ABSTRACT BACKGROUND Few studies have evaluated both the overall effect of intensive care unit (ICU) telemedicine programs and the effect of individual components of the intervention on clinical outcomes. METHODS The effects of non-randomized ICU telemedicine interventions on crude and adjusted mortality and length of stay (LOS) were measured. Additionally, individual intervention components related to process and setting of care, were evaluated for their association with mortality and LOS. RESULTS Overall, 118,990 (11,558 control; 107,432 intervention) adult patients from 56 ICUs in 32 hospitals from 19 US health care systems were included. After statistical adjustment, hospital (HR=0.84, 95%CI: 0.78-0.89, p<.001) and ICU (HR=0.74, 95%CI: 0.68-0.79, p<.001) mortality in the ICU telemedicine intervention group was significantly better than that of controls. Moreover, adjusted hospital LOS was reduced, on average, by 0.5 (95%CI: 0.4-0.5), 1.0 (95%CI: 0.7-1.3), and 3.6 (95%CI: 2.3-4.8) days, and adjusted ICU LOS was reduced by 1.1 (95%CI: 0.8-1.4), 2.5 (95%CI: 1.6-3.4), and 4.5 (95%CI: 1.5-7.2) days among those who stayed in the ICU for ≥7, ≥14, and ≥30 days, respectively. Individual components of the interventions that were associated with lower mortality and/or reduced LOS included: i) intensivist case review within 1 hour of admission, ii) timely use of performance data, iii) adherence to ICU best practices, and iv) quicker alert response times. CONCLUSIONS ICU telemedicine interventions, specifically interventions that increase early intensivist case involvement, improve adherence to ICU best practices, reduce response times to alarms, and encourage the use of performance data were associated with lower mortality and LOS.
INTRODUCTION: This study examined tobacco smoke pollution (also known as thirdhand smoke, THS) in hotels with and without complete smoking bans and investigated whether non-smoking guests staying overnight in these hotels were exposed to tobacco smoke pollutants. METHODS: A stratified random sample of hotels with (n=10) and without (n=30) complete smoking bans was examined. Surfaces and air were analysed for tobacco smoke pollutants (ie, nicotine and 3-ethynylpyridine, 3EP). Non-smoking confederates who stayed overnight in guestrooms provided urine and finger wipe samples to determine exposure to nicotine and the tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone as measured by their metabolites cotinine and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), respectively. FINDINGS: Compared with hotels with complete smoking bans, surface nicotine and air 3EP were elevated in non-smoking and smoking rooms of hotels that allowed smoking. Air nicotine levels in smoking rooms were significantly higher than those in non-smoking rooms of hotels with and without complete smoking bans. Hallway surfaces outside of smoking rooms also showed higher levels of nicotine than those outside of non-smoking rooms. Non-smoking confederates staying in hotels without complete smoking bans showed higher levels of finger nicotine and urine cotinine than those staying in hotels with complete smoking bans. Confederates showed significant elevations in urinary NNAL after staying in the 10 most polluted rooms. CONCLUSIONS: Partial smoking bans in hotels do not protect non-smoking guests from exposure to tobacco smoke and tobacco-specific carcinogens. Non-smokers are advised to stay in hotels with complete smoking bans. Existing policies exempting hotels from complete smoking bans are ineffective.
- Scandinavian journal of trauma, resuscitation and emergency medicine
- Published over 5 years ago
BACKGROUND: When medical wards become saturated, the common practice is to resort to outlying patients in another ward until a bed becomes free.Objectives: Compare the quality of care provided for inpatients who are outlying (O) in inappropriate wards because of lack of vacant beds in appropriate specialty wards to the care given to non outlying (NO) patients. METHODS: We propose a matched-pair cluster study. The exposed group consisted of inpatients that were outliers in inappropriate wards because of lack of available beds. Non-exposed subjects (the control group) were those patients who were hospitalized in the ward that corresponded to the reason for their admission. Each patient of the exposed group was matched to a specific control subject. The principal objective was to prospectively measure differences in the length of hospital stays, the secondary objectives were to assess mortality, rate of re-admission at 28 days, and rate of transfer into intensive care. RESULTS: 238 were included in the NO group, 245 in the O group. More patients in the O group (86% vs 76%) were transferred into a ward with prescription completed. O patients remained in hospital for 8 days [4-15] vs 7 days [4-13] for NO patients (p = 0.04). 124 (52%) of the NO patients received heparin-based thromboembolic prevention during their stay in hospital vs 104 (42%) of the O patient group (p = 0.03). 66 (27%) O patients were re-admitted to hospital within 28 days vs 40 (17%) NO patients (p = 0.008). CONCLUSION: O patients had a worse prognosis than NO patients.
The frail elderly in Canada face a tough decision when they start to lose autonomy: whether to stay at home or move to another location. This study seeks to scale up and evaluate the implementation of shared decision-making (SDM) in interprofessional (IP) home care teams caring for elderly clients or their caregivers facing a decision about staying at home or moving elsewhere.
Older age and higher acuity are associated with prolonged hospital stays and hospital readmissions. Early discharge planning may reduce lengths of hospital stay and hospital readmissions; however, its effectiveness with acutely admitted older adults is unclear.
Most older adults wish to stay at home during their late life years, but physical disabilities and cognitive impairment may force them to face a housing decision. However, they lack relevant information to make informed value-based housing decisions. Consequently, we sought to identify the sets of factors influencing the housing decision-making of older adults.
To assess the association between different types of coercive measures (forced medication, seclusion, and restraint) used during involuntary psychiatric admission and two treatment outcomes: retrospective views of patients towards their admission and length of inpatient stay. A secondary analysis was conducted of data previously gathered by the EUNOMIA study (n = 2030 involuntarily detained inpatients across 10 European countries, of whom 770 were subject to one or more coercive measures). Associations between coercive measures and outcomes were tested through multivariable regression models adjusted for patients' socio-demographic and clinical characteristics. Use of forced medication was associated with patients being significantly less likely to justify their admission when interviewed after three months. All coercive measures were associated with patients staying longer in hospital. When the influence of other variables was considered in a multi-variate analysis, seclusion remained as a significant predictor of longer inpatient stay, adding about 25 days to the average admission. Of the three coercive measures, forced medication appears to be unique in its significant impact on patient disapproval of treatment. While all coercive measures are associated with patients staying longer in hospital, only use of seclusion is associated with longer inpatient stays independently of coerced patients' having higher symptom scores at the time of admission.
Prolonged emergency department (ED) stays make a disproportionate contribution to ED overcrowding, but the factors associated with longer stays have not been systematically reviewed.
Impact of a new model of intensive care medicine upon healthcare in a department of intensive care medicine
- Medicina intensiva / Sociedad Espanola de Medicina Intensiva y Unidades Coronarias
- Published about 6 years ago
OBJECTIVES: To evaluate a new organizational model in an intensive care unit, with the implementation of early warning systems and a support unit. DESIGN: A retrospective, comparative cohort study was carried out. SETTING: The study was carried out in the Department of Intensive Care Medicine (DICM) of a tertiary hospital (2009-2011), with the comparison of three time periods (P1, P2 and P3) that differed in terms of organization and logistics. PATIENTS: We analyzed all patients admitted to the ICU during the study period. Patients from maternal and infant intensive care were excluded. VARIABLES OF INTEREST: Percentage of patients with stays of under two days, with invasiveness used; readmission to the DICM, type of admission and percentage of stays of longer than one month; APACHE II score, mean stay in the ICU and shift distribution of the admissions. RESULTS: We analyzed a sample of 3209 patients (65% males), with a mean age of 58.23 (18.23) years, a mean APACHE II score of 16.67 (8.23), and presenting an occupancy rate of 7.3 (10.3) days in the analyzed period. The ratio APACHE II score/number of beds was 0.69 (0.34) in P1, compared to 0.68 (0.33) in P2 and 0.76 (0.37) in P3 (p<0.001). The intervention surveillance grade (grade 1) was 42% (39-46%) in P1, 40% (37-43%) in P2 and 31% (28-35%) in P3 (p<0.001). The average stay in the ICU ranged from 7.10 days (8.82) in P1to 6.60 days (9.49) in P2 and 8.42 days (12.73) in P3 (p<0.001). CONCLUSIONS: There has been an increase in the number of patients seen in our DICM, with a decrease in the patients admitted to the conventional ICU. Patients now admitted to the ICU are more seriously ill, require a greater level of intervention, and give rise to an increase in the mean duration of stay in the ICU.
- Gastrointestinal endoscopy clinics of North America
- Published 9 months ago
Open surgical intervention for treatment of simple pancreatic pseuodocyst (PP) has a high success rate and has been the historical gold standard. Open surgical intervention, however, confers significant morbidity and mortality, which has spurred the development of less invasive techniques. Laparoscopic approaches are feasible with the potential for lower complication rates and length of stay. The endoscopic approach has the appeal of potentially shorter hospitalization length of stays and does not require general anesthesia. Complicated PPs or those that arise in the setting of chronic pancreatitis warrant additional workup and special consideration.