Clinical diagnosis of pyloric stenosis: a declining art.

OBJECTIVE--To assess whether diagnostic imaging of pyloric stenosis has made a difference in rapidity of diagnosis, duration of pre-operative hydration, and length of stay in hospital. DESIGN--Chart review of infants with confirmed diagnosis of pyloric stenosis. SETTING--Paediatric teaching hospital. SUBJECTS--215 infants with a confirmed diagnosis of pyloric stenosis seen during 1974-7 and 187 infants with pyloric stenosis seen during 1988-91. MAIN OUTCOME MEASURES--State of hydration on admission, time between presentation to hospital and a definite diagnosis, techniques used to make the diagnosis, whether a pyloric mass was felt before or after an imaging procedure, time between presentation and surgery, and length of stay in hospital. RESULTS--The average age at presentation was 40 days in both groups. A pyloric mass was palpated either without or before an imaging study in 87% (187/215) of cases during 1974-7 but in only 49% (91/187) during 1988-91. The use of barium meal examination and ultrasonography increased from 20% (42/215) of cases during 1974-7 to 61% (114/187) during 1988-91. There were no significant differences between the two groups in the time taken to establish a diagnosis, the mean duration of preoperative treatment, or the length of stay in hospital (after allowance for the decline in average length of stay of all hospital patients between the two periods). CONCLUSIONS--An increased use of diagnostic imaging for pyloric stenosis did not lead to earlier diagnosis or better management. While imaging is important in identifying pyloric stenosis in difficult cases, increasing reliance on imaging has reduced doctors'' skills in diagnosing pyloric stenosis clinically.     

Quality improvement report: The “jaundice hotline” for the rapid assessment of patients with jaundice

ProblemPatients with jaundice require rapid diagnosis and treatment, yet such patients are often subject to delay.DesignAn open referral, rapid access jaundice clinic was established by reorganisation of existing services and without the need for significant extra resources.

Background and setting

A large general hospital in a largely rural and geographically isolated area.

Key measures for improvement

Waiting times for referral, consultation, diagnosis, and treatment, length of stay in hospital, and general practitioners'' and patients'' satisfaction with the service.

Strategies for change

Referrals were made through a 24 hour telephone answering machine and fax line. Initial assessment of patients was carried out by junior staff as part of their working week. Dedicated ultrasonography appointments were made available.

Effects of change

Of 107 patients seen in the first year of the service, 62 had biliary obstruction. The mean time between referral and consultation was 2.5 days. Patients who went on to endoscopic retrograde cholangiopancreatography waited 5.7 days on average. The mean length of stay in hospital in the 69 patients who were admitted was 6.1 days, compared with 11.5 days in 1996, as shown by audit data. Nearly all the 36 general practices (95%) and the 30 consecutive patients (97%) that were surveyed rated the service as above average or excellent.

Lessons learnt

An open referral, rapid access service for patients with jaundice can shorten time to diagnosis and treatment and length of stay in hospital. These improvements can occur through the reorganisation of existing services and with minimal extra cost.     

Use of hospital beds: a cohort study of admissions to a provincial teaching hospital.

An instrument was developed to study the use of hospital beds and discharge arrangements of a cohort of 847 admissions to the John Radcliffe Hospital, Oxford, for a three week period during February-March 1986. For only 38% of bed days were patients considered to have medical, nursing, or life support reasons for requiring a provincial teaching hospital bed. The requirements for a bed in the hospital decreased with the patient''s age and length of stay in hospital. For only a tenth of patients was the general practitioner concerned in discussions with hospital staff about the patient''s discharge and less than one third of patients had been given more than 24 hours'' notice of discharge. Several features might increase the proportion of bed days that are occupied by patients with positive reasons for being in hospital. Among these are an increased frequency of ward rounds by consultants, or delegating discharge decisions by consultants to other staff; providing diagnostic related protocols for planning the length of stay in hospital; planned discharges; and providing liaison nurses to help with communication with primary care staff.     

Inpatient admissions and outpatient appointments in the first year post cancer diagnosis: A population based study from England

BackgroundTime spent in hospital (length of stay) is an important component of patient experience and the financial cost of cancer care. This study documents the length of stay across English cancer diagnoses at a national level and reports on variation by patient demographics and tumour characteristics.MethodsData on all diagnoses of malignant neoplasms from the English National Cancer Registration and Analysis Service for 252,202 patients first diagnosed in 2015 was linked with NHS Digital’s Admitted Patient Care and Outpatient Hospital Episode Statistics datasets to quantify length of stay within one year following diagnosis. Length of stay was modelled using linear regression adjusted for sex, age, tumour type, stage, time spent alive during the study period, vital status at end of study period, region, deprivation and ethnicity.ResultsPatients spend a mean of 25 days (median = 17 days; IQR = 8–34 days) in hospital in their first year. Tumour type, stage, age and vital status corrections had the strongest effects in the model adjusting for other independent variables. Younger patients tended towards longer stays.ConclusionLength of stay varies among patients by tumour type, age and stage. Estimating future health service demands should account for changes in incident tumour characteristics.     

The psychogeriatric patient in hospital

The records of 148 geriatric patients discharged from the Royal Ottawa Hospital over an 18-month period were studied. The readmission rate, 38%, was similar to that of all inpatients in this hospital. The largest diagnostic category was depressive neurosis. More women than men had diagnoses of affective disorders, while more men had organic brain disease; these differences were statistically significant. The average length of hospital stay was 25 days. Those patients with diagnoses of organic brain disease and alcoholism had shorter stays than those with affective disorders. The implications of these findings in terms of setting up a psychogeriatric unit are discussed.     

Impact of a province-wide nurses' strike on medical care in a regional referral centre.

A 4-week, province-wide nurses'' strike in Alberta in 1982 caused the closure of 57% of the acute care beds, including 47% of the intensive care beds, in Calgary. The effects of the strike on patient care at Foothills Provincial General Hospital, where nurses did not strike, were assessed. The number of emergency admissions, severity of illness and rate of death in the intensive care unit increased. On the other hand, the rate of death, length of stay and number of unexpected deaths on the medical wards were similar to those in the control periods before and after the strike. A subjective perception by hospital personnel of deteriorating patient care caused much anxiety; however, the results of analysis of measurable aspects of care suggested that the patients admitted to hospital received care during the strike that was comparable to care given before or after the strike. The inconvenience and potential harm to the patients not admitted because they had less severe illness were not measured.     

"Homeward bound": a minimal care rehabilitation unit.

A 20 bed minimal care rehabilitation unit was set up by Newham District Health Authority in a small hospital originally scheduled for closure when a new district general hospital was opened. During the first year 114 patients were admitted (throughput 5.7), with a median length of stay of 30 days; in the second year 173 patients were admitted (throughput 8.65) with a median length of stay of 28.5 days. The cost per inpatient day was less than that of an inpatient day at the district''s long stay geriatric unit. Before the unit opened 24% of the acute beds had been occupied for more than six weeks, whereas two years later only 6% of the acute beds were occupied for such a period.     

Gastric Bypass as Treatment for Obesity: Trends,Characteristics, and Complications

Objective: This paper describes national trends in gastric bypass procedures from 1998 through 2003 and explores the demographic and health profile of those who receive this procedure. Short‐term outcomes such as length of stay and in‐hospital complication rates are also examined. Research Methods and Procedures: Data on obese hospital inpatients who had gastric bypass were obtained from the 1998 to 2003 National Hospital Discharge Survey. Gastric bypass was reported for an estimated 288,000 discharges during the 6‐year study period. Trends within the 6‐year period were tested using weighted regression. Characteristics of gastric bypass patients were compared with those of other inpatients using a χ² test of independence and the two‐sided t test. Results: The estimated number of hospital discharges with gastric bypass increased significantly, from 14,000 in 1998 to 108,000 in 2003. During this period, the average length of stay declined by 56% from 7.2 to 3.2 days. Gastric bypass patients were primarily women (84%), 25 to 54 years of age (82%), and privately insured (76%). A 1 in 10 complication rate was found for discharges with gastric bypass. Discussion: Gastric bypass procedures in the United States have increased rapidly since 1998, whereas the average hospital stay has decreased. The decreasing length of stay needs to be evaluated in conjunction with potential complication rates and the permanent change in anatomy and lifestyle that must accompany this procedure. Monitoring trends in use of this procedure is important, especially if reimbursement policies change and the epidemic of obesity continues.     

骨盆骨折患者住院日及预测因子分析

目的:分析上海市某三甲医院创伤中心骨盆骨折患者住院日及其预测因子。方法:抽取上海市第一人民医院南院创伤中心2013年全部62名骨盆骨折住院患者病历,对住院日进行单因素分析、相关分析和有序logistic回归。结果:研究对象中位住院日为19.00天。单因素分析显示受伤原因、骨盆骨折数、患侧和是否输血是住院日的预测因子(P0.05)。相关分析显示手术次数、手术时长、输血量、手术失血、检验次数、CT检查次数和超声检查次数分别与住院日存在相关关系(P0.05)。有序logistic回归表明手术次数、CT检查次数和手术失血量是住院日的独立预测因子(P0.05)。结论:骨盆骨折住院患者平均住院时间长,住院日主要受手术次数、CT检查次数和手术失血量影响,减少不必要的影像学检查和术中出血可缩短住院日。     

Shortening hospital stay for psychiatric care: effect on patients and their families

A one-year cohort of patients from a defined catchment area with acute functional disorders were allocated at random to brief care (experimental group) or standard care (control group) in hospital to examine the effect of shortening hospital stay on the clinical and social functioning of patients and the distress abnormal functioning caused to others. A total of 127 patients were interviewed on entry to the study, and 106 were followed up. The brief care group had significantly shorter mean and median lengths of stay than the control group, but there was no difference between the groups in the number of days spent in hospital during subsequent admissions. The groups were well matched for clinical and social variables. Rates of improvement over 13 weeks were essentially the same by all measures of outcome, including the Present State Examination and Patient''s Behaviour Assessment Scale, which was developed for the study to measure deterioration in behaviour and social functioning and adverse effects and distress on others. There was no difference between the two groups in burden to the community supporting services, social security requirements, or GP attendances. Improvement rates were nearly identical on all measures within and across diagnostic subgroups. Brief care resulted in a 33% reduction in average length of stay compared with the year before but was associated with a corresponding increase in day hospital use. The short-stay policy continued the year after the study finished.The findings confirm the value of shortening hospital stay and improving day care facilities for most localities.     

Mortality and hospital stay associated with resistant Staphylococcus aureus and Escherichia coli bacteremia: estimating the burden of antibiotic resistance in Europe

Background

The relative importance of human diseases is conventionally assessed by cause-specific mortality, morbidity, and economic impact. Current estimates for infections caused by antibiotic-resistant bacteria are not sufficiently supported by quantitative empirical data. This study determined the excess number of deaths, bed-days, and hospital costs associated with blood stream infections (BSIs) caused by methicillin-resistant Staphylococcus aureus (MRSA) and third-generation cephalosporin-resistant Escherichia coli (G3CREC) in 31 countries that participated in the European Antimicrobial Resistance Surveillance System (EARSS).

Methods and Findings

The number of BSIs caused by MRSA and G3CREC was extrapolated from EARSS prevalence data and national health care statistics. Prospective cohort studies, carried out in hospitals participating in EARSS in 2007, provided the parameters for estimating the excess 30-d mortality and hospital stay associated with BSIs caused by either MRSA or G3CREC. Hospital expenditure was derived from a publicly available cost model. Trends established by EARSS were used to determine the trajectories for MRSA and G3CREC prevalence until 2015. In 2007, 27,711 episodes of MRSA BSIs were associated with 5,503 excess deaths and 255,683 excess hospital days in the participating countries, whereas 15,183 episodes of G3CREC BSIs were associated with 2,712 excess deaths and 120,065 extra hospital days. The total costs attributable to excess hospital stays for MRSA and G3CREC BSIs were 44.0 and 18.1 million Euros (63.1 and 29.7 million international dollars), respectively. Based on prevailing trends, the number of BSIs caused by G3CREC is likely to rapidly increase, outnumbering the number of MRSA BSIs in the near future.

Conclusions

Excess mortality associated with BSIs caused by MRSA and G3CREC is significant, and the prolongation of hospital stay imposes a considerable burden on health care systems. A foreseeable shift in the burden of antibiotic resistance from Gram-positive to Gram-negative infections will exacerbate this situation and is reason for concern. Please see later in the article for the Editors'' Summary     

Two factors that can increase the length of hospital stay of patients with dementia

ObjectivesPatients with dementia are at greater risk of a long hospital stay and this is associated with adverse outcomes. The aim of this service evaluation was to identify variables most predictive of increased length of hospital stay amongst patients with dementia.Methods/DesignWe conducted a retrospective analysis on a cross-sectional hospital dataset for the period January–December 2016. Excluding length of stay less than 24 h and readmissions, the sample comprised of 1133 patients who had a dementia diagnosis on record.ResultsThe highest incidence rate ratio for length of stay in the dementia sample was: (a) discharge to a care home (IRR: 2.443, 95% CI 1.778–3.357), (b) falls without harm (IRR: 2.486, 95% CI 2.029–3.045).ConclusionsBased on this dataset, we conclude that improvements made to falls prevention strategies in hospitals and discharge planning procedures can help to reduce the length of stay for patients with dementia.     

Trends and variations in length of hospital stay for childbirth in Canada

BACKGROUND: Early discharge after childbirth is widely reported. In this study the authors examined trends in maternal length of hospital stay in Canada from fiscal year 1984-85 through fiscal year 1994-95. They also examined variations in length of stay in 1994-95 in most of the Canadian provinces and the territories. METHODS: Epidemiologic analyses of the temporal and geographic variations in maternal length of hospital stay in Canada from 1984-85 to 1994-95 (even years only), based on hospital discharge data collected by the Canadian Institute for Health Information, with a total of 1,456,800 women for the 6 study years. RESULTS: Mean length of hospital stay decreased during the decade, from 5.3 days in 1984-85 to 3.0 days in 1994-95, with similar trends for both cesarean and vaginal delivery. The decrease resulted from both increasing rates of short stay (less than 2 days) and decreasing rates of long stay (more than 4 days). Substantial temporal and interprovincial variations in several medical and obstetric complications were also observed but did not explain the corresponding variations in length of stay. The reduction in length of hospital stay was not restricted to uncomplicated cases: there was an equivalent decrease in cases with complications. In 1994-95 the average length of hospital stay in Alberta was 2.6 days, 0.3 to 1.7 days shorter than in the other provinces and the territories. INTERPRETATION: Length of hospital stay for childbirth has decreased substantially in Canada in recent years, but there remain important interprovincial variations. These trends and variations are not likely due to changes or differences in patient-specific factors.     

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.     

基于灰熵关联的平均住院日影响因素研究

目的:分析医疗指标与平均住院日的关联程度,为医院有效缩短平均住院日提供参考依据。方法:建立基于灰熵优化的加权灰色关联度模型,对影响平均住院日的医疗指标进行重要程度的分析。结果:根据关联程度分析,可知影响平均住院日的医疗指标重要程度依次为开放床位数、床位周转次数、治疗有效率、床位使用率、年门诊量、住院手术人次和出院人数。结论:基于灰熵优化的加权灰色关联分析方法可以有效分析医疗指标对平均住院日的影响程度,提高医疗服务质量。     

Isolated Aortocoronary Bypass Operations in Patients Over 70 Years of Age: A Comparison With Results in Patients 50 to 59 Years Old

The early and late morbidity, mortality and beneficial effects of isolated aortocoronary bypass operations in a group of 35 patients 70 years old or older were compared with those factors in patients 50 to 59 years old. The patients in both groups were matched according to the year in which the operation was done and the number of vessels bypassed. Left ventricular function, estimated by the angiographically calculated ejection fraction, was not statistically different in the two groups. Cardiac index, while adequate in both groups, was significantly lower in the older age group. Comparisons were made of “early” events, such as perioperative myocardial infarction, perioperative death and length of post-operative hospital stay; and of “late” events, including myocardial infarction, angina pectoris, congestive heart failure and death, which occurred after patients were discharged from the hospital. The mean length of follow-up of patients was similar in both groups.In comparing early events in the two groups, there was no statistically significant difference in the incidence of perioperative myocardial infarction, perioperative mortality or mean length of postoperative hospital stays. With regard to late events, there was no statistically significant difference in the incidences of myocardial infarction, angina pectoris or mortality.     

Increasing Short-Stay Unplanned Hospital Admissions among Children in England; Time Trends Analysis ’97–‘06

Background

Timely care by general practitioners in the community keeps children out of hospital and provides better continuity of care. Yet in the UK, access to primary care has diminished since 2004 when changes in general practitioners'' contracts enabled them to ‘opt out’ of providing out-of-hours care and since then unplanned pediatric hospital admission rates have escalated, particularly through emergency departments. We hypothesised that any increase in isolated short stay admissions for childhood illness might reflect failure to manage these cases in the community over a 10 year period spanning these changes.

Methods and Findings

We conducted a population based time trends study of major causes of hospital admission in children <10 years using the Hospital Episode Statistics database, which records all admissions to all NHS hospitals in England using ICD10 codes. Outcomes measures were total and isolated short stay unplanned hospital admissions (lasting less than 2 days without readmission within 28 days) from 1997 to 2006. Over the period annual unplanned admission rates in children aged <10 years rose by 22% (from 73.6/1000 to 89.5/1000 child years) with larger increases of 41% in isolated short stay admissions (from 42.7/1000 to 60.2/1000 child years). There was a smaller fall of 12% in admissions with length of stay of >2 days. By 2006, 67.3% of all unplanned admissions were isolated short stays <2 days. The increases in admission rates were greater for common non-infectious than infectious causes of admissions.

Conclusions

Short stay unplanned hospital admission rates in young children in England have increased substantially in recent years and are not accounted for by reductions in length of in-hospital stay. The majority are isolated short stay admissions for minor illness episodes that could be better managed by primary care in the community and may be evidence of a failure of primary care services.     

PICCO在重型颅脑损伤患者容量管理中的临床应用价值研究

目的:探讨脉搏指数连续心输出量(PICCO)技术在重型颅脑损伤患者液体管理中的临床应用价值。方法:回顾性分析重型颅脑损伤患者46例(男性27例,女性19例),以应用PICCO技术监测血流动力学指标指导液体管理的患者为治疗组(n=26),未应用PICCO技术指导液体管理的患者为对照组(n=20)。比较两组患者的日平均液体量、格拉斯哥昏迷评分(GCS)、急性生理与慢性健康评分(APACHE II)、肺水肿发生率、住院时间、住院总费用以及治疗6个月后的格拉斯哥预后评分(GOS)、生存率、颅脑损伤恢复良好率。结果:治疗期间,治疗组的GCS评分以及APACHEII评分均优于对照组,而治疗组的住院总费用高于对照组,但差异并无统计学意义(P0.05)。治疗组的日平均液体量、肺水肿发生率及住院时间均明显少于对照组,差异有统计学意义(P0.05)。治疗6个月后,治疗组患者的GOS评分、生存率和颅脑损伤恢复良好率均高于对照组,但差异亦无统计学意义(P0.05)。结论:应用PICCO技术监测血流动力学指标指导重型颅脑损伤患者的容量管理可在一定程度上缩短危重患者的住院时间并降低肺水肿的发生率,但并不能明显改善患者的预后。     

Inappropriate hospital use by patients receiving care for medical conditions: targeting utilization review

OBJECTIVE: To describe characteristics associated with inappropriate hospital use by patients in Manitoba in order to help target concurrent utilization review. Utilization review was developed to reduce inappropriate hospital use but can be a very resource-intensive process. DESIGN: Retrospective chart review of a sample of adult patients who received care for medical conditions in a sample of Manitoba hospitals during the fiscal year 1993-94; assessment of patients at admission and for each day of stay with the use of a standardized set of objective, nondiagnosis-based criteria (InterQual). PATIENTS: A total of 3904 patients receiving care at 26 hospitals. OUTCOME MEASURES: Acute (appropriate) and nonacute (inappropriate) admissions and days of stay for adult patients receiving care for medical conditions. RESULTS: After 1 week, 53.2% of patients assessed as needing acute care at admission no longer required acute care. Patients 75 years of age or older consumed more than 50% of the days of stay, and 74.8% of these days of stay were inappropriate. Four diagnostic categories accounted for almost 60% of admissions and days, and more than 50% of those days of stay were inappropriate. Patients admitted through the emergency department were more likely to require acute care (60.9%) than others (41.7%). Patients who were Treaty Indians had a higher proportion of days of stay requiring acute care than others (45.9% v. 32.8%). Patients'' income and day of the week on admission (weekday v. weekend) were not predictive factors of inappropriate use. CONCLUSION: Rather than conducting a utilization review for every patient, hospitals might garner more information by targeting patients receiving care for medical conditions with stays longer than 1 week, patients with nervous system, circulatory, respiratory or digestive diagnoses, elderly patients and patients not admitted through the emergency department.     

Quality of Care of Hospitalized Internal Medicine Patients Bedspaced to Non-Internal Medicine Inpatient Units

Background

When the number of patients requiring hospital admission exceeds the number of available department-allotted beds, patients are often placed on a different specialty''s inpatient ward, a practice known as “bedspacing”. Whether bedspacing affects quality of patient care has not been previously studied.

Methods

We reviewed consecutive general internal medicine (GIM) admissions for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and pneumonia at St. Michael''s Hospital in Toronto, Canada, from 2007 to 2011 and examined whether quality of care differs between bedspaced and nonbedspaced patients. We matched each bedspaced patient with a GIM ward patient admitted on the same call shift with the same diagnosis. The primary outcome was the ratio of the actual to the estimated length of stay (ELOS). General and disease specific measures for CHF, COPD, and pneumonia (e.g. fluid restriction) were evaluated, as well as 30-day Emergency Department (ED) and hospital readmissions.

Results

Overall, 1639 consecutive admissions were reviewed, and 39 matched pairs for CHF, COPD and pneumonia were studied. Differences in both general and disease specific care measures were not detected between groups. For many disease-specific comparisons, ordering and adherence to quality of care indicators was low in both groups.

Conclusions

We were unable to detect differences in quality of care between bedspaced and nonbedspaced patients. As high patient volumes and hospital overcrowding remains, bedspacing will likely continue. More research is required in order to determine if quality of care is compromised by this ongoing practice.