The effects of hospitalization on multiple units

Patients are often cared for on multiple units during the course of a hospitalization. This study used general linear modeling and logistic regression analyses to demonstrate the effect of hospitalization on multiple units upon selected nursing treatments, resource use, and clinical outcomes. Primary medical diagnosis, comorbid medical conditions, and severity of illness were controlled for in the analyses. A significant association was found between hospitalizations on multiple units and selected nursing treatments, resource use, and all clinical outcomes except for mortality. Nurses play a central role in coordinating the care that patients receive across inpatient units and are positioned to develop and implement strategies to mediate the negative impacts associated with patients moving across multiple units.

Modified critical care and treatment space considerations for mass casualty critical illness and injury

Mass critical care events are increasingly likely, yet the resource challenges to augment everyday, unrestricted critical care for a surge of disaster victims are insurmountable for nearly all communities. In light of these limitations, an expert panel defined a circumscribed set of key critical care interventions that they believed could be offered to many additional people and yet would also continue to offer substantial life-sustaining benefits for nonmoribund critically ill and injured people. They proposed Emergency Mass Critical Care, which is based on the set of key interventions and includes recommendations for necessary surge medical equipment, treatment space characteristics, and staffing competencies for mass critical care response. To date, Emergency Mass Critical Care is untested, and the real benefits of implementation remain uncertain. Nonetheless, Emergency Mass Critical Care currently remains the only comprehensive construct for mass critical care preparedness and response. This paper reviews current concepts to provide life-sustaining care for hundreds or thousands of people outside of traditional critical care sites.

Nursing home residents in emergency departments: a Foucauldian analysis

AIM

This paper is a critical review of current knowledge about use of emergency departments by nursing home residents.

BACKGROUND

A great deal of literature focuses on the challenges presented by older adults in acute care environments. Nursing home residents who transfer to emergency departments have been identified as being particularly problematic because they use considerable resources and their needs are not always amenable to acute interventions.

METHOD

A literature search was conducted in May 2006 using the CINAHL, Medline and Cochrane databases and Google Scholar with the keywords 'nursing home resident', 'long-term care resident', 'hospital transfer', and 'acute illness and emergency room'. No date restrictions were imposed. Foucault's concept of subjectivity was used to demonstrate how power derived from medical knowledge is used by emergency department personnel to construct nursing home residents as problematic.

FINDINGS

Knowledge about the use of emergency departments by nursing home residents has been derived mainly from retrospective record reviews, while the events in nursing homes that lead to transfers have been virtually ignored. Moreover, the primary focus of these investigations has been the effect of residents on emergency departments, rather than how residents themselves were affected.

CONCLUSION

Current understanding of the care of nursing home residents in emergency departments is embedded in a complex web of social, historical and political factors. Research is needed that considers multiple perspectives, including those of both emergency department and nursing home staff, residents and ambulance personnel who act as mediators between the two settings.

Helicopter Emergency Ambulance Service (HEAS) transfer: an analysis of trauma patient case-mix, injury severity and outcome

INTRODUCTION

A retrospective review of all patients transferred by helicopter ambulance to the Great Western Hospital over a 20-month period between January 2003 and September 2004 was undertaken to establish the case-mix of patients (trauma and non-trauma) transferred and the outcome.

PATIENTS AND METHODS

Details of all Helicopter Emergency Ambulance Service (HEAS) transfers to this unit in the study time period were obtained from the three HEAS providers in the area and case notes were reviewed.

RESULTS

There were 156 trauma patients transferred (total 193) in the study period with 111 cases identified for analysis with a mean age of 33 years (range, 1-92 years). Average Injury Severity Score on admission was 12 (range, 1-36). Forty-five patients were discharged home from the emergency department, 24 cases had operation, 10 patients required ICU care and 2 were pronounced dead in the emergency department. Average hospital stay following HEAS transfer was 2.97 days (range, 0-18 days).

DISCUSSION

Helicopter ambulance transfer in the acute setting is of debated value. Triage criteria are at fault if as many as 41% of patients transferred are being discharged home from casualty having incurred the financial cost of helicopter transfer. We suggest that the triage criteria for helicopter emergency transfer should be reviewed.

Transferring patients with a urinary catheter

Transferring patients with indwelling urinary catheters from secondary to primary care can be problematic and the process requires careful planning. Both the patient and the healthcare professional taking over the plan of care need details on the reason for catheterisation and plans for ongoing care. Failure to plan transfers, including the provision of appropriate equipment for use at home, can lead to inappropriate care and, on occasion, results in referral back to hospital. Coral Seymour outlines new guidelines to assist nurses in making a discharge plan for these patients.

Graphical representation of the comprehensive patient flow through the hospital

Representing the patient flow through the hospital is quite a difficult task, considering the amount of data to be taken into account. In this article, some usual visual representations are first shown, then new charts are proposed. Several real examples are given. Those charts have been implemented in a web-based query interface, using PHP5 and generating SVG outputs on the fly, without any a priori knowledge. These charts allow for representing a large amount of data on the same graph: the occupancy of each medical department, their linking and transfers, allowing to display the whole care sequence. SVG, an XML-based free vector graphics format, allows rich end-user interaction. Practical applications: length of stay reducing, cost reducing, cost breakdown, further statistical study, administrative authorizations.

Predicting ambulance diversion in an adult Emergency Department using a Gaussian process

When the Emergency Department (ED) reaches a critical level of overcrowding, it diverts ambulances to other hospitals. We evaluated the accuracy of a Gaussian process for prediction of ambulance diversion using March 1, 2005 November 30, 2005 data. The area under the receiver operating curve (AUC) for 120 minutes in advance was 0.93 (SE: 0.19). The instrument demonstrated a high AUC and may be used to alert ED managers earlier of a diversion episode.

Leaving critical care: facilitating a smooth transition

Patient transfers from one area to another occur frequently within the inpatient healthcare environment. During transfers, nurses pass on information about patients to one another in a variety of ways. This article discusses the types of patient transfers, the problems that can occur throughout the transfer process, and strategies to decrease the identified problems. The perspectives of both the nursing staff and patients/families illustrate concerns related to patient transfers. The most important aspect of the patient transfer is systematically communicating necessary information to the receiving nurse in such a way that patient safety is not compromised and continuity of care is enhanced.

The Effect of Referral and Transfer Patients on Hospital Funding in a Capitated Health Care Delivery System

OBJECTIVES

(1) To investigate whether inpatients referred or transferred between facilities result in increased financial loss compared with those admitted directly, in a health care delivery system funded by capitation methods. (2) To determine whether the higher cost of those patients transferred or referred is fairly compensated by a diagnosis-based risk adjustment system, and whether tertiary care facilities bear an unfair financial burden for such patients in a capitated financing environment.

METHODS

The study cohort included all Veterans Affairs (VA) beneficiaries who received inpatient care during fiscal year (FY) 2004. Referral was defined as an outpatient visit to 1 facility followed by an admission to another facility. Transfers were consecutive inpatient stays at different hospitals. We defined loss as cost minus the share of budget determined by a Diagnostic Cost Group-based allocation. Both t tests and linear regression were used to compare the effect on cost and loss for patients transferred or not and referred or not.

RESULTS

Mean loss to a facility for patients transferred in was 1231 dollars more than for those not transferred. Mean loss for referred patients was 3341 dollars more than for those not referred, controlling for disease burden. For tertiary hospitals, the difference in losses for transfer patients was less than for other hospitals but greater for referral patients.

CONCLUSIONS

Patients referred or transferred from other facilities are more costly than those who are not. The difference may not be compensated by a diagnosis-based allocation system. A capitated health care system may consider additional funding to cover the cost of such patients.

Innovative Approach to the Aims for Improvement

Los Angeles County is in crisis with its emergency ambulatory care. Many barriers exist at the hospital level that affect patient throughput. A case study is presented for St. Francis Medical Center, a 384-bed hospital in southeast Los Angeles. Its governing board has put out a call to have its emergency department oversee intraprocess and interprocess improvements to enhance patient movement through the system. These innovative front- and back-end initiatives are examined using the Institute of Medicine's Six Aims for Improvement. Details on each of the initiatives are provided along with how the leadership monitors the progress.

Patient navigators show the way to faster flow

Nurses or physician assistants designated as patient navigators can ease the burden on the rest of the staff, improve relations with outside physicians, and improve patient flow in your ED. Provide them with separate phone numbers that primary care physicians can call to check on the condition of referred patients. Make them an integral part of your bed flow team, and have them serve as liaisons to admitting. Navigators also can be used to check with radiology when test results appear to be delayed.