Hospital resuscitation from ventricular fibrillation in Brighton.

The overall results over three and a half years of the treatment of ventricular fibrillation secondary to ischaemic heart disease in the Royal Sussex County Hospital were reviewed. Records of all patients who were brought to hospital by resuscitation ambulances or who were admitted to the coronary care unit from any source were analysed. Eighty-seven of the 174 patients (50%) who developed ventricular fibrillation were discharged. The survivors included 13 out of 61 patients (21%) in whom fibrillation was secondary to cardiogenic shock or severe left ventricular failure. The presence of resuscitation equipment and nursing staff trained to use it in the general wards and emergency areas ensured a uniformly high success rate throughout the hospital, similar to that achieved in the coronary care unit. Prompt defibrillation in the general wards and the accident and emergency department may improve overall survival.     

Care of dying patients in hospital.

OBJECTIVE--To study the process of care of dying patients in general hospitals. DESIGN--Non-participant observer (MM) carried out regular periods of continuous comprehensive observation in wards where there were dying patients, recording the quantity and quality of care given. Observations were made in 1983. SETTING--13 wards (six surgical, six medical, and one specialist unit) in four large teaching hospitals (bed capacity 504-796) in west of Scotland. SUBJECTS--50 dying patients (29 female, 21 male) with mean age of 66 (range 40-89); 29 were dying from cancer and 21 from non-malignant disease. RESULTS--Final period of hospitalisation ranged from 6 hours to 24 weeks. More than half of all patients retained consciousness until shortly before death. Basic interventions to maintain patients'' comfort were often not provided: oral hygiene was often poor, thirst remained unquenched, and little assistance was given to encourage eating. Contact between nurses and the dying patients was minimal; distancing and isolation of patients by most medical and nursing staff were evident; this isolation increased as death approached. CONCLUSIONS--Care of many of the dying patients observed in these hospitals was poor. We need to identify and implement practical steps to facilitate high quality care of the dying. Much can be learned from the hospice movement, but such knowledge and skills must be replicated in all settings.     

Coronary Care Unit in a General Medical Ward

A five-bedded coronary care unit has been set up within a general medical ward without the provision of extra medical or nursing staff. During 30 months 1,000 patients were admitted. Sixty-three developed cardiac arrest; 28 were resuscitated successfully initially; and 18 were eventually discharged. The corresponding figures for the 28 patients with ventricular fibrillation treated by direct current defibrillation were 20 and 12 respectively. The mortality rate during the first three days (the usual length of stay in the unit) was 8·9% compared with 9·7% after transfer to the general ward. It is suggested that these results are comparable with those from more highly staffed purpose-built units.     

Ward meetings: a forum for patients' concerns.

A series of meetings between patients and staff were held on two general medical wards to discuss the concerns of patients. Issues ranged from the quality of hospital food, ward facilities, and visiting arrangements to the medical and nursing care provided and patients'' views on medical students. Most issues were raised by the patients themselves and the outcome was either acceptance or rejection of a suggestion, an explanation by the staff, or a general discussion if a specific decision was inappropriate. Most staff and patients considered the meetings to be valuable. Ward meetings thus seem to provide a way of making hospitals more responsive to patients'' concerns.     

Multipurpose Intensive Care Unit in a District General Hospital

The advantages of a four-bedded purpose-built general intensive care unit in a district general hospital are described. In addition to 1,447 inpatients treated between January 1968 and December 1971 the unit was used to conduct outpatient investigations. This has filled an important gap in conventional arrangements, and is practical and economical. The unit has proved to have advantages, not only for seriously ill patients but also has benefited the hospital in other ways. It has been of material assistance in recruiting and training nursing and medical staff and has been welcomed and supported by patients and their relatives. It has also attracted practical support from voluntary organizations whose generosity has enabled much additional equipment to be purchased.     

Psychological and social evaluation in cases of deliberate self-poisoning seen in an accident department.

The outcome in 115 consecutive patients with mild self-poisoning seen by junior medical staff and discharged from the accident department was compared with that of 98 similar patients admitted to the medical wards. Psychiatrists saw only four patients in the accident department and 25 admissions. In making their assessments the junior medical staff considered psychosocial factors as well as the patients'' physical condition. Most patients recommended for further care, and discharged from the accident department, subsequently received it. Repetition rates were similar in the two groups and there had been no suicides when patients were followed up at one year. It is feasible for junior staff in an accident department to decide whether patients with self-poisoning need admission or may be discharged with or without subsequent referral for psychiatric or social work help.     

特需病房护理工作面临的问题及对策

摘要目的：探讨在特需病房护理工作中所面临的相关问题及相应的解决办法。方法：选取2010年11月至2012年11月在我院特需病房接受过“一切以病人为中心”的护理观念和人性化护理方式的1000例相关病症患者的临床资料,并对患者在护理过程中的护理方式的满意度评价等进行回顾性分析。结果：该护理方法得到了患者以及患者家属的一致好评。在我院接受特需病房护理的1000例患者中,有900例（90．00％）患者表示非常愿意接受该种护理方法。有950例（95．00％）患者的家属也十分赞同该护理方法。但仍有部分患者在护理过程中对人性化护理有更高的要求,这对于护理人员是一个重大的挑战;另外,特需病房护理人员的素质以及专业技能也存在不足;护理环境以及护理方法仍存在些许漏洞。结论：本着“一切以病人为中心”的原则,结合患者的相关病症及相应需求采用人性化的护理模式,与患者以及患者家属进行合理的沟通。在进行特需病房患者的护理过程中注重人性化对于患者的康复具有重要的意义。     

A More Efficient Use of Hospital Beds?

Faced with a shortage of trained nursing staff and a high wastage rate among learners the management of a district general hospital decided to close some of its acute beds. A beds committee attempted to minimize the effects of these closures by introducing a bed bureau, “pooling,” and a simple system for forecasting waiting list admissions.The figures for recruitment and wastage of nurses improved, and a very high turnover per available bed was achieved. This increased efficiency in numerical terms was not mirrored by an improvement in the morale of the doctors and nurses working on the wards, who were subjected to new pressures and considered that at times the standard of patient care deteriorated.     

Patients in acute surgical wards: a survey in Glasgow.

A survey was made of all patients in general surgical, urological, and orthopaedic and accident wards in Glasgow on one day in June 1975. Its purpose was to define features of acute surgical practice of relevance to the future planning of resources, particularly bed numbers. Over 40% of the patients in both surgical and orthopaedic wards were over 65 years. Most patients had serious conditions and could not have been treated other than by admission to an acute surgical ward. But a substantial minority no longer needed such facilities and could have been transferred to second-line beds, although many still required skilled nursing care. Delay in the discharge of elderly patients from acute surgical wards as a consequence of non-surgical (often medical or social) problems results in a proportion of acute surgical beds fulfilling a second-line function. Unless arrangements for the earlier discharge of these patients are made any reduction in acute surgical beds is likely to restrict elective surgery, especially in orthopaedics.     

Mortality in elderly patients admitted for respite care.

OBJECTIVE--To determine whether admitting elderly patients to hospital to give temporary relief to their carers is associated with increased mortality. DESIGN--Prospective multicentre study comparing the mortality of patients admitted on a one off or rotational basis with that experienced while they were awaiting admission. SETTING--A wide range of urban and rural district general, geriatric or long stay, and general practitioner hospitals. PATIENTS--474 Patients aged 70 or over who had 601 admissions. MAIN OUTCOME MEASURE--Death. RESULTS--16 (3.4%) Of the 474 patients (2.7% of all 601 admissions) died while in hospital during an average stay of 15.7 days whereas 23 (4.9%) patients died while awaiting admission (average waiting time was 34.2 days). The 16 deaths in hospital and the 23 deaths during the longer waiting period correspond to death rates of 19.9 and 12.5 per 10,000 person days respectively. The difference between these of 7.4 is not statistically significant (95% confidence interval -3.6 to 18.3). The estimated relative risk of dying in hospital is 1.59 but the 95% confidence interval is wide (0.84 to 3.01). CONCLUSION--Although the death rates are slightly higher in those admitted to hospital for relief care than in those awaiting admission, the difference was not significant, and the death rate in both groups was reassuringly small.     

Differences in mortality from acute myocardial infarction between coronary care unit and medical ward: treatment or bias?

To analyse the effectiveness of coronary care units in reducing mortality from myocardial infarction 18 hospitals ranging from large urban teaching hospitals to small country hospitals were stratified into four levels of care. Previous analysis had failed to show significant differences in the overall mortality in hospital among levels. There were significant differences in mortality, however, between those patients allocated to be cared for in the coronary care unit and those in the medical wards in the more advanced hospitals. The differences were largest in the hospitals with the most elaborate facilities (level 1) and non-existent in those with the least (level 4). Several analytical approaches to these observed differences indicated that they were: (a) reduced by adjustment for age and severity of infarction; (b) paralleled by differences in coexisting disease recorded on death certificates; (c) no longer significant at level 1 after allowing for differences in coexisting disease; and (d) not significant at any level after exclusion of patients first diagnosed at necropsy. These findings suggest that the observed differences in mortality between coronary care units and medical wards are largely due to bias in selection and diagnosis.     

Relation between bed use,social deprivation,and overall bed availability in acute adult psychiatric units,and alternative residential options: a cross sectional survey,one day census data,and staff interviews.

OBJECTIVES: To examine the relation between bed use, social deprivation, and overall bed availability in acute adult psychiatric units and to explore the range of alternative residential options. DESIGN: Cross sectional survey, combined with one day census data; ratings by and interviews with staff; examination of routine data sources. SETTINGS: Nationally representative sample of acute psychiatric units. SUBJECTS: 2236 patients who were inpatients on census day. MAIN OUTCOME MEASURES: Bed occupancy levels, judged need for continuing inpatient care, reasons preventing discharge, scores on the Health of the Nation outcome scales. RESULTS: Bed occupancy was related to social deprivation and total availability of acute beds (r = 0.66, 95% confidence interval 0.19 to 0.88, F = 8.72, df = 2.23; P = 0.002). However, 27% (603/2215) of current inpatients (61% (90/148) of those with stays of > 6 months) were judged not to need continuing admission. The major reasons preventing discharge were lack of suitable accommodation (37% (176/482) of patients in hospital < 6 months v 36% (31/86) of those in hospital > 6 months); inadequate domiciliary based community support (23% (113) v 9% (8)); and lack of long term rehabilitation places (21% (100) v 47% (40)). Scores on the Health of the Nation outcome scale were generally consistent with these staff judgments. CONCLUSIONS: The shortage of beds in acute psychiatric units is related to both social deprivation and the overall availability of acute beds. Patients currently inappropriately placed on acute admission wards should be relocated into more suitable accommodation, either in hospital or in the community. A range of provisions is required; simply providing more acute beds is not the answer.     

Cognitive status and behavioral problems in older hospitalized patients

OBJECTIVES: (a) To determine the quantity and quality of behavioral problems in older hospitalized patients on acute care units; (b) to determine the burden of these behaviors on staff; and (c) to identify predictors of behavioral problems. METHODS: Upon admission, patients performed the Mini-Mental State Exam (MMSE), the Geriatric Depression Scale (GDS), and information was obtained on age, ethnicity, level of education, living arrangement, and psychiatric history. Two days post-admission, a clinical staff member caring for each patient, performed the Neuropsychiatric Inventory-Questionnaire (NPI-Q) to assess patients' behavioral problems and staff distress. PARTICIPANTS AND SETTING : Forty-two patients, over 60 years of age, admitted to medical and surgical units of the Veterans Affairs Hospitals in Palo Alto and San Francisco, participated. RESULTS: Twenty-three of 42 (55%) patients exhibited behavioral problems. Anxiety, depression, irritability, and agitation/aggression were the most frequently observed behaviors. The severity of the behavioral problems was significantly correlated with staff distress. Lower performance on the MMSE at admission was significantly associated with higher NPI-Q ratings. Specifically, of those cases with scores less than or equal to 27 on the MMSE, 66% had behavioral problems during hospitalization, compared to only 31% of those with scores greater than 27. CONCLUSION: Behavioral problems in older hospitalized patients appear to occur frequently, are a significant source of distress to staff, and can result in the need for psychiatric consultation. Assessment of the mental status of older adults at admission to hospital may be valuable in identifying individuals at increased risk for behavioral problems during hospitalization.     

Geriatric medicine in Hull: a comprehensive service.

A partially age-related admission policy coupled with a "single-ward" scheme for treatment and rehabilitation was introduced by the Hull geriatric department in 1970. With rare exceptions, elderly patients needing hospital care have been admitted directly to the geriatric unit, and the proportion of the retired population admitted by the general physicians has been greatly reduced. The proportion of inpatients needing continuing care has been reduced to less than 20%, the mean length of inpatient stay has fallen to under 30 days, and separate long-stay wards are no longer needed. More than 91% of patients are admitted without preceding domiciliary assessment, and only 5-6% of admissions are transferred from other units within the area.     

Area security unit in a psychiatric hospital.

Since 1974 a psychiatric hospital security unit, designed to serve the whole catchment area, has cared for mentally ill (mostly psychotic) patients with disturbed behaviour that cannot be managed in open wards. There are a few long-term dangerous patients but most stay only briefly. The admission of women to the unit was not followed by the expected reduction in violence. The unit has facilities for occupational therapy, physical recreation, work, and study, which are particularly important for those who are too dangerous to leave it. The unit''s calming influence depends as much on the supportive effect of the high staff ratio as on the use of tranquillisers. This type of unit is not suitable for patients with personality disturbances who "act out" or for mentally abnormal offenders; but it functions well as a crisis centre for the disturbed mentally ill, and there is an increasing demand for its services.     

Development of an index to measure oral health care priority among nursing staff

Objective: To develop an index to measure oral health care priority among nursing staff. Background: Nursing staff, working on hospital wards, at nursing homes and at other facilities, have to deal with oral health care and there are many reports about the low priority that is given to oral health care by nursing staff. It is difficult to measure oral health care priority among nursing staff. A Dental Coping Beliefs Scale (DCBS) index was used in an intervention study and was found to be easy to handle but did not have the ability to reveal significant differences in small study samples. A development process consisting of added items and item numbering by chance was carried out. During this process, different nursing staff test groups were used. The aim was to develop an oral health care priority index that can be used both on hospital wards and at special facilities to measure oral health care priority among nursing staff over time and between groups. Material and methods: Nursing staff at both special facilities and hospital wards and nursing students. Results: It was found that the index, the nursing DCBS, was more stable compared with the version that was used in the initial intervention study. It was also noted that its ability to discriminate between the items was improved. Conclusion: The nursing DCBS index is a suitable tool for use in further studies where the aim is to measure how different nursing staff groups give priority to and allocate responsibility for oral health care, even where study samples are small.     

Nurses and Physicians in a Medical Admission Unit Can Accurately Predict Mortality of Acutely Admitted Patients: A Prospective Cohort Study

Background

There exist several risk stratification systems for predicting mortality of emergency patients. However, some are complex in clinical use and others have been developed using suboptimal methodology. The objective was to evaluate the capability of the staff at a medical admission unit (MAU) to use clinical intuition to predict in-hospital mortality of acutely admitted patients.

Methods

This is an observational prospective cohort study of adult patients (15 years or older) admitted to a MAU at a regional teaching hospital. The nursing staff and physicians predicted in-hospital mortality upon the patients'' arrival. We calculated discriminatory power as the area under the receiver-operating-characteristic curve (AUROC) and accuracy of prediction (calibration) by Hosmer-Lemeshow goodness-of-fit test.

Results

We had a total of 2,848 admissions (2,463 patients). 89 (3.1%) died while admitted. The nursing staff assessed 2,404 admissions and predicted mortality in 1,820 (63.9%). AUROC was 0.823 (95% CI: 0.762–0.884) and calibration poor. Physicians assessed 738 admissions and predicted mortality in 734 (25.8% of all admissions). AUROC was 0.761 (95% CI: 0.657–0.864) and calibration poor. AUROC and calibration increased with experience. When nursing staff and physicians were in agreement (±5%), discriminatory power was very high, 0.898 (95% CI: 0.773–1.000), and calibration almost perfect. Combining an objective risk prediction score with staff predictions added very little.

Conclusions

Using only clinical intuition, staff in a medical admission unit has a good ability to identify patients at increased risk of dying while admitted. When nursing staff and physicians agreed on their prediction, discriminatory power and calibration were excellent.     

The need for acute,subacute, and nonacute care at 105 general hospital sites on Ontario

BACKGROUND: Previous studies of hospital utilization have not taken into account the use of acute care beds for subacute care. The authors determined the proportion of patients who required acute, subacute and nonacute care on admission and during their hospital stay in general hospitals in Ontario. From this analysis, they identified areas where the efficiency of care delivery might be improved. METHODS: Ninety-eight of 189 acute care hospitals in Ontario, at 105 sites, participated in a review that used explicit criteria for rating acuity developed by Inter-Qual Inc., Marlborough, Mass. The records of 13,242 patients who were discharged over a 9-month period in 1995 after hospital care for 1 of 8 high-volume, high-variability diagnoses or procedures were randomly selected for review. Patients were categorized on the basis of the level of care (acute, subacute or nonacute) they required on admission and during subsequent days of hospital care. RESULTS: Of all admissions, 62.2% were acute, 19.7% subacute and 18.1% nonacute. The patients most likely to require acute care on admission were those with acute myocardial infarction (96.2% of 1826 patients) or cerebrovascular accident (84.0% of 1596 patients) and those admitted for elective surgery on the day of their procedure (73.4% of 3993 patients). However, 41.1% of patients awaiting hip or knee replacement were admitted the day before surgery so did not require acute care on admission. The proportion of patients who required acute care on admission and during the subsequent hospital stay declined with age; the proportion of patients needing nonacute care did not vary with age. After admission, acute care was needed on 27.5% of subsequent days, subacute care on 40.2% and nonacute care on 32.3%. The need for acute care on admission was a predictor of need for acute care during subsequent hospital stay among patients with medical conditions. The proportion of patients requiring subacute care during the subsequent hospital stay increased with age, decreased with the number of inpatient beds in each hospital and was highest among patients with congestive heart failure, chronic obstructive pulmonary disease and pneumonia. INTERPRETATION: In 1995, inpatients requiring subacute care accounted for a substantial proportion of nonacute care days in Ontario''s general hospitals. These findings suggest a need to evaluate the efficiencies that might be achieved by introducing a subacute category of care into the Canadian health care system. Generally, efforts are needed to reduce the proportion of admissions for nonacute care and of in-hospital days for other than acute care.     

Prospective randomised study of an orthopaedic geriatric inpatient service.

A randomised controlled trial of two management regimens was carried out in women patients over 65 years of age with hip fractures. Ninety seven patients were admitted to a designated orthopaedic geriatric unit and 125 to orthopaedic wards. No difference was observed in mortality, length of stay, or placement of patients between the two groups. More medical conditions were recognised and treated in patients in the orthopaedic geriatric unit group. It is concluded that designated orthopaedic geriatric units can provide medical care to these patients and should be administered without additional cost.