Blocked beds.

In a cross-sectional survey of 325 surgical and orthopaedic beds 43 (16%) of the 265 occupied beds were filled by patients who had no medical need to be in an acute ward. They had been in hospital for a median time of 40 weeks up to the survey date. Of the 43 patients, 11 were awaiting transfer to a geriatric ward; 13 to community residential care; and seven to their homes. There was no plan for discharge or transfer for the remaining 12 (28%). Those "at risk" of becoming long-stay patients for social reasons on these wards were women, over 75, living alone or with one relative, who had been admitted to hospital in emergency with a fractured femur, head injury, or other trauma. Action necessary to reduce the number of social long-stay patients includes (a) changing attitudes to the solving of social case problems; (b) revising procedures of assessment and planning of future care; (c) improving teamwork and record keeping within the hospital and the community services; (d) providing a better balance of acute, medium and long-stay hospital beds; and (e) putting more resources into rehabilitation.     

Census of mental hospital patients and life expectancy of those unlikely to be discharged.

A census in a London mental hospital was performed so that the numbers of patients requiring permanent care for the next 20 to 40 years could be estimated. Of 1467 resident patients 20% had been admitted in the preceding five months and 15% in the year before that. Of the 65% who had been in hospital for over 17 months 1% (16 patients) had been in hospital for over 5o years. Altogether 257 (18%) patients would probably be discharged, 339 (23%) might possibly be discharged if there were adequate community facilities, but 871 (59%) were not likely to be discharged; 239 patients under the age of 65 who had been admitted between 1950 and 1973 were unlikely to be discharged. There were about 10 new younger long-stay patients from each year''s admissions. Three conditions--schizophrenia, organic brain syndrome, and affective illness--affected 79% of the population. Fourteen per cent had been employed on admission and 28% were considered employable or possibly employable. Half of those who might be considered for discharge (296) would need a hostel. No rehabilitation was needed or possible for 40% of the patients; 299 (20%) patients were chairbound or bedridden and 400 (27%) were totally dependent on nursing and 587 (40%) partly dependent. Twenty months after the census 361 (25%) patients had left (59 had been readmitted), 284 (19%) had died, and 822 (56%) had remained as inpatients. The most realistic future prediction was that 210 (14%) of these patients would still be in the hospital in 20 years and 43 (3%) in 40 years. In the light of these findings and the scarceness of resources current Department of Health and Social Security plans for phasing out mental hospitals must be challenged.     

Long-Stay Patients in Canadian Mental Hospitals, 1955-1963

Changes in the number and characteristics of patients in Canadian mental hospitals during 1955-1963 were studied in order to assess the future need for long-term hospital care.Despite marked increases in the number of first admissions and readmissions, the average number of patients in hospital decreased 6% from 49,537 in 1955 to 46,498 in 1963.Patients who were “long stay” in 1955 continued to leave hospital at the same rate during the years 1960-1963 as during 1955-1959. No “hard core” of long-stay patients with reduced potential for discharge seemed to have formed by 1963.Since 1955 the number of “admissions” remaining continuously hospitalized has progressively decreased for the elderly and for patients with psychoses. No build-up of new long-stay patients from patients with repeated short admissions was evident.The estimate of the Royal Commission on Health Services that the ratio of patients in mental hospitals could be reduced from 3.0 per 1000 in 1961 to 1.5 per 1000 by 1971 seems feasible.     

Review of Schizophrenics in a Rural Practice over 26 Years

Over 26 years some 73 patients with schizophrenia were observed. Three types were considered, true schizophrenia, schizophrenia simplex, and schizoaffective disorders. Of those traced and alive in 1971, some 18% of the group had recovered, 46% had made a social recovery, 25% were unemployed in the community, and 11% were long-stay hospital patients.     

Psychiatric Inpatients from an Urban Community, 1968-72

The psychiatric inpatient population from Salford was analysed in five successive annual censuses, from 1 January 1968 to 1 January 1972. Short-stay and medium-stay patients (under one year) remained constant. Long-stay patients reduced only slowly, and the length of stay increased. Over 200 patients (60%) had been in for 20 years or more at 1 January 1972. Analysis showed that the 1968 long-stay cohort diminished by 122 patients (29%) in four years, while 54 new long-stay patients accumulated. There seems little prospect of emptying large psychiatric hospitals of their long-stay population.     

Risk of severe outcomes among patients admitted to hospital with pandemic (H1N1) influenza

Background

We describe the disease characteristics and outcomes, including risk factors for admission to intensive care unit (ICU) and death, of all patients in Canada admitted to hospital with pandemic (H1N1) influenza during the first five months of the pandemic.

Methods

We obtained data for all patients admitted to hospital with laboratory-confirmed pandemic (H1N1) influenza reported to the Public Health Agency of Canada from Apr. 26 to Sept. 26, 2009. We compared inpatients who had nonsevere disease with those who had severe disease, as indicated by admission to ICU or death.

Results

A total of 1479 patients were admitted to hospital with confirmed pandemic (H1N1) influenza during the study period. Of these, 1171 (79.2%) did not have a severe outcome, 236 (16.0%) were admitted to ICU and survived, and 72 (4.9%) died. The median age was 23 years for all of the patients, 18 years for those with a nonsevere outcome, 34 years for those admitted to ICU who survived and 51 years for those who died. The risk of a severe outcome was elevated among those who had an underlying medical condition and those 20 years of age and older. A delay of one day in the median time between the onset of symptoms and admission to hospital increased the risk of death by 5.5%. The risk of a severe outcome remained relatively constant over the five-month period.

Interpretation

The population-based incidence of admission to hospital with laboratory-confirmed pandemic (H1N1) influenza was low in the first five months of the pandemic in Canada. The risk of a severe outcome was associated with the presence of one or more underlying medical conditions, age of 20 years or more and a delay in hospital admission.The first cases of pandemic (H1N1) influenza in Canada were reported on Apr. 26, 2009. Retrospective case-finding determined that the onset of symptoms in the first Canadian case, involving a traveller returning from Mexico, occurred on Apr. 12, 2009. The first patient admitted to hospital began to experience symptoms on Apr. 18.During the first few weeks of the outbreak, in-depth follow-up and reporting of cases was conducted in keeping with the World Health Organization’s pandemic plans for each country to comprehensively assess its first 100 cases.¹ By mid-May, many Canadian jurisdictions moved away from this approach because it became increasingly taxing on both public health human resources and laboratory capacity. It was decided that reporting of individual cases would continue nationally only for patients who were admitted to hospital or who died. We provide a detailed review of the disease characteristics and outcomes, including risk factors for admission to intensive care unit (ICU) and death, of patients admitted to hospital in Canada during the first five months of the pandemic.     

A Patient-Centered Understanding of the Referral System in Ethiopian Primary Health Care Units

Background

Primary healthcare systems in sub-Saharan Africa have undergone substantial development in an effort to expand access to appropriate facilities through a well-functioning referral system. The objective of this study was to evaluate the current patterns of seeking prior care before arriving at a health center or a hospital as a key aspect of the referral system of the primary health care unit (PHCU) in three regions in Ethiopia. We examined what percentage of patients had either sought prior care or had been referred to the present facility and identified demographic and clinical factors associated with having sought prior care or having been referred.

Methods and Findings

We conducted a cross-sectional study using face-to-face interviews in the local language with 796 people (99% response rate) seeking outpatient care in three primary health care units serving approximately 100,000 people each and reflecting regional and ethnic diversity; 53% (N = 418) of the sample was seeking care at hospital outpatient departments, and 47% of the sample was seeking care at health centers (N = 378). We used unadjusted and adjusted logistic regression to identify factors associated with having been referred or sought prior care. Our findings indicated that only 10% of all patients interviewed had been referred to their current place of care. Among those in the hospital population, 14% had been referred; among those in the health center population, only 6% had been referred. Of those who had been referred to the hospital, most (74%) had been referred by a health center. Among those who were referred to the health center, the plurality portion (32%) came from a nearby hospital (most commonly for continued HIV treatment or early childhood vaccinations); only 18% had come from a health post. Among patients who had not been formally referred, an additional 25% in the hospital sample and 10% in the health center sample had accessed some prior source of care for their present health concern. In the adjusted analysis, living a longer distance from the source of care and needing more specialized care were correlated with having sought prior care in the hospital sample. We found no factors significantly associated with having sought prior care in the health center sample.

Conclusions

The referral system among health facilities in Ethiopia is used by a minority of patients, suggesting that intended connections between health posts, health centers, and hospitals may need strengthening to increase the efficiency of primary care nationally.     

Hospital Mental Health Admissions in Women after Unsuccessful Infertility Treatment and In Vitro Fertilization: An Australian Population-Based Cohort Study

Objective

To examine the association between in vitro fertilization (IVF) and later admission to hospital with a mental health diagnosis in women who remained childless after infertility treatment.

Methods

This was a population-based cohort study using linked administrative hospital and registry data. The study population included all women commencing hospital treatment for infertility in Western Australia between the years 1982 and 2002 aged 20–44 years at treatment commencement who did not have a recorded birth by the end of follow-up (15 August 2010) and did not have a hospital mental health admission prior to the first infertility admission (n=6,567). Of these, 2,623 women had IVF and 3,944 did not. We used multivariate Cox regression modeling of mental health admissions and compared women undergoing IVF treatment with women having infertility treatment but not IVF.

Results

Over an average of 17 years of follow-up, 411 women in the cohort were admitted to hospital with a mental health diagnosis; 93 who had IVF and 318 who did not. The unadjusted hazard ratio (HR) for a hospital mental health admission comparing women who had IVF with those receiving other infertility treatment was 0.50 (95% confidence interval [CI] 0.40–0.63). After adjustment for age, calendar year and socio-economic status the HR was 0.56 (95% CI 0.44–0.71).

Conclusions

IVF treatment is associated with a reduced risk of hospital mental health admissions in women after unsuccessful infertility treatment. This may be explained by the healthy cohort effect.     

Augmented home nursing as an alternative to hospital care for chronic elderly invalids.

A scheme of augmented home care for disabled elderly invalids is compared with long-stay hospital care. Initial results suggest that selected patients may be suitable for home care if they can be left unsupervised at night or if a relative is available to provide supervision. The cost of such care is in most cases cheaper than keeping the patient in hospital, and schemes such as this might reduce the need for additional long-stay geriatric beds to meet the necessary demands of our growing elderly population.     

Staphylococci in Bronchi of Hospital Patients: An Autopsy Study

Swabs were taken from the main bronchi of hospital patients at routine autopsy, and cultures examined for the presence of coagulase-positive staphylococci. The proportion of patients yielding positive cultures increased steadily with the length of stay in hospital. There was no correlation between positive cultures and age or sex. The results of this study suggest that bronchi of long-stay patients may form a significant source of dissemination of staphylococci producing “hospital” infections.     

Effect of a geriatric consultation service on management of patients in an acute care hospital.

Elderly patients present particular management challenges. We conducted a randomized clinical trial of the effect of a geriatric consultation service on the management of elderly patients in an acute care hospital. A total of 113 patients aged 75 years or more who met certain criteria were assigned to either receive (57 patients) or not receive (56) care by the service. At the end of their hospital stay the patients were assessed with regard to predetermined outcomes. The patients were followed up for 1 year after discharge to determine death rates and direct health care expenditures. The intervention group showed significantly greater improvement in mental status (p less than 0.01), were receiving fewer medications at discharge (p less than 0.05) and had lower short-term death rates (p less than 0.05) than the control group. A geriatric consultation service can improve the hospital care and health of the elderly.     

Cost analysis of early discharge after hip fracture.

OBJECTIVE--To ascertain the economic impact of an early discharge scheme for hip fracture patients. DESIGN--Population based study comparing costs of care for patients who had "hospital at home" as an option for rehabilitation and those who had no early discharge service available in their area of residence. SETTING--District hospital orthopaedic and rehabilitation wards and community hospital at home scheme. PATIENTS--1104 consecutively admitted patients with fractured neck of femur. 24 patients from outside the district were excluded. MAIN OUTCOME MEASURES--Cost per patient episode and number of bed days spent in hospital. RESULTS--Patients with the hospital at home option spent significantly less time as inpatients (mean of 32.5 v 41.7 days; p < 0.001). Those patients who were discharged early spent a mean of 11.5 days under hospital at home care. The total direct cost to the health service was significantly less for those patients with access to early discharge than those with no early discharge option (4884 pounds v 5606 pounds; p = 0.048). CONCLUSIONS--About 40% of patients with fractured neck of femur are suitable for early discharge to a scheme such as hospital at home. The availability of such a scheme leads to lower direct costs of rehabilitative care despite higher readmission costs. These savings accrue largely from shorter stays in orthopaedic and geriatric wards.     

Composition and temporal stability of the gut microbiota in older persons

The composition and function of the human gut microbiota has been linked to health and disease. We previously identified correlations between habitual diet, microbiota composition gradients and health gradients in an unstratified cohort of 178 elderly subjects. To refine our understanding of diet–microbiota associations and differential taxon abundance, we adapted an iterative bi-clustering algorithm (iterative binary bclustering of gene sets (iBBiG)) and applied it to microbiota composition data from 732 faecal samples from 371 ELDERMET cohort subjects, including longitudinal samples. We thus identified distinctive microbiota configurations associated with ageing in both community and long-stay residential care elderly subjects. Mixed-taxa populations were identified that had clinically distinct associations. Microbiota temporal instability was observed in both community-dwelling and long-term care subjects, particularly in those with low initial microbiota diversity. However, the stability of the microbiota of subjects had little impact on the directional change of the microbiota as observed for long-stay subjects who display a gradual shift away from their initial microbiota. This was not observed in community-dwelling subjects. This directional change was associated with duration in long-stay. Changes in these bacterial populations represent the loss of the health-associated and youth-associated microbiota components and gain of an elderly associated microbiota. Interestingly, community-associated microbiota configurations were impacted more by the use of antibiotics than the microbiota of individuals in long-term care, as the community-associated microbiota showed more loss but also more recovery following antibiotic treatment. This improved definition of gut microbiota composition patterns in the elderly will better inform the design of dietary or antibiotic interventions targeting the gut microbiota.     

Old people not known to the general practitioner: low risk group.

The elderly patients in a large general practice aged 75 and over who lived at home (n = 877) were divided into two groups according to the general practitioner''s knowledge of their risk status and were designated "risk status known" (n = 679) and "risk status not known" (n = 198). Forty-three high risk patients in the risk status known group had a functional disability score and experience of mortality that was not dissimilar to those of elderly people in institutions. The medical and social characteristics of a random sample (n = 150) of the risk status known group, after excluding the high risk patients, were compared with the risk status not known group using a Barber Wallis questionnaire. A response rate of 90% was achieved from both groups and a cumulative risk score was calculated by totalling unfavourable replies to the questions. The risk status not known group, which comprised 14% of the patients who lived at home after correcting for the number who had died and moved, had appreciably less contact with the general practitioners, had an appreciably lower cumulative risk score, were confined at home less because of ill health, were less concerned about their health, and were less in need of nursing attention. The findings of this study suggest that the elderly patients who are not known to their general practitioners are in relatively good health when compared with the patients that the general practitioner knows well.     

"New chronic" patients.

A five-year follow-up of 1467 mental hospital patients showed that 501 had died, 449 had been discharged, and 517 were still resident. During this period 81 "new chronic" patients aged under 65 were admitted: 49 were readmissions and 15 of 32 first admissions had had previous periods in other psychiatric hospitals. Many new chronic patients were old chronic with intervals of community care, and one-third of them were likely to require permanent care. These findings provide no comfort for those who believe that present DHSS plans for mental health services can ever be realised.     

Post tracheostomy and post intubation tracheal stenosis: Report of 31 cases and review of the literature

Background

There is increasing evidence that patients with low-risk community acquired pneumonia (CAP) can be effectively treated as outpatients. This study aimed to explore patients' experiences of having pneumonia and seeking health care; their perceptions of the information provided by health professionals; how they self managed at home; their information and support needs; and their beliefs and preferences regarding site of care.

Methods

We conducted qualitative, semi-structured interviews with 15 patients who had a confirmed diagnosis of low-risk CAP and had received fewer than 3 days hospital care. Interviews were audio recorded and transcribed, and data were analysed thematically.

Results

Most patients left hospital with no clear understanding of pneumonia, its treatment or follow-up and most identified additional-other specific information needs when they got home. Some were unable to independently address their activities of daily living in their first days at home. Main concerns after discharge related to the cause and implications of pneumonia, symptom trajectory and prevention of transmission. Most sought advice from their GP in their first days at home, and indicated they would have appreciated a follow-up phone call or visit to discuss their concerns. Patients' preferences for site of care varied and appeared to be influenced by beliefs about safety (fear of rapid deterioration at home or acquiring an infection in hospital), family burden, access to support, or confidence in home-care services. Those who received intravenous (IV) medication were more likely to state a preference for hospital care.

Conclusion

Trends to support community-based treatment of CAP should be accompanied by increased attention to the information and support needs of patients who go home to self-manage. Although some information needs can be anticipated and addressed on diagnosis, specific needs often do not become apparent until patients return home, so some access to information and support in the community is likely to be necessary. Our finding that patients who received IV treatment for low-risk CAP were concerned about the relative safety of home-based care highlights the potential importance of the inferences patients make from treatment modalities, and also the need to ensure that patients' expectations and understandings are managed effectively.     

Raised respiratory rate in elderly patients: a valuable physical sign.

Measurements of respiratory rate in 82 long-stay patients aged 67-101 years yielded a normal range of 16-25 breaths a minute. In a prospective study of 60 consecutive acute admissions to a geriatric unit, 19 out of 21 patients diagnosed as lower respiratory tract infections had respiratory rates above the upper limit of normal on the day of diagnosis; the rise in respiratory rate preceded the clinical diagnosis. All eight patients who were diagnosed on admission as having a lower respiratory tract infection had a respiratory rate greater than 26, with a mean of 29.7 breaths a minute. Patients admitted for other conditions-for example, urinary tract infection-rarely had respiratory rates outside the normal range. Accurate measurement of respiratory rate is a valuable diagnostic aid in elderly patients.     

"Asset stripping" the declining mental hospital.

A psychogeriatric day hospital was developed from a long-stay back ward of a large mental hospital whose population of patients had decreased by half. Women in the 70-80 age group with varying degrees of dementia benefited most from such facilities. In view of the current cut-back in Government spending one of the greatest assets in providing a comprehensive service for the elderly mentally infirm may well be found in the declining mental hospital.     

Do-not-resuscitate order. What happens after hospital discharge?

We observed 55 inpatients with "do-not-resuscitate" (DNR) orders to determine what happened to their DNR status after hospital discharge. All were admitted to the medical service of a Department of Veterans Affairs hospital. Of the 55 patients, 16 died in the hospital, 10 were discharged to inpatient hospice units, and 1 was transferred to an acute care hospital. An additional 19 patients were discharged to nursing homes. The other 9 patients (16% of the total) survived their hospital stays; 6 successful contacts were made with patients'' spouses. In 1 case the spouse thought a DNR order was no longer desirable. In the other 5 cases the spouse said the DNR status was "probably" or "definitely" still warranted, but only 1 spouse had a written DNR order at home. We contacted 9 of the 14 house officers who had cared for the patients in hospital. Only 2 had ever written a DNR order after hospital discharge. Two house officers said they routinely discussed with family members a patient''s expected dying process at home. Unwanted resuscitation is as undesirable at home as in the hospital. Physicians should discuss future resuscitation procedures with patients who have DNR orders at the time of hospital discharge. Physicians, paramedic service directors, and policymakers also should develop protocols and standardized home DNR orders so that paramedics can honor the wishes of patients in the prehospital setting.     

Psychiatric morbidity of a long stay hospital population with chronic schizophrenia and implications for future community care.

In the United Kingdom there are plans to close most mental hospitals over the next 10 years. There is continuing uncertainty about the effectiveness of community psychiatric services that will be expected to cope with mental hospital inpatients after discharge, most of whom have schizophrenia. A survey was conducted to assess the severity of illness among such patients and implications for their future care. All 222 patients in non-psychogeriatric long stay wards of a mental hospital who met research diagnostic criteria for schizophrenia were interviewed by two psychiatrists with the comprehensive psychopathological rating scale to establish the prevalence of psychiatric symptomatology. A complete interview was not possible for 28 patients, mainly for reasons related to their schizophrenia. Despite energetic pharmacological and social treatments almost half of the 194 patients interviewed had enduring florid psychotic symptoms that presented as one or more delusions or auditory hallucinations, or both, and a sizable proportion showed behaviour that would set them apart in a community setting. The results illustrate a problem that is still imperfectly understood by policy makers and administrators in central and local government and in health authorities who are responsible for planning and implementing services for psychiatric care in the community.