to 0.53; NNT 8) and significantly higher odds of survival without severe brain injury (1.37, 1.09 to 1.73; NNT 14). No significant differences were found in outcomes between the horizontal transfer group (n=305) and controls (n=1525). CONCLUSIONS: In extremely preterm infants, birth in a non-tertiary hospital and transfer within 48 hours are associated with poor outcomes when compared with birth in a tertiary setting. We recommend perinatal services promote pathways that facilitate delivery of extremely preterm infants in tertiary hospitals in preference to postnatal transfer.


Assuntos
Lesões Encefálicas , Salas de Parto , Doenças do Prematuro , Transferência de Pacientes , Lesões Encefálicas/diagnóstico , Lesões Encefálicas/etiologia , Lesões Encefálicas/mortalidade , Salas de Parto/classificação , Salas de Parto/estatística & dados numéricos , Feminino , Finlândia/epidemiologia , Idade Gestacional , Humanos , Lactente , Mortalidade Infantil , Lactente Extremamente Prematuro , Recém-Nascido , Doenças do Prematuro/diagnóstico , Doenças do Prematuro/etiologia , Doenças do Prematuro/mortalidade , Masculino , Transferência de Pacientes/métodos , Transferência de Pacientes/estatística & dados numéricos , Gravidez , Resultado da Gravidez/epidemiologia , Pontuação de Propensão , Análise de Sobrevida , Centros de Atenção Terciária/estatística & dados numéricos
7.
BMC Med ; 17(1): 184, 2019 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-31570106

RESUMO

BACKGROUND: The healthcare system can be understood as the dynamic result of the interaction of hospitals, patients, providers, and government configuring a complex network of reciprocal influences. In order to better understand such a complex system, the analysis must include characteristics that are feasible to be studied in order to redesign its functioning. The analysis of the emergent patterns of pregnant women flows crossing municipal borders for birth-related hospitalizations in a region of São Paulo, Brazil, allowed to examine the functionality of the regional division in the state using a complex systems approach and to propose answers to the dilemma of concentration vs. distribution of maternal care regional services in the context of the Brazilian Unified Health System (SUS). METHODS: Cross-sectional research of the areas of influence of hospitals using spatial interaction methods, recording the points of origin and destination of the patients and exploring the emergent patterns of displacement. RESULTS: The resulting functional region is broader than the limits established in the legal provisions, verifying that 85% of patients move to hospitals with high technology to perform normal deliveries and cesarean sections. The region has high independence rates and behaves as a "service exporter." Patients going to centrally located hospitals travel twice as long as patients who receive care in other municipalities even when the patients' conditions do not demand technologically sophisticated services. The effects of regulation and the agents' preferences reinforce the tendency to refer patients to centrally located hospitals. CONCLUSIONS: Displacement of patients during delivery may affect indicators of maternal and perinatal health. The emergent pattern of movements allowed examining the contradiction between wider deployments of services versus concentration of highly specialized resources in a few places. The study shows the potential of this type of analysis applied to other type of patients' flows, such as cancer or specialized surgery, as tools to guide the regionalization of the Brazilian Health System.


Assuntos
Procedimentos Clínicos/estatística & dados numéricos , Parto Obstétrico/estatística & dados numéricos , Serviços de Saúde Materna/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Adulto , Brasil/epidemiologia , Cesárea/estatística & dados numéricos , Cidades/epidemiologia , Cidades/estatística & dados numéricos , Procedimentos Clínicos/organização & administração , Procedimentos Clínicos/normas , Estudos Transversais , Assistência à Saúde/organização & administração , Assistência à Saúde/normas , Parto Obstétrico/métodos , Parto Obstétrico/normas , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Serviços de Saúde Materna/organização & administração , Serviços de Saúde Materna/normas , Transferência de Pacientes/organização & administração , Gravidez , Indicadores de Qualidade em Assistência à Saúde , Encaminhamento e Consulta/estatística & dados numéricos , Análise de Sistemas , Transporte de Pacientes/estatística & dados numéricos
8.
Bone Joint J ; 101-B(9): 1087-1092, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31474144

RESUMO

AIMS: The aim of this study was to assess the effects of transferring patients to a specialized arthroplasty centre between the first and second stages (interstage) of prosthetic joint infection (PJI) of the knee. PATIENTS AND METHODS: A search of our institutional database was performed to identify patients having undergone two-stage revision total knee arthroplasty (TKA) for PJI. Two cohorts were created: continuous care (CC) and transferred care (TC). Baseline characteristics and outcomes were collected and compared between cohorts. RESULTS: A total of 137 patients were identified: 105 in the CC cohort (56 men, 49 women; mean age 67.9) and 32 in the TC cohort (17 men, 15 women; mean age 67.8 years). PJI organism virulence was greater in the CC cohort (36.2% vs 15.6%; p = 0.030). TC patients had a higher rate of persisting or recurrent infection (53.6% vs 13.4%; p < 0.001), soft-tissue complications (31.3 vs 14.3%; p = 0.030), and reduced requirement for porous metal augments (78.1% vs 94.3%; p = 0.006). Repeat first stage debridement after transfer led to greater need for plastic surgical procedures (58.3% vs 0.0%; p < 0.001). CONCLUSION: Patient transfer during the interstage of treatment for infected TKA leads to poorer outcomes compared with patients receiving all their treatment at a specialized arthroplasty centre. Cite this article: Bone Joint J 2019;101-B:1087-1092.


Assuntos
Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/estatística & dados numéricos , Hospitais Especializados/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Infecções Relacionadas à Prótese/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Continuidade da Assistência ao Paciente/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Infecções Relacionadas à Prótese/etiologia , Reoperação/estatística & dados numéricos , Resultado do Tratamento
9.
Br J Neurosurg ; 0(0): 1-11, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31407596

RESUMO

Purpose: Cauda equina syndrome (CES) is a spinal emergency with clinical symptoms and signs that have low diagnostic accuracy. National guidelines in the United Kingdom (UK) state that all patients should undergo an MRI prior to referral to specialist spinal units and surgery should be performed at the earliest opportunity. We aimed to evaluate the current practice of investigating and treating suspected CES in the UK. Materials and Methods: A retrospective, multicentre observational study of the investigation and management of patients with suspected CES was conducted across the UK, including all patients referred to a spinal unit over 6 months between 1st October 2016 and 31st March 2017. Results: A total of 28 UK spinal units submitted data on 4441 referrals. Over half of referrals were made without any previous imaging (n = 2572, 57.9%). Of all referrals, 695 underwent surgical decompression (15.6%). The majority of referrals were made out-of-hours (n = 2229/3517, 63.4%). Patient location and pre-referral imaging were not associated with time intervals from symptom onset or presentation to decompression. Patients investigated outside of the spinal unit experienced longer time intervals from referral to undergoing the MRI scan. Conclusions: This is the largest known study of the investigation and management of suspected CES. We found that the majority of referrals were made without adequate investigations. Most patients were referred out-of-hours and many were transferred for an MRI without subsequently requiring surgery. Adherence to guidelines would reduce the number of referrals to spinal services by 72% and reduce the number of patient transfers by 79%.


Assuntos
Síndrome da Cauda Equina/diagnóstico , Encaminhamento e Consulta/estatística & dados numéricos , Adulto , Síndrome da Cauda Equina/cirurgia , Procedimentos Clínicos , Descompressão Cirúrgica/estatística & dados numéricos , Tratamento de Emergência , Utilização de Instalações e Serviços , Feminino , Humanos , Imagem por Ressonância Magnética/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Utilização de Procedimentos e Técnicas , Estudos Retrospectivos , Coluna Vertebral/cirurgia , Reino Unido
10.
Pediatr Emerg Care ; 35(8): 568-574, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31369494

RESUMO

OBJECTIVES: Few studies have evaluated impact of emergency department (ED) management on delayed transfers to the pediatric intensive care unit (PICU). Our study objectives were to describe patient characteristics of PICU transfers less than or equal to 12 hours of admission and determine the reason for transfer. METHODS: We conducted a retrospective chart review of patients transferred to PICU less than or equal to 12 hours of admission. We extracted patient demographics, emergency severity index category, ED, floor and PICU length of stay (LOS), and PICU "significant" interventions. Charts were reviewed independently by the study principal investigator and a PICU attending who classified transfers as secondary to progression of disease or error in ED management. Furthermore, errors were classified as diagnostic, management, or disposition errors. RESULTS: A total of 164 patients met inclusion criteria. Most were male (86/164, 52.4%), with emergency severity index category 2 (116/164, 70.7%) and respiratory diagnosis (98/164, 59.8%). Most transfers (136/164, 82.9%) resulted from progression of illness. No significant interventions were performed in 48.8% (80/164) of patients. Of 164 transfers, 28 (17.1%) resulted from ED error, and half of these were management errors. Compared with disease progression, the ED error group had a significantly shorter median floor LOS {3.45 [interquartile range (IQR): 2.15, 7.56] vs 6.58 (IQR: 3.70, 9.20); P = 0.005}, more PICU interventions [1.5 (IQR: 0, 4) vs 0 (IQR: 0, 2); P = 0.006], and longer PICU LOS [2.50 (IQR: 1.09, 4.25) vs 1.36 (IQR: 0.80, 2.50); P = 0.013]. CONCLUSIONS: Most PICU transfers less than or equal to 12 hours after admission result from illness progression. Half of these do not require significant interventions. The PICU transfers after ED management error had significantly shorter floor LOS, longer PICU LOS, and more interventions.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Admissão do Paciente/tendências , Transferência de Pacientes/estatística & dados numéricos , Medicina de Emergência Pediátrica/estatística & dados numéricos , Adolescente , Criança , Progressão da Doença , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva Pediátrica , Masculino , Erros Médicos , Medicina de Emergência Pediátrica/normas , Estudos Retrospectivos , Fatores de Tempo , Adulto Jovem
11.
J Surg Res ; 243: 391-398, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31277017

RESUMO

BACKGROUND: Despite the frequent occurrence of interhospital transfers in emergency general surgery (EGS), rates of transfer of complications are undescribed. Improved understanding of hospital transfer patterns has a multitude of implications, including quality measurement. The objective of this study was to describe individual hospital transfer rates of mortal encounters. MATERIALS AND METHODS: A retrospective review was undertaken from 2013 to 2015 of the Maryland Health Services Cost Review Commission database. Two groups of EGS encounters were identified: encounters with death following transfer and encounters with death without transfer. The percentage of mortal encounters transferred was defined as the percentage of EGS hospital encounters with mortality initially presenting to a hospital transferred to another hospital before death at the receiving hospital. RESULTS: Overall, 370,242 total EGS encounters were included, with 17,003 (4.6%) of the total EGS encounters with mortality. Encounters with death without transfer encompassed 15,604 (91.8%) of mortal EGS encounters and encounters with death following transfer 1399 (8.2%). EGS disease categories of esophageal varices or perforation, necrotizing fasciitis, enterocutaneous fistula, and pancreatitis had over 10% of these total mortal encounters with death following transfer. For individual hospitals, percentage of mortal encounters transferred ranged from 0.8% to 35.2%. The percentage of mortal encounters transferred was inversely correlated with annual EGS hospital volume for all state hospitals (P < 0.001, r = -0.57). CONCLUSIONS: Broad variability in individual hospital practices exists for mortality transferred to other institutions. Application of this knowledge of percentage of mortal encounters transferred includes consideration in hospital quality metrics.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Cirurgia Geral/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Assistência Terminal/estatística & dados numéricos , Doente Terminal/estatística & dados numéricos , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Maryland , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
12.
Am J Health Syst Pharm ; 76(7): 436-443, 2019 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-31361822

RESUMO

PURPOSE: The study derives and validates a 30-day hospital readmission risk index to predict a patient's likelihood of readmission, utilizing a health systems electronic medical record. METHODS: A retrospective data extraction and analysis was conducted using data from the electronic medical record to identify risks of 30-day all-cause hospital readmission on adult patients admitted to a large multi-site health system. Univariate and multivariable logistic regression was performed on a derivation cohort of hospital admissions (n = 40,668) and analyzed 91 variables associated with 30-day hospital readmission. A 10-variable risk prediction equation was generated and validated in a second patient cohort (n = 7,820). The prediction index's discriminative ability was determined using the c-statistic, and calibration of the prediction index was assessed with the use of the Hosmer-Lemeshow test. RESULTS: The hospital all-cause thirty-day readmission index (HATRIX) identified 10 variables to be highly associated with 30-day readmission. The discriminative ability of the derived prediction equation was determined using the c-statistic and was calculated to be 0.73 (95% confidence interval [CI] 0.72-0.73) for the derivation cohort. The prediction equation was validated using a second cohort of patients and resulted with an area under the curve (AUC) of 0.72 (95% CI 0.70-0.73), indicating modest discrimination. CONCLUSION: An original risk prediction index for 30-day hospital readmission was derived and validated using 2 cohorts of patients. Identifying patients who have an increased risk of 30-day hospital readmission with the use of the electronic medical record is an ideal method for targeting interventions and improving transitions-of-care to reduce hospital readmissions.


Assuntos
Hospitais/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Adulto , Idoso , Registros Eletrônicos de Saúde/estatística & dados numéricos , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Transferência de Pacientes/organização & administração , Transferência de Pacientes/estatística & dados numéricos , Melhoria de Qualidade , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Estados Unidos
13.
Medicine (Baltimore) ; 98(25): e15993, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31232932

RESUMO

Organizing interfacility transfers is an essential component of regionalized care to improve patient outcomes. This study examines transfer characteristics after establishing a transfer center in a tertiary care center in Beirut Lebanon, and identifies predictors of success in patient transfers.This retrospective observational chart review examined all transfer center requests to and from the tertiary care center over a 4-year period (2013-2017). Descriptive analysis was done, followed by a bivariate analysis comparing transfers based on final decision (accepted yes/no) and by a multivariate logistic regression to identify predictors of successful transfers.A total of 4100 transfer requests were analyzed. Incoming transfer requests were more common than outgoing requests (56.5% vs 43.4%) and were mainly for adult patients (71.0% incoming and 78.7% outgoing). Reasons of transfers were mostly medical (99.4%) for incoming transfers and financial (73.1%) and medical (17.9%) for outgoing transfers. Requested level of care was most commonly intensive care unit for incoming transfers (61.6%) and regular floor for outgoing transfers (48.6%). Outgoing transfers were more successful than incoming transfers (59.9% vs 39.6%). Predictors of success in patient transfers within the healthcare system were identified: These included specific types of financial coverage, diagnoses, levels of care, and medical services for incoming transfers in addition to age groups and receiving hospital location for outgoing transfers.Transfer centers can be implemented successfully in any healthcare system to improve patient care and safety. Identifying facilitators and barriers to successful transfers can help healthcare administrators and policymakers address gaps in the system and improve access to care.


Assuntos
Serviços Médicos de Emergência/normas , Segurança do Paciente , Transferência de Pacientes/normas , Centros de Atenção Terciária , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Serviços Médicos de Emergência/economia , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Humanos , Lactente , Recém-Nascido , Líbano/epidemiologia , Masculino , Pessoa de Meia-Idade , Cultura Organizacional , Transferência de Pacientes/economia , Transferência de Pacientes/estatística & dados numéricos , Melhoria de Qualidade , Estudos Retrospectivos , Adulto Jovem
14.
West J Emerg Med ; 20(3): 433-437, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31123542

RESUMO

Introduction: We sought to determine the association of abnormal vital signs with emergency department (ED) process outcomes in both discharged and admitted patients. Methods: We performed a retrospective review of five years of operational data at a single site. We identified all visits for patients 18 and older who were discharged home without ancillary services, and separately identified all visits for patients admitted to a floor (ward) bed. We assessed two process outcomes for discharged visits (returns to the ED within 72 hours and returns to the ED within 72 hours resulting in admission) and two process outcomes for admitted patients (transfer to a higher level of care [intermediate care or intensive care] within either six hours or 24 hours of arrival to floor). Last-recorded ED vital signs were obtained for all patients. We report rates of abnormal vital signs in each group, as well as the relative risk of meeting a process outcome for each individual vital sign abnormality. Results: Patients with tachycardia, tachypnea, or fever more commonly experienced all measured process outcomes compared to patients without these abnormal vitals; admitted hypotensive patients more frequently required transfer to a higher level of care within 24 hours. Conclusion: In a single facility, patients with abnormal last-recorded ED vital signs experienced more undesirable process outcomes than patients with normal vitals. Vital sign abnormalities may serve as a useful signal in outcome forecasting.


Assuntos
Serviços Médicos de Emergência/métodos , Serviço Hospitalar de Emergência , Admissão do Paciente/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Sinais Vitais , Adulto , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Transferência de Pacientes/métodos , Transferência de Pacientes/estatística & dados numéricos , Prognóstico , Estudos Retrospectivos , Medição de Risco/métodos , Triagem/métodos
15.
Int J Clin Pharm ; 41(4): 831-852, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31123900

RESUMO

Background Medication discrepancies arising at care transitions are prevalent and are linked with adverse drug events and increased healthcare utilization. Evidence is lacking about which pharmacy-supported interventions at care transitions are most effective for both the patient and the healthcare system. Aim of the review To invesitigate the content and effect of pharmacy-supported interventions at transitions of care. Method The PubMed, Ovid/Medline and Cochrane Database of Systematic Reviews databases were used. The search was limited to systematic reviews and meta-analyses published in English up to May 2018. Included reviews investigated any intervention related to medication therapy performed by pharmacists or multiple healthcare professionals, including a pharmacist, at transition points in any healthcare setting. Reviews were excluded if interventions were not clearly defined or were not performed at care transitions or were not related to medications. A quality assessment was performed using the PRISMA guidelines. The data extracted included general characteristics, methodology, point of transition, pharmacy-supported interventions and outcomes. For systematic reviews, narrative conclusions were extracted. For meta analyses, reported relative risks or odds ratios were extracted along with the 95% confidence intervals. Results Nine systematic reviews and 5 meta-analyses reporting 162 studies were included. The interventions analysed included medication reconciliation (7 reviews) and composite interventions (7 reviews). Six studies reviewed interventions performed by pharmacists alone, while 8 studies explored interventions by different healthcare professionals, including a pharmacist. A positive effect on either medication discrepancies or (potential) ADEs was observed in all reviews. Mixed effects were observed for hospitalizations rates (9 reviews) and costs (4 reviews), regardless of the intervention applied. Mixed effects were also observed for both medication reconciliation and composite interventions on the number of emergency department visit. Interventions showed no significant effect on mortality (4 reviews). The quality of the reviews showed significant variability. Conclusion Pharmacy-supported interventions at transitions of care are heterogeneous and potentially improve medication safety, but show no significant effect on mortality. The effect on healthcare utilization and costs is inconclusive.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Reconciliação de Medicamentos/métodos , Transferência de Pacientes/estatística & dados numéricos , Assistência Farmacêutica , Pessoal de Saúde , Humanos , Papel Profissional
16.
J Trauma Acute Care Surg ; 87(3): 666-671, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31135767

RESUMO

BACKGROUND: The effect of Level IV trauma center (TC) accreditation within an existing trauma network remains understudied. This study compared preaccreditation to postaccreditation data from Level IV TCs within a mature trauma system in Pennsylvania to determine whether TC designation affected time to and/or rate of transfer to definitive care. Level IV TCs were hypothesized to have a decreased time to transfer following accreditation and improved mortality. METHODS: The Pennsylvania Trauma Systems Foundation collects predesignation and postdesignation data from hospitals pursuing accreditation. Data from Pennsylvania Trauma Systems Foundation between 2012 and 2017 were analyzed. Variables of interest included patient demographics, injury severity, mortality, and incidence of surgical interventions precredentialingto postcredentialing. A multilevel mixed-effects logistic regression model assessed the adjusted impact of Level IV TC accreditation on transfer rate. ArcGIS Desktop was used for geospatial mapping of lives and geographic area covered by the addition of Level IV TCs in Pennsylvania. RESULTS: Five hospitals underwent Level IV credentialing from 2012 to 2017, providing data on 5,076 cases (pre, 2,395 [47.2%]; post, 2,681 [52.8%]). No significant difference in age, admission Glasgow Coma Scale score, or shock index was observed preaccreditation to postaccreditation. A difference in transfer rate was observed after credentialing in unadjusted (62.7% vs. 63.3%; p < 0.014) and adjusted analyses (adjusted odds ratios, 1.13, p = 0.389). There was a trend toward reduced odds of mortality postcredentialing (adjusted odds ratios, 0.59, p = 0.261). Major surgical intervention decreased (Pre, 0.42%; Post, 0.04%; p = 0.004). CONCLUSION: Level IV TC accreditation has beneficial effects on increased transfer rates and may improve mortality. It is important to continue to observe the impact of Level IV TCs on patient outcomes within a mature trauma system. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.


Assuntos
Centros de Traumatologia/organização & administração , Acreditação , Serviços Médicos de Emergência/organização & administração , Feminino , Escala de Coma de Glasgow , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Transferência de Pacientes/estatística & dados numéricos , Pennsylvania , Sistema de Registros , Centros de Traumatologia/normas , Centros de Traumatologia/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapia
17.
BMC Health Serv Res ; 19(1): 329, 2019 May 23.
Artigo em Inglês | MEDLINE | ID: mdl-31122226

RESUMO

BACKGROUND: The overuse of tertiary hospitals and underuse of primary care facilities has been one of the key reasons leading to fast health expenditure increase and health service utilization inequity in China. Recent health care reform in China tries to enforce a patient transfer system to make the health services utilization more efficient. This study examined the pattern and associated factors of inter-facility transfer of inpatients in Sichuan province of Western China. METHODS: Patient discharge records (n = 1,490,695) from 604 general hospitals during the period of April to June 2015 in Sichuan were extracted from the front page of the medical records system with individual information on demographics, insurance coverage, diagnoses, hospitals admitted and discharge type. We calculated the percentage of inpatients transferring to other health facilities, the Inter-Facility Transfer Rate (IFTR) with adjustment for Charlson Comorbidity Index (CCI). Multi-level logistic regression models were established to identify factors associated with IFTRs. RESULTS: A small number of tertiary hospitals (n = 75, 12.41%) shared 51.71% (n = 770,823) of all admitted cases while a large number of primary/unrated hospitals (n = 321, 53.15%) shared only 8.15%. The overall CCI-adjusted IFTR was 2.08% with 3.73% among secondary hospitals, 1.87% among tertiary hospitals and 1.30% among primary/unrated hospitals. Uninsured patients (OR = 1.13) and those with a lower level of insurance entitlements (OR = 1.12 for the New Rural Cooperative Medical Scheme and the Basic Medical Insurance for Urban Residents) were more likely to experience inter-facility transfer than those with a higher level of insurance entitlements (the Basic Medical Insurance for Urban Employees). CONCLUSION: The level of IFTR in general hospitals in Sichuan is low, which is associated with the level of hospitals and insurance entitlements. Further studies are needed to better understand how patients and health care providers respond to different insurance policies and make decisions on inter-facility transfer.


Assuntos
Hospitalização/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , China , Estudos Transversais , Feminino , Reforma dos Serviços de Saúde/economia , Reforma dos Serviços de Saúde/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Serviços de Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Hospitalização/economia , Hospitais , Humanos , Lactente , Recém-Nascido , Pacientes Internados/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , Transferência de Pacientes/economia , Saúde da População Rural/economia , Saúde da População Rural/estatística & dados numéricos , Adulto Jovem
18.
J Pediatr Surg ; 54(9): 1848-1853, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31003730

RESUMO

OBJECTIVE: Malrotation with midgut volvulus is a time-sensitive pediatric surgical disease that requires emergent operative exploration to avoid bowel loss; however, it also requires specialized pediatric care. The purpose of this study was to identify disparities in bowel resection in children who underwent emergency surgery for malrotation; particularly the role of transfer status. METHODS: The Pediatric Health Information System was used to identify a multicenter cohort of patients who underwent emergency surgical intervention for malrotation. Univariate and multivariable analyses were used to determine factors associated with the primary outcome of bowel resection; secondary outcomes included surgical complications, prolonged length of stay, TPN dependence, and death. RESULTS: Of 3373 patients with malrotation included, 44.8% were transferred in. Younger age, prematurity and other comorbidity, nonwhite race, and public insurance were associated with transfer. Transferred patients were more likely to undergo bowel resection on univariate (30.7 vs 16.4%, p < .001) and multivariable analysis (RR =1.38, p < .010). After adjusting for bowel resection, only patient factors including age and comorbidity were associated with surgical complications, TPN dependence, and death. CONCLUSION: Patients who require hospital-to-hospital transfer for emergent surgical management of malrotation are more likely to require bowel resection which is in turn associated with greater morbidity. Further work is needed to optimize access to prompt surgical care for this condition especially given race and insurance disparities in transfer status. LEVEL OF EVIDENCE: III, prognostic study.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório , Volvo Intestinal , Transferência de Pacientes/estatística & dados numéricos , Criança , Estudos de Coortes , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Serviços Médicos de Emergência , Humanos , Volvo Intestinal/epidemiologia , Volvo Intestinal/cirurgia , Intestinos/cirurgia , Complicações Pós-Operatórias , Prognóstico , Resultado do Tratamento
19.
Urology ; 130: 175-180, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31029673

RESUMO

OBJECTIVE: To examine secondary overtriage for isolated renal trauma patients and to use secondary overtriage criteria to determine factors associated with unnecessary interhospital transfers in patients with isolated renal trauma. METHODS: The National Trauma Data Bank was used to identify isolated renal trauma patients of any age who were transferred to a level I or II trauma center from 2007 to 2014. Secondary overtriage criteria were defined as hospital length of stay <72 hours, no ICU admission, no emergent transfer from the ED to the OR, no operating room procedure, and no renal IR/OR procedure. Adjusted risk ratios (RR) and 95% confidence intervals were estimated using Poisson regression. RESULTS: A total of 8156 isolated renal injury patients who were transferred to either a level I or II trauma center were identified. More than half (53%) of the transferred patients had low-grade renal injuries (American Association for the Surgery of Trauma (AAST) Grade I/II). Our definition of secondary overtriage was met in 3005 patients (37%). In this group, 59% had low-grade renal injuries. The risk of being overtriaged was significantly reduced with increasing renal injury grade, hypotension in the emergency department, firearm injuries, older age (>65 years), medicare payer status, and any substance abuse. CONCLUSION: Secondary overtriage is common in isolated renal trauma. Factors associated with secondary overtriage are age ≤65 years, falls, and low renal injury grade. The high rate of unnecessary transfers shows that there is a need for disease-specific transfer guidelines to assure safe, cost-effective, and efficient health care in isolated renal trauma.


Assuntos
Rim/lesões , Transferência de Pacientes/estatística & dados numéricos , Triagem/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Adulto Jovem
20.
Surgery ; 165(6): 1128-1135, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30981416

RESUMO

BACKGROUND: Data on predictors of nonroutine discharge among patients undergoing hepatopancreatic surgery remain poorly defined. We sought to define factors associated with nonroutine discharge to home with home health care or to a skilled nursing facility or intermediate care facility and determine the impact of discharge destination on outcomes after hepatopancreatic surgery. METHODS: The Nationwide Readmissions Database was queried for individuals who underwent hepatopancreatic surgeries 2010-2014 and were discharged home with home health care or to a skilled nursing facility/intermediate care facility. RESULTS: A total of 42,189 patients underwent hepatopancreatic surgery. Of those, 2,825 (6.70%) were discharged to a skilled nursing facility or intermediate care facility, whereas 10,925 (25.9%) were discharged with home health care. A majority of patients underwent major hepatectomy (N = 14,516, 34.4%) or minor pancreatectomy (N = 13,824, 32.8%). Compared with patients discharged home, patients discharged to a skilled nursing facility or intermediate care facility were older (median age: 60 years, interquartile range: 50-68 vs 73, 67-79) and had more comorbidities (median score: 3, interquartile range: 1-8 vs 4, interquartile range: 2-8; P < .001). Type of operative procedure was not associated with discharge to a skilled nursing facility versus with home health care. Rather, patients with extreme loss of function, based on preoperative assessment, had 2.76 times higher odds of discharge to a skilled nursing facility or intermediate care facility versus with home health care (odds ratio 2.76, 95% confidence interval 1.98-3.85). Similarly, older (odds ratio 1.06, 95% confidence interval 1.06-1.07) and female patients (odds ratio 1.37, 95% confidence interval 1.25-1.51) were more likely to be discharged to a skilled nursing facility or intermediate care facility versus with home health care. CONCLUSION: One in four patients undergoing hepatopancreatic surgery were readmitted within 90 days of surgery. Age, severity of comorbidities, and perioperative course, including incidence of complications, were associated with nonroutine discharge.


Assuntos
Hepatectomia/efeitos adversos , Pancreatectomia/efeitos adversos , Alta do Paciente/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Fatores Etários , Idoso , Comorbidade , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Serviços de Assistência Domiciliar/estatística & dados numéricos , Humanos , Hepatopatias/epidemiologia , Hepatopatias/cirurgia , Masculino , Pessoa de Meia-Idade , Pancreatopatias/epidemiologia , Pancreatopatias/cirurgia , Readmissão do Paciente/estatística & dados numéricos , Período Perioperatório/estatística & dados numéricos , Prognóstico , Melhoria de Qualidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos
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