Association of the Trauma of Hospitalization With 30-Day Readmission or Emergency Department Visit

Relationship between continuous EEG monitoring findings and prognostic factors in patients with status epilepticus

BACKGROUND AND PURPOSE

Little information is available regarding the use of continuous electroencephalography (cEEG) monitoring findings to predict the prognosis of patients with status epilepticus, which could aid in prognostication. This study investigated the relationship between cEEG monitoring findings and various prognostic indicators in patients with status epilepticus.

METHODS

We reviewed the clinical profiles and cEEG monitoring data of 28 patients with status epilepticus over a ten-year period. Patient demographics, etiology, EEG features, duration of hospital stay, number of antiseizure medications, and outcome measures were analyzed. Functional outcomes were assessed using the modified Rankin Scale (mRS), which evaluates the degree of daily living impairment and dependence on others resulting from neurological injury.

RESULTS

Patients exhibiting electrographic status epilepticus (ESE) demonstrated significantly longer duration of status epilepticus (77.75 ± 58.25 vs. 39.86 ± 29.81 h, p = 0.024) and total length of hospital stay (13.00 ± 6.14 vs. 8.14 ± 5.66 days, p = 0.038) when compared to those with ictal-interictal continuum (IIC). Individuals who displayed any increase in modified Rankin Scale (mRS) score between their premorbid state and discharge also had significantly longer duration of status epilepticus (74.09 ± 34.94 vs. 51.56 ± 54.25 h, p = 0.041) and total length of hospital stay (15.89 ± 6.05 vs. 8.05 ± 4.80 days, p = 0.004) when compared to those who showed no difference. The most prevalent etiology of status epilepticus in our study was chronic structural brain lesions.

CONCLUSIONS

This suggests that ESE may serve as a predictor of prolonged duration of status epilepticus and increased hospitalization among patients with status epilepticus.

Vulnerability to functional decline is associated with noncardiovascular cause of 90-day readmission in hospitalized patients with heart failure

BACKGROUND

Hospital readmission is common among patients with heart failure. Vulnerability to decline in physical function may increase the risk of noncardiovascular readmission for these patients, but the association between vulnerability and the cause of unplanned readmission is poorly understood, inhibiting the development of effective interventions.

OBJECTIVES

We examined the association of vulnerability with the cause of readmission (cardiovascular vs. noncardiovascular) among hospitalized patients with acute decompensated heart failure.

DESIGNS, SETTINGS, AND PARTICIPANTS

This prospective longitudinal study is part of the Vanderbilt Inpatient Cohort Study.

MAIN OUTCOME AND MEASURES

The primary outcome was the cause of unplanned readmission (cardiovascular vs. noncardiovascular). The primary independent variable was vulnerability, measured using the Vulnerable Elders Survey (VES-13).

RESULTS

Among 804 hospitalized patients with acute decompensated heart failure, 315 (39.2%) experienced an unplanned readmission within 90 days of discharge. In a multinomial logistic model with no readmission as the reference category, higher vulnerability was associated with readmission for noncardiovascular causes (relative risk ratio [RRR] = 1.36, 95% confidence interval [CI]: 1.06-1.75) in the first 90 days after discharge. The VES-13 score was not associated with readmission for cardiovascular causes (RRR = 0.94, 95% CI: 0.75-1.17).

CONCLUSIONS

Vulnerability to functional decline predicted noncardiovascular readmission risk among hospitalized patients with heart failure. The VES-13 is a brief, validated, and freely available tool that should be considered in planning care transitions. Additional work is needed to examine the efficacy of interventions to monitor and mitigate noncardiovascular concerns among vulnerable patients with heart failure being discharged from the hospital.

Comparison of Medical and Mental Health Sequelae Following Hospitalization for COVID-19, Influenza, and Sepsis

Importance

People who survive hospitalization for COVID-19 are at risk for developing new cardiovascular, neurological, mental health, and inflammatory autoimmune conditions. It is unclear how posthospitalization risks for COVID-19 compare with those for other serious infectious illnesses.

Objective

To compare risks of incident cardiovascular, neurological, and mental health conditions and rheumatoid arthritis in 1 year following COVID-19 hospitalization against 3 comparator groups: prepandemic hospitalization for influenza and hospitalization for sepsis before and during the COVID-19 pandemic.

Design, Setting, and Participants

This population-based cohort study included all adults hospitalized for COVID-19 between April 1, 2020, and October 31, 2021, historical comparator groups of people hospitalized for influenza or sepsis, and a contemporary comparator group of people hospitalized for sepsis in Ontario, Canada.

Exposure

Hospitalization for COVID-19, influenza, or sepsis.

Main Outcome and Measures

New occurrence of 13 prespecified conditions, including cardiovascular, neurological, and mental health conditions and rheumatoid arthritis, within 1 year of hospitalization.

Results

Of 379 366 included adults (median [IQR] age, 75 [63-85] years; 54% female), there were 26 499 people who survived hospitalization for COVID-19, 299 989 historical controls (17 516 for influenza and 282 473 for sepsis), and 52 878 contemporary controls hospitalized for sepsis. Hospitalization for COVID-19 was associated with an increased 1-year risk of venous thromboembolic disease compared with influenza (adjusted hazard ratio, 1.77; 95% CI, 1.36-2.31) but with no increased risks of developing selected ischemic and nonischemic cerebrovascular and cardiovascular disorders, neurological disorders, rheumatoid arthritis, or mental health conditions compared with influenza or sepsis cohorts.

Conclusions and Relevance

In this cohort study, apart from an elevated risk of venous thromboembolism within 1 year, the burden of postacute medical and mental health conditions among those who survived hospitalization for COVID-19 was comparable with other acute infectious illnesses. This suggests that many of the postacute consequences of COVID-19 may be related to the severity of infectious illness necessitating hospitalization rather than being direct consequences of infection with SARS-CoV-2.

Prospective single-center study of health-related quality of life after COVID-19 in ICU and non-ICU patients

Long-term sequelae in hospitalized Coronavirus Disease 2019 (COVID-19) patients may result in limited quality of life. The current study aimed to determine health-related quality of life (HRQoL) after COVID-19 hospitalization in non-intensive care unit (ICU) and ICU patients. This is a single-center study at the University Hospital of Wuerzburg, Germany. Patients eligible were hospitalized with COVID-19 between March 2020 and December 2020. Patients were interviewed 3 and 12 months after hospital discharge. Questionnaires included the European Quality of Life 5 Dimensions 5 Level (EQ-5D-5L), patient health questionnaire-9 (PHQ-9), the generalized anxiety disorder 7 scale (GAD-7), FACIT fatigue scale, perceived stress scale (PSS-10) and posttraumatic symptom scale 10 (PTSS-10). 85 patients were included in the study. The EQ5D-5L-Index significantly differed between non-ICU (0.78 ± 0.33 and 0.84 ± 0.23) and ICU (0.71 ± 0.27; 0.74 ± 0.2) patients after 3- and 12-months. Of non-ICU 87% and 80% of ICU survivors lived at home without support after 12 months. One-third of ICU and half of the non-ICU patients returned to work. A higher percentage of ICU patients was limited in their activities of daily living compared to non-ICU patients. Depression and fatigue were present in one fifth of the ICU patients. Stress levels remained high with only 24% of non-ICU and 3% of ICU patients (p = 0.0186) having low perceived stress. Posttraumatic symptoms were present in 5% of non-ICU and 10% of ICU patients. HRQoL is limited in COVID-19 ICU patients 3- and 12-months post COVID-19 hospitalization, with significantly less improvement at 12-months compared to non-ICU patients. Mental disorders were common highlighting the complexity of post-COVID-19 symptoms as well as the necessity to educate patients and primary care providers about monitoring mental well-being post COVID-19.

Elder veteran program: A description of a nurse practitioner-led inpatient geriatric consult model

ABSTRACT

This article describes the Elder Veteran Program (EVP), a nurse practitioner (NP)-led inpatient consult service at one Midwestern Veterans Administration (VA) hospital. The EVP was designed to address the needs of older hospitalized veterans and serves as a model that uses geriatric expert clinicians as mentors to grow geriatric expertise. Unique to EVP, nurses are coached to identify high-risk older veterans, initiate the consult process to drive geriatric medical and nursing review, and implement best geriatric nursing practice. As a result of EVP implementation, there was a 13-fold increase in the number of older hospitalized veterans receiving geriatric evaluation. The EVP highlights how NPs lead implementation of an evidence-based program that creates a path for engaging, educating, and growing geriatric nursing knowledge and skill while improving veteran access to geriatric sensitive care.

Multisite analysis of patient experience scores and risk of hospital admission: a retrospective cohort study

BACKGROUND

Routinely collected patient experience scores may inform risk of patient outcomes. The objective of the study was to evaluate the risk of hospital admission within 30-days following third-party receipt of the patient experience survey and guide interventions.

METHODS

In this retrospective cohort study, we analyzed Hospital Consumer Assessment of Healthcare Providers and Systems surveys, January 2016-July 2019, from an institution's 20 hospitals in four U.S. states. Surveys were routinely sent to patients using census sampling. We analyzed surveys received ≤60 days following discharge from patients living ≤60 miles of any of the institution's hospitals. The exposures were 19 survey items. The outcome was hospital admission within 30 days after third-party receipt of the survey. We evaluated the association of favorable (top-box) vs unfavorable (non-top-box) score for survey items with risk of 30-day hospital admission in models including patient and hospitalization characteristics and reported adjusted odds ratios (aOR [95% confidence interval]).

RESULTS

Among 40,162 respondents (mean age ± standard deviation: 68.1 ± 14.0 years), 49.8% were women and 4.3% had 30-day hospital admission. Patients with 30-day hospital admission, compared to those not admitted, were more likely to be discharged from a medical service line (62.9% vs 42.3%; P < 0.001) and have a higher Elixhauser index. Favorable vs unfavorable score for hospital rating was associated with lower odds of 30-day hospital admission in the overall cohort (0.88 [0.77-0.99]; P = 0.04), medical service line (0.81 [0.70-0.94]; P = 0.007), and upper tertile of Elixhauser index (0.79 [0.67-0.92]; P = 0.003). Favorable score for recommend hospital was associated with lower odds of 30-day hospital admission in the medical service line (0.83 [0.71-0.97]; P = 0.02) but for others (e.g. cleanliness of hospital environment) showed no association.

CONCLUSION

In routinely collected patient experience scores, favorable hospital rating was associated with lower odds of 30-day hospital admission and may inform risk stratification and interventions. Evidence-based survey items linked to patient outcomes may also inform future surveys.

Potentially avoidable admissions to general internal medicine at an academic teaching hospital: an observational study

BACKGROUND

Identifying potentially avoidable admissions to Canadian hospitals is an important health system goal. With general internal medicine (GIM) accounting for 40% of hospital admissions, we sought to develop a method to identify potentially avoidable admissions and characterize patient, provider and health system factors.

METHODS

We conducted an observational study of GIM admissions at our institution from August 2019 to February 2020. We defined potentially avoidable admissions as admissions that could be managed in an appropriate and safe manner in the emergency department or ambulatory setting and asked staff physicians to screen admissions daily and flag candidates as potentially avoidable admissions. For each candidate, we prepared a case review and debriefed with members of the admitting team. We then reviewed each candidate with our research team, assigned an avoidability score (1 [low] to 4 [high]) and identified contributing factors for those with scores of 3 or more.

RESULTS

We screened 601 total admissions and staff physicians flagged 117 (19.5%) of these as candidate potential avoidable admissions. Consensus review identified 67 candidates as potentially avoidable admissions (11.1%, 95% confidence interval 8.8%-13.9%); these patients were younger (mean age 65 yr v. 72 yr), had fewer comorbidities (Canadian Institute for Health Information Case Mix Group+ 0.42 v. 1.14), had lower resource-intensity weighting scores (0.72 v. 1.50) and shorter hospital lengths of stay (29 h v. 105 h) (p < 0.01). Common factors included diagnostic and therapeutic uncertainty, perceived need for short-term monitoring, government directive of a 4-hour limit for admission decision-making and subspecialist request to admit.

INTERPRETATION

Our prospective method of screening, flagging and case review showed that 1 in 9 GIM admissions were potentially avoidable. Other institutions could consider adapting this methodology to ascertain their rate of potentially avoidable admissions and to understand contributing factors to inform improvement endeavours.

In-hospital stress and patient outcomes: A systematic review and meta-analysis

BACKGROUND

Hospital inpatients are exposed to high levels of stress during hospitalisation that may increase susceptibility to major adverse health events post-hospitalisation (known as post-hospital syndrome). However, the existing evidence base has not been reviewed and the magnitude of this relationship remains unknown. Therefore, the aim of the current systematic review and meta-analysis was to: 1) synthesise existing evidence and to determine the strength of the relationship between in-hospital stress and patient outcomes, and 2) determine if this relationship differs between (i) in-hospital vs post-hospital outcomes, and (ii) subjective vs objective outcome measures.

METHODS

A systematic search of MEDLINE, EMBASE, PsychINFO, CINAHL, and Web of Science from inception to February 2023 was conducted. Included studies reported a measure of perceived and appraised stress while in hospital, and at least one patient outcome. A random-effects model was generated to pool correlations (Pearson's r), followed by sub-group and sensitivity analyses. The study protocol was preregistered on PROSPERO (CRD42021237017).

RESULTS

A total of 10 studies, comprising 16 effects and 1,832 patients, satisfied the eligibility criteria and were included. A small-to-medium association was found: as in-hospital stress increased, patient outcomes deteriorated (r = 0.19; 95% CI: 0.12-0.26; I2 = 63.6; p < 0.001). This association was significantly stronger for (i) in-hospital versus post-hospital outcomes, and (ii) subjective versus objective outcome measures. Sensitivity analyses indicated that our findings were robust.

CONCLUSIONS

Higher levels of psychological stress experienced by hospital inpatients are associated with poorer patient outcomes. However, more high-quality, larger scale studies are required to better understand the association between in-hospital stressors and adverse outcomes.

Sleep in hospitalized pediatric and adult patients – A systematic review and meta-analysis

Background

Sleep is essential for recovery from illness. As a result, researchers have shown a growing interest in the sleep of hospitalized patients. Although many studies have been conducted over the past years, an up to date systematic review of the results is missing.

Objective

The objective of this systematic review was to assess sleep quality and quantity of hospitalized patients and sleep disturbing factors.

Methods

A systematic literature search was conducted within four scientific databases. The search focused on synonyms of 'sleep’ and 'hospitalization’. Papers written in English or Dutch from inception to April 25th,2022 were included for hospitalized patients >1 year of age. Papers exclusively reporting about patients receiving palliative, obstetric or psychiatric care were excluded, as well as patients in rehabilitation and intensive care settings, and long-term hospitalized geriatric patients. This review was performed in accordance with the PRISMA guidelines.

Results

Out of 542 full text studies assessed for eligibility, 203 were included, describing sleep quality and/or quantity of 17,964 patients. The median sample size of the studies was 51 patients (IQR 67, range 6–1472). An exploratory meta-analysis of the Total Sleep Time showed an average of 7.2 h (95%-CI 4.3, 10.2) in hospitalized children, 5.7 h (95%-CI 4.8, 6.7) in adults and 5.8 h (95%-CI 5.3, 6.4) in older patients (>60y). In addition, a meta-analysis of the Wake After Sleep Onset (WASO) showed a combined high average of 1.8 h (95%-CI 0.7, 2.9). Overall sleep quality was poor, also due to nocturnal awakenings. The most frequently cited external factors for poor sleep were noise and number of patients in the room. Among the variety of internal/disease-related factors, pain and anxiety were most frequently mentioned to be associated with poor sleep.

Conclusion

Of all studies, 76% reported poor sleep quality and insufficient sleep duration in hospitalized patients. Children sleep on average 0.7–3.8 h less in the hospital than recommended. Hospitalized adults sleep 1.3–3.2 h less than recommended for healthy people. This underscores the need for interventions to improve sleep during hospitalization to support recovery.

•

An overview of the magnitude of sleep deprivation in hospitalized patients.

•

A meta-analysis of studies reporting on some of the main sleep outcomes.

•

An overview of internal and external factors affecting sleep in hospitalized patients.

•

Guidance for potential interventions to improve sleep during clinical admission.

•

Uncovers a knowledge gap regarding the sleep quality of hospitalized children and daytime sleep of hospitalized adults.

Participation in daily activities after acute illness hospitalization among high-functioning older adults: a qualitative study

AIMS AND OBJECTIVES

To describe high-functioning older adults' experiences of participation in daily activities and perceived barriers and facilitators to participation one- and 3-months post-acute hospitalization.

BACKGROUND

Older adults discharged after acute illness hospitalization are at risk for functional decline and adverse health outcomes. Yet, little is known about the subjective experience of resuming participation in meaningful activities beyond the immediate post-discharge period among high-functioning older adults, a mostly overlooked sub-sample.

DESIGN

Qualitative descriptive longitudinal study adhering to the COREQ guidelines.

METHODS

Forty two participants ages ≥65 years (mean age 75, SD ± 7.9) were recruited from internal medicine wards. Semi-structured interviews were conducted at participants' homes one-month post-discharge, followed by a telephone interview 3-months after. Data were analyzed using thematic analysis.

RESULTS

Participants perceived the hospitalization as a disruption of healthy and meaningful routines. This first key theme had unique expressions over time and included two sub-themes. At one month: (1) reduced life spaces and sedentary routines. At 3 months: (2) a matter of quality not quantity - giving up even one meaningful activity can make a difference. The second key theme was described as a combination of physical and psychological barriers to participation over time. These themes demonstrated the profound impact of the hospitalization on behavior (participation) and feelings (e.g., symptoms). The third key theme was described as a dyad of intrinsic and extrinsic facilitators to participation.

CONCLUSIONS

Acute illness hospitalization may lead to subtle decreases in participation in meaningful health-promoting activities, even among high-functioning older adults. These changes may impact overall well-being and possibly mark the beginning of functional decline.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the need for a more comprehensive assessment of participation, relevant for high-functioning older adults, to enable person-centered care. Intervention programs should address the modifiable barriers and facilitators identified in this study.

Psychosocial Profiles of Patients Admitted to Psychiatric Emergency Services: Results from the Signature Biobank Project

OBJECTIVES

Patients admitted to psychiatric emergency services (PES) are highly heterogenous. New tools based on a transdiagnosis approach could help attending psychiatrists in their evaluation process and treatment planning. The goals of this study were to: (1) identify profiles of symptoms based on self-reported, dimensional outcomes in psychiatric patients upon their admission to PES, (2) link these profiles to developmental variables, that is, history of childhood abuse (CA) and trajectories of externalizing behaviours (EB), and (3) test whether this link between developmental variables and profiles was moderated by sex.

METHODS

In total, 402 patients were randomly selected from the Signature Biobank, a database of measures collected from patients admitted to the emergency of a psychiatric hospital. A comparison group of 92 healthy participants was also recruited from the community. Symptoms of anxiety, depression, alcohol and drug abuse, impulsivity, and psychosis as well as CA and EB were assessed using self-reported questionnaires. Symptom profiles were identified using cluster analysis. Prediction of profile membership by sex, CA, and EB was tested using structural equation modelling.

RESULTS

Among patients, four profiles were identified: (1) low level of symptoms on all outcomes, (2) high psychotic symptoms, (3) high anxio-depressive symptoms, and (4) elevated substance abuse and high levels of symptoms on all scales. An indirect effect of CA was found through EB trajectories: patients who experienced the most severe form of CA were more likely to develop chronic EB from childhood to adulthood, which in turn predicted membership to the most severe psychopathology profile. This indirect effect was not moderated by sex.

CONCLUSION

Our results suggest that a transdiagnostic approach allows to highlight distinct clinical portraits of patients admitted to PES. Importantly, developmental factors were predictive of specific profiles. Such transdiagnostic approach is a first step towards precision medicine, which could lead to develop targeted interventions.

Exploring Wearables to Focus on the “Sweet Spot” of Physical Activity and Sleep After Hospitalization: Secondary Analysis

Background

Inadequate sleep and physical activity are common during and after hospitalization, but their impact on patient-reported functional outcomes after discharge is poorly understood. Wearable devices that measure sleep and activity can provide patient-generated data to explore ideal levels of sleep and activity to promote recovery after hospital discharge.

Objective

This study aimed to examine the relationship between daily sleep and physical activity with 6 patient-reported functional outcomes (symptom burden, sleep quality, physical health, life space mobility, activities of daily living, and instrumental activities of daily living) at 13 weeks after hospital discharge.

Methods

This secondary analysis sought to examine the relationship between daily sleep, physical activity, and patient-reported outcomes at 13 weeks after hospital discharge. We utilized wearable sleep and activity trackers (Withings Activité wristwatch) to collect data on sleep and activity. We performed descriptive analysis of device-recorded sleep (minutes/night) with patient-reported sleep and device-recorded activity (steps/day) for the entire sample with full data to explore trends. Based on these trends, we performed additional analyses for a subgroup of patients who slept 7-9 hours/night on average. Differences in patient-reported functional outcomes at 13 weeks following hospital discharge were examined using a multivariate linear regression model for this subgroup.

Results

For the full sample of 120 participants, we observed a “T-shaped” distribution between device-reported physical activity (steps/day) and sleep (patient-reported quality or device-recorded minutes/night) with lowest physical activity among those who slept <7 or >9 hours/night. We also performed a subgroup analysis (n=60) of participants that averaged the recommended 7-9 hours of sleep/night over the 13-week study period. Our key finding was that participants who had both adequate sleep (7-9 hours/night) and activity (>5000 steps/day) had better functional outcomes at 13 weeks after hospital discharge. Participants with adequate sleep but less activity (<5000 steps/day) had significantly worse symptom burden (z-score 0.93, 95% CI 0.3 to 1.5; P=.02), community mobility (z-score –0.77, 95% CI –1.3 to –0.15; P=.02), and perceived physical health (z-score –0.73, 95% CI –1.3 to –0.13; P=.003), compared with those who were more physically active (≥5000 steps/day).

Conclusions

Participants within the “sweet spot” that balances recommended sleep (7-9 hours/night) and physical activity (>5000 steps/day) reported better functional outcomes after 13 weeks compared with participants outside the “sweet spot.” Wearable sleep and activity trackers may provide opportunities to hone postdischarge monitoring and target a “sweet spot” of recommended levels for both sleep and activity needed for optimal recovery.

Trial Registration

ClinicalTrials.gov NCT03321279; https://clinicaltrials.gov/ct2/show/NCT03321279

Feasibility and Impact of Trauma-Informed Care Training in Internal Medicine Residency: A Pilot Study

Introduction: Mounting evidence indicates that early life trauma is highly prevalent and associated with adverse health outcomes later in life. However, primary care providers report lacking the training to effectively address trauma encountered in daily practice. There is a paucity of research describing the implementation and evaluation of trauma-informed care (TIC) curricula within Graduate Medical Education.

Methods: We piloted a three-hour TIC workshop facilitated by a community-based psychologist expert to assess the feasibility and impact of TIC training on Internal Medicine (IM) residents’ knowledge, attitudes and skills related to TIC. Participants were a subset of IM residents in a health-equity-focused curricular pathway in the University of Colorado IM Residency. Residents completed anonymous surveys one week before and after the workshop, and a final survey 10 weeks later. Residents who did not participate in the workshop completed a similar baseline survey (control group). Data were analyzed using matched pair T-tests.

Results: Fourteen of 20 residents (70%) who participated in the pilot workshop completed the initial survey. Of these, 10 (71%) completed the first post-workshop survey, and seven (50%) completed the final survey. We observed significant improvements in residents’ self-reported knowledge, attitudes and skills related to TIC. The majority of residents in the control group reported a desire for TIC training.

Conclusions: TIC is an important curricular gap in IM training. A single, brief TIC workshop was feasible and was associated with improved self-reported knowledge, attitudes and skills among IM residents.

Establishing an alternative accommodation for stable hospitalised antepartum patients: barriers and challenges

BACKGROUND

Patients in remote communities who risk premature delivery require transfer to a tertiary care centre for obstetric and neonatal care. Following stabilisation, many patients are candidates for outpatient management but cannot be discharged to their home communities due to lack of neonatal intensive care unit (ICU) support.

PROBLEM

Without outpatient accommodation proximal to neonatal ICU, these patients face prolonged hospitalisation-an expensive option with medical, social and psychological consequences. Therefore, we sought to establish an alternative accommodation for out-of-town stable antepartum patients.

METHODS

Quality Improvement approaches were used to identify process strengths and opportunities for improvement on the antepartum ward in a tertiary care centre. Physician and patient surveys informed outpatient accommodation programme development by a multidisciplinary team. The intervention was implemented using a plan-do-study-act cycle. Barriers to patient discharge and enrolment in the programme were analysed by completing thematic and strengths-weaknesses-opportunities-threats (SWOT) analysis.

RESULTS

Physicians broadly supported safe outpatient management, whereas patients were hesitant to leave the hospital even when physicians assured safety. Our alternative accommodation was pre-existing and cost-effective, however, we encountered significant barriers. The physical space limited family visits and social interaction, lacked desired amenities,and the programme proved inconvenient to patients. The thematic and SWOT analysis identified aspects of the intervention which can be optimised to develop future actionable strategies.

CONCLUSION

The utilisation of acute care beds is costly for the healthcare system and must be allocated judiciously. Patient needs, experience and health system barriers need to be considered when establishing alternative outpatient accommodations and strategies for stable antepartum patients.

Physician Experience Design (PXD): More Usable Machine Learning Prediction for Clinical Decision Making

Delirium is an acute neurocognitive disorder, which is difficult to identify and predict. Using GEMINI, Canada's largest hospital data and analytics study, we had a labeled sample of around 4,000 cases with approximately 25% of cases being labeled as having delirium. Based on this labeled data, we developed machine learning (ML) models and interacted with physicians to interpret the ML models and their predictions. We developed a preliminary Explainable Artificial Intelligence (XAI) framework for physician experience design (PXD) to improve the uptake of ML models by improving the transparency of model results, thereby increasing physician trust in models as well as the uptake of model results for clinical decision making. We developed our PXD approach first with Conceptual Investigation to collect and extract physicians' feedback on ML models and their evaluation requirements. We carried out a case study, working closely with the physicians in a participatory design process to develop a dashboard that presents ML delirium identification results interactively based on physician selections and inputs. In this approach a physician-preferred ML model for clinical decision making is selected through PXD evaluation.

The Prospective Association of Patient Hospitalization with Spouse Depressive Symptoms and Self-Reported Heath

After hospital discharge, patients experience a period of generalized risk for adverse mental and physical health outcomes (post-hospital syndrome [PHS]). Hospital stressors can explain these effects in patients (e.g., sleep disruption, deconditioning). Patients' partners also experience adverse outcomes following patient hospitalization, but mechanisms of these effects are unknown. The purpose of this study was to test whether greater times and nights of patient hospitalization (proxies for partner exposure to hospital stressors) are prospectively associated with greater increases in partner depression and in partner self-reported poor health. Participants were 7,490 married couples (11,208 individuals) enrolled in the Health and Retirement Study. Outcomes were prospective changes in depressive symptoms and self-reported poor health, and primary predictors were spouse hospitalization over the past two years (yes/no), spouse hospitalized ≥ two times (yes/no), and spouse spent ≥ eight nights in-hospital (yes/no). Covariates included age, gender, race, ethnicity, income, own hospitalization experiences during the past 12 months, and one's own and spouse comorbidities. Having a spouse who experienced two or more hospitalizations was associated with an increase in one's own depression over time, as was having a spouse who spent eight or more nights in-hospital. Spouse hospitalization was not associated with prospective changes in self-reported health. Results suggest that PHS mechanisms may account for adverse post-hospitalization outcomes in patients' partners.

Melatonin Administration Patterns for Pediatric Inpatients in a Tertiary Children's Hospital

OBJECTIVES

Melatonin has been trialed with reported increasing use for sleep dysregulation and prevention of ICU delirium in critically ill adults; however, reports of use in hospitalized pediatric patients are limited. We anecdotally observed an increase in prescribing of melatonin in our tertiary care children's hospital and therefore aimed to retrospectively characterize prescribing practices over time.

METHODS

Melatonin dispensing data over a 4-year time frame were extracted. Melatonin doses were categorized as being either ICU or non-ICU administered and dosed during daytime versus nighttime, respectively. Descriptive statistics were used to characterize patients who were administered melatonin, dosing information, and quantitative change in annual melatonin orders between areas. The comparison of daytime versus nighttime melatonin administrations and ratio of administrations between ICU and non-ICU areas for each study year were compared via χ² test.

RESULTS

Administration of melatonin increased 246.2% between years 1 and 3, with a shift from predominance in ICU to non-ICU areas over the study period (P < .0001). The average dosing varied by age, with the most frequent dose being 5 mg (28.3%), predominantly in patients ≥12 years of age. Ninety-eight percent (n = 9434) of doses were scheduled for nighttime administration, suggesting an indication of sleep regulation. There were significantly more daytime administrations of melatonin in non-ICU areas (P < .0001).

CONCLUSIONS

Prescribing of melatonin for pediatric inpatients has increased substantially over a 4-year period, despite limited research on dosing, in this single-center. Further research is needed to determine best practices for melatonin prescribing for hospitalized children.

Trauma of Hospitalization Is Common in Medical Inpatients But Is Not Associated with Post-Discharge Outcomes

BACKGROUND

Trauma of hospitalization is characterized by patient-reported disturbances in sleep, mobility, nutrition, and/or mood and one study suggested it was associated with more 30-day readmissions.

OBJECTIVE

To define the trauma of hospitalization in medical inpatients and determine whether higher rates of disturbance correlate with adverse post-discharge outcomes.

DESIGN

A prospective cohort study was conducted between June 2018 and August 2019 with patients reporting disturbances in sleep, mobility, nutrition, and/or mood. High trauma of hospitalization was defined as disturbance in 3 or 4 domains.

PARTICIPANTS

General medicine inpatients at an academic hospital in Edmonton, Canada.

MAIN MEASURES

7-day, 30-day, and 90-day rates of death, unplanned hospital readmission, or emergency department (ED) visit.

KEY RESULTS

Of 299 patients (mean age 65.9 years, 47.8% female, mean Charlson score 3.6, and mean length of stay 8.2 days), 260 (87.0%) reported disturbance in at least one domain (most commonly nutrition or mobility) during their hospitalization, 179 (59.9%) reported disturbances in multiple domains, and 87 (29.1%) met the criteria for high trauma of hospitalization. Patients who reported a high trauma of hospitalization did not differ from those reporting less hospitalization disturbances in terms of demographics, burden of comorbidities, or length of stay, but did report higher rates of pre-hospital disturbances in sleep (32.3% vs. 14.4%, p = 0.03), nutrition (77.4% vs. 54.4%, p = 0.02), and mood (41.9% vs. 13.3%, p = 0.0007). High trauma of hospitalization was not significantly associated with death, readmission, or ED visit at 7 days (12.6% vs. 11.3%, aOR 1.13 [95% CI 0.52-2.46]), 30 days (31.0% vs. 32.1%, aOR 1.03 [95% CI 0.59-1.79]), or 90 days (52.9% vs. 50.9%, aOR 1.16 [95% CI 0.69-1.94]) after discharge.

CONCLUSIONS

In-hospital disturbances in sleep, mobility, nutrition, and mood are common in medical inpatients but were not associated with post-discharge outcomes.

Reliability of Patient-Report, Physician-Report, and Medical Record Review to Identify Hospital-Acquired Complications: A Prospective Cohort Study

This prospective study of internal medicine inpatients treated at 2 hospitals in Toronto, Canada, between September 1, 2016, and September 1, 2017, compared patient-report, physician-report, and detailed medical record review to identify specific hospital-acquired complications. Six complications were assessed: delirium, catheter-associated urinary tract infection, acute kidney injury, deep vein thrombosis/pulmonary embolism, hospital-acquired pneumonia, or fall. The study included 207 patients and physician responses were obtained for 156 (75%). Complications were identified in 28 (14%) patients by medical record review, 30 (14%) patients by patient-report, and 11 (7%) patients by physician-report. Fifty-four (26%) patients experienced a complication as identified through at least one of the 3 methods. There was little agreement between the 3 methods (Fleiss' ĸ 0.15, P < 0.001). All 3 sources agreed on the occurrence of a specific complication in only 1 patient (1%). Multiple approaches likely are needed to adequately measure hospital-acquired complications.

Evaluation of an intervention targeted with predictive analytics to prevent readmissions in an integrated health system: observational study

OBJECTIVES

To determine the associations between a care coordination intervention (the Transitions Program) targeted to patients after hospital discharge and 30 day readmission and mortality in a large, integrated healthcare system.

DESIGN

Observational study.

SETTING

21 hospitals operated by Kaiser Permanente Northern California.

PARTICIPANTS

1 539 285 eligible index hospital admissions corresponding to 739 040 unique patients from June 2010 to December 2018. 411 507 patients were discharged post-implementation of the Transitions Program; 80 424 (19.5%) of these patients were at medium or high predicted risk and were assigned to receive the intervention after discharge.

INTERVENTION

Patients admitted to hospital were automatically assigned to be followed by the Transitions Program in the 30 days post-discharge if their predicted risk of 30 day readmission or mortality was greater than 25% on the basis of electronic health record data.

MAIN OUTCOME MEASURES

Non-elective hospital readmissions and all cause mortality in the 30 days after hospital discharge.

RESULTS

Difference-in-differences estimates indicated that the intervention was associated with significantly reduced odds of 30 day non-elective readmission (adjusted odds ratio 0.91, 95% confidence interval 0.89 to 0.93; absolute risk reduction 95% confidence interval -2.5%, -3.1% to -2.0%) but not with the odds of 30 day post-discharge mortality (1.00, 0.95 to 1.04). Based on the regression discontinuity estimate, the association with readmission was of similar magnitude (absolute risk reduction -2.7%, -3.2% to -2.2%) among patients at medium risk near the risk threshold used for enrollment. However, the regression discontinuity estimate of the association with post-discharge mortality (-0.7% -1.4% to -0.0%) was significant and suggested benefit in this subgroup of patients.

CONCLUSIONS

In an integrated health system, the implementation of a comprehensive readmissions prevention intervention was associated with a reduction in 30 day readmission rates. Moreover, there was no association with 30 day post-discharge mortality, except among medium risk patients, where some evidence for benefit was found. Altogether, the study provides evidence to suggest the effectiveness of readmission prevention interventions in community settings, but further research might be required to confirm the findings beyond this setting.

Short-term physical health effects of sleep disruptions attributed to the acute hospital environment: a systematic review

The sleep disruption experienced by patients admitted to hospital may have a negative effect on health but the nature and magnitude of the effect has not been conclusively outlined. The review was designed to examine the impact of sleep disruption associated with being a hospital inpatient, on short-term physical health outcomes in adult patients. Searches comprised journal databases, gray literature sources, and backward and forward citation searching. Two reviewers independently screened the records. Original studies of adult hospitalized patients' sleep were included if physical outcomes were also measured. Interventional studies were excluded. The methodological quality was assessed independently by 2 reviewers using CASP checklists. Sleep assessment measures and results, physical outcomes and contextual data were extracted. Results were synthesized according to frequently reported outcomes: delirium, pain intensity, physical strength, and respiratory function. A meta-analysis was not performed; studies were heterogeneous and reporting was limited. Of 9919 retrieved records, 26 published studies were included (published: 2001-2020). Risk of bias was moderately high. Confounding factors were poorly reported. Total sleep time was either normal or reduced. Sleep was disrupted: arousal indices were high (mean: 0 5-21/h); slow wave sleep proportions were limited. Subjective sleep quality was poor. The association between sleep reduction or disruption and short-term health outcomes was negative, mixed or equivocal and included increased delirium, higher pain intensity, poorer strength, and adverse respiratory function. The impact of sleep disruption on outcomes for hospitalized patients is not well defined.

Influences on emergency department attendance among frail older people with deteriorating health: a multicentre prospective cohort study

OBJECTIVES

To examine the patterns and influences on repeated emergency department attendance among frail older people with deteriorating health.

STUDY DESIGN

Multicentre prospective cohort study (International Access Rights and Empowerment II study) with convergent mixed methods design.

METHODS

Eligible patients were aged ≥65 years, with Clinical Frailty Score ≥5, and ≥1 hospital admission or ≥2 acute attendances in the previous 6 months. Questionnaires were administered to participants over 6 months and we extracted clinical data from the medical records. We conducted modified Poisson multivariable regression analysis to identify factors associated with repeated emergency department attendance (≥2 over 6 months) and thematic analysis of qualitative interviews.

RESULTS

A total of 90 participants were recruited. The mean age was 84 years, and 63% were women. Of 87 participants, 21 experienced repeated emergency department attendance. Severe and/or overwhelming pain (adjusted prevalence ratio 2.44, 95% confidence interval 1.17-5.11), greater number of comorbidities (1.32, 1.08-1.62), ≥10 community nursing contacts (2.93, 1.31-6.56), and a total of ≥2 weeks spent in hospital during the previous 6 months (2.91, 1.24-6.84) were associated with repeated attendance. From 45 interviews, we identified influences on emergency department attendance: 1. inaccessibility of community healthcare; 2. perceived barriers to community healthcare seeking; 3. perceived benefits of hospital admission; 4. barriers to recovery during previous hospital admission (unsuitable food, inactivity); and 5. poorly coordinated transitions between settings.

CONCLUSIONS

We identified missed opportunities to optimise older people's recovery during hospital admission, such as improved food and a timely and coordinated discharge, which may reduce reattendances. Proactive care in the community with systematic assessment of symptoms may be required, particularly for those with multimorbidity.

A qualitative study exploring the lived experiences of deconditioning in hospital in Ontario, Canada

Background

Older adults, especially those with physical and social complexities are at risk of hospital-associated deconditioning. Hospital-associated deconditioning is linked to increased length of stay in hospital, stress, and readmission rates. To date, there is a paucity of research on the experiences and implications of deconditioning in hospital from different perspectives. Therefore, the objectives of this exploratory, descriptive qualitative study were to explore hospital-associated deconditioning from the views of different stakeholders and to develop an understanding of deconditioning from physical, social, and cognitive perspectives.

Methods

Between August 2018 and July 2019, in-depth, semi-structured interviews were conducted with patients 50 years or older, who had a hip fracture or delay in discharge, as well as caregivers, providers, and decision-makers who provided support or impacted care processes for these patients. Participants were recruited from one urban and one rural health region located in Ontario, Canada. All interviews were audio-recorded, transcribed, and analyzed using a constant comparison approach.

Results

A total of 80 individuals participated in this study. Participants described insufficient activities in hospital leading to boredom and mental and physical deconditioning. Patients were frustrated with experiencing deconditioning and their decline in function seemed to impact their sense of self and identity. Deconditioning had substantive impacts on patients’ ability to leave hospital to their next point of care. Providers and decision-makers understood the potential for deconditioning but felt constrained by factors beyond their control. Factors that appeared to impact deconditioning included the hospital’s built environment and social capital resources (e.g., family, roommates, volunteers, staff).

Conclusions

Participants described a substantial lack of physical, cognitive, and social activities, which led to deconditioning. Recommendations to address deconditioning include: (1) measuring physical/psychological function and well-being throughout hospitalization; (2) redesigning hospital environments (e.g., create social spaces); and (3) increasing access to rehabilitation during acute hospital stays, while patients wait for the next point-of-care.

Development of claims-based measures of unplanned acute care with superior power for assessing the effectiveness of interventions following acute care

OBJECTIVE

To develop outcome measures that are more sensitive than current measures for evaluating primary or transitional care after hospitalizations, emergency department (ED) visits, or observation stays.

DATA SOURCES

Medicare claims data from January 1, 2015, to October 31, 2017, for 1 261 707 Medicare fee-for-service beneficiaries served by (a) primary care practices participating in Track 1 of the Comprehensive Primary Care Plus (CPC+) initiative, and (b) their matched comparison practices.

STUDY DESIGN

Given the poor statistical power in many studies to detect effects on readmissions, we developed two novel claims-based measures of unplanned acute care (UAC) following an index acute care event. The first measure assesses the proportion of hospitalizations followed by an unplanned readmission, ED visit, or observation stay within 30 days of discharge; the second assesses the proportion of ED visits and observation stays followed by a hospitalization, ED visit, or observation stay within 30 days. We calculate minimum detectable effects (MDEs) for both measures and for a conventional measure of 30-day unplanned readmissions, using CPC+ data.

PRINCIPAL FINDINGS

Repeat UAC events are common among Medicare beneficiaries served by the CPC+ practices. In 2017, 22% of discharges and 21% of ED visits and observation stays had a UAC event within 30 days. Readmissions were the most common UAC event following discharge, whereas ED visits were most common following index ED visits or observation stays. MDEs are 25%-40% lower for the new measures than for the standard 30-day readmissions measure, indicating better statistical power to detect impacts of primary or transitional care interventions.

CONCLUSIONS

This study introduces two new claims-based measures to assess quality of care during a patient's vulnerable period following acute care. The new measures complement existing measures, covering a broader range of UAC events than the standard 30-day readmissions measure, and yielding greater statistical power.

180-day readmission risk model for older adults with acute myocardial infarction: the SILVER-AMI study

OBJECTIVE

To develop a 180-day readmission risk model for older adults with acute myocardial infarction (AMI) that considered a broad range of clinical, demographic and age-related functional domains.

METHODS

We used data from ComprehenSIVe Evaluation of Risk in Older Adults with AMI (SILVER-AMI), a prospective cohort study that enrolled participants aged ≥75 years with AMI from 94 US hospitals. Participants underwent an in-hospital assessment of functional impairments, including cognition, vision, hearing and mobility. Clinical variables previously shown to be associated with readmission risk were also evaluated. The outcome was 180-day readmission. From an initial list of 72 variables, we used backward selection and Bayesian model averaging to derive a risk model (N=2004) that was subsequently internally validated (N=1002).

RESULTS

Of the 3006 SILVER-AMI participants discharged alive, mean age was 81.5 years, 44.4% were women and 10.5% were non-white. Within 180 days, 1222 participants (40.7%) were readmitted. The final risk model included 10 variables: history of chronic obstructive pulmonary disease, history of heart failure, initial heart rate, first diastolic blood pressure, ischaemic ECG changes, initial haemoglobin, ejection fraction, length of stay, self-reported health status and functional mobility. Model discrimination was moderate (0.68 derivation cohort, 0.65 validation cohort), with good calibration. The predicted readmission rate (derivation cohort) was 23.0% in the lowest quintile and 65.4% in the highest quintile.

CONCLUSIONS

Over 40% of participants in our sample experienced hospital readmission within 180 days of AMI. Our final readmission risk model included a broad range of characteristics, including functional mobility and self-reported health status, neither of which have been previously considered in 180-day risk models.

Provider-Documented Anxiety in the ICU: Prevalence, Risk Factors, and Associated Patient Outcomes

PURPOSE

To determine the prevalence of provider-documented anxiety in critically ill patients, associated risk factors, and related patient outcomes.

METHOD

Chart review of 100 randomly sampled, adult patients, with a length of stay ≥48 hours in a medical or trauma/surgical intensive care unit (ICU). Provider-documented anxiety was identified based on a comprehensive retrospective chart review of the ICU stay, searching for any acute episode of anxiety (e.g., documented words related to anxiety, panic, and/or distress).

RESULTS

Of 100 patients, 45% (95% confidence interval: 35%-55%) had documented anxiety, with similar prevalence in medical vs. trauma/surgical ICU. Patients with documented anxiety more frequently had history of anxiety (22% vs. 4%, p = .004) and substance abuse (40% vs. 22%, p = .048). In the ICU, they had greater severity of illness (median (IQR) Acute Physiology Score 16(13,21) vs. 13(8,19), p = .018), screened positive for delirium at least once during ICU stay, (62% vs. 31%, p = .002), benzodiazepines and antipsychotics use (87% vs. 58%, p = .002; 33% vs. 13%, p = .013, respectively), and mental health consultation (31% vs. 18%, p = .132). These patients also had longer ICU and hospital lengths of stay (6(4,11) vs. 4(3,6), p<.001 and 18(10,30) vs. 10(6,16) days, p<.001, respectively) and less frequent discharge back to home (27% vs. 44%, p = .079).

CONCLUSIONS

Documented anxiety, occurring in almost half of ICU patients with length of stay ≥48 hours, was associated with a history of anxiety and/or substance abuse, and greater ICU severity of illness, delirium, psychiatric medications, and length of stay. Increased awareness along with more standardized protocols for assessment of anxiety in the ICU, as well as greater evaluation of non-pharmacological treatments for anxiety symptoms in the ICU are warranted.

Older adults experiences with ambulation during a hospital stay: A qualitative study

Older adults often lose their ability to independently ambulate during a hospital stay. Few studies have investigated older adults' experiences with ambulation during hospitalization. The purpose of this study was to understand older adults' perceptions of and experiences with ambulation during a hospital admission. A qualitative study using Inductive Content Analysis was conducted. Community-dwelling older adults (N = 11) were recruited to participant in five focus group meetings each lasting 90 min. All individuals participated in each focus group. Participants described high complexity in deciding whether or not they could ambulate. Six categories were identified: Uncertainty, Restriction Messaging, Non-Welcoming Space, Caring for Nurse and Self, Feeling Isolated, and Presenting Self. This study provides a detailed understanding of older adults' experiences and perceptions of a hospital stay. Findings from this study can serve as a foundation for future interventions to improve older adult patient ambulation during hospitalization.

Electronic Communication Patterns Could Reflect Preoperative Anxiety and Serve as an Early Complication Warning in Elective Spine Surgery Patients with Affective Disorders: A Retrospective Analysis of a Cohort of 1199 Elective Spine Patients

OBJECTIVE

The analysis of perioperative electronic patient portal (EPP) communication may provide risk stratification and insight for complication prevention in patients with affective disorders (ADs). We aimed to understand how patterns of EPP communication in patients with AD relate to preoperative narcotic use, surgical outcomes, and readmission rates.

METHODS

The records of adult patients who underwent elective spinal surgery between January 2010 and August 2017 at a single institution were retrospectively reviewed for analysis. Primary outcomes included preoperative narcotic use, the number of perioperative EPP messages sent, rates of perioperative complications, hospital length of stay, emergency department (ED) visits within 6 weeks, and readmissions within 30 days after surgery.

RESULTS

A total of 1199 patients were included in the analysis. Patients with an AD were more likely to take narcotics before surgery (51.69% vs. 41%, P < 0.001) and to have active EPP accounts (75.36% vs. 69.75%, P = 0.014) compared with controls. They were also more likely to send postoperative messages (38.89% vs. 32.75%, P = 0.030) and tended to send more messages (0.67 vs. 0.48, P = 0.034). The AD group had higher rates of postoperative complications (8.21% vs. 3.98%, P = 0.001), ED visits (4.99% vs. 2.43%, P = 0.009), and readmissions postoperatively (2.49% vs. 1.38%, P = 0.049).

CONCLUSIONS

AD patients have specific patterns of perioperative EPP communication. They are at a higher risk of postoperative complications. Addressing these concerns early may prevent more serious morbidity and avoid unnecessary ED visits and readmissions, thus reducing costs and improving patient care.

Melatonin Increasingly Used in Hospitalized Patients

The frequency of melatonin use for insomnia in hospitalized patients is unknown. This study assessed temporal trends of melatonin use in the hospital and compared them with those of use of zopiclone and lorazepam. We performed a retrospective observational study over 6 years from January 2013 to December 2018 at two academic urban hospitals in Toronto, Canada. We abstracted pharmacy dispensing data and standardized rates of medication use by inpatient days. Melatonin use increased from almost none to more than 70 doses per 1,000 inpatient days during 2013-2018, while zopiclone use decreased by 20 doses per 1,000 inpatient days. Melatonin use was twice as high at one hospital and was higher on internal medicine and critical care. Overall use of the three medications increased by 25.7%, which mainly reflects a marked increase in melatonin use. Melatonin is likely being used in a proportion of patients who would not otherwise have received a sleep medication.

Risk factors, costs and complications of delayed hospital discharge from internal medicine wards at a Canadian academic medical centre: retrospective cohort study

Background

Hospitalized patients are designated alternate level of care (ALC) when they no longer require hospitalization but discharge is delayed while they await alternate disposition or living arrangements. We assessed hospital costs and complications for general internal medicine (GIM) inpatients who had delayed discharge. In addition, we developed a clinical prediction rule to identify patients at risk for delayed discharge.

Methods

We conducted a retrospective cohort study of consecutive GIM patients admitted between 1 January 2015 and 1 January 2016 at a large tertiary care hospital in Canada. We compared hospital costs and complications between ALC and non-ALC patients. We derived a clinical prediction rule for ALC designation using a logistic regression model and validated its diagnostic properties.

Results

Of 4311 GIM admissions, 255 (6%) patients were designated ALC. Compared to non-ALC patients, ALC patients had longer median length of stay (30.85 vs. 3.95 days p < 0.0001), higher median hospital costs ($22,459 vs. $5003 p < 0.0001) and more complications in hospital (25.5% vs. 5.3% p < 0.0001) especially nosocomial infections (14.1% vs. 1.9% p < 0.0001). Sensitivity analyses using propensity score and pair matching yielded similar results. In a derivation cohort, seven significant risk factors for ALC were identified including age > =80 years, female sex, dementia, diabetes with complications as well as referrals to physiotherapy, occupational therapy and speech language pathology. A clinical prediction rule that assigned each of these predictors 1 point had likelihood ratios for ALC designation of 0.07, 0.25, 0.66, 1.48, 6.07, 17.13 and 21.85 for patients with 0, 1, 2, 3, 4, 5, and 6 points respectively in the validation cohort.

Conclusions

Delayed discharge is associated with higher hospital costs and complication rates especially nosocomial infections. A clinical prediction rule can identify patients at risk for delayed discharge.

Strategies older adults use in their work to get back to normal following hospitalization

Loss of function is a significant concern among hospitalized older adults, and prior research suggests they engage in dedicated work to regain "normal" function following hospitalization. This paper aims to describe the strategies older adults use to return to normal function and the conditions that influence their ability to do so. Recently discharged adults aged 65 and older (N = 14) completed in-depth one-on-one interviews. Data were analyzed using open, axial, and selective coding. Participants described strategies they used to regain their normal function following hospitalization: doing exercises, expanding physical space, resuming activities and daily cares, and tracking improvement with benchmarks. Several conditions, such as presence of informal and formal support, perceived threats, and poor physical or physiologic function, acted as barriers and facilitators to participants' ability to work back to normal function. Findings increase our understanding of patients' work to regain normal function and have important implications for practice.

America's Health Care System is Broken: What Went Wrong and How We Can Fix It. Part 3: Hospitals and Doctors

Thirty-two percent of US health care spending goes to hospital care, and 20% goes to physicians' charges. The cost of hospital care in the United States is 2-3 times greater than in most similar countries. A large part of the high cost is due to a very large administrative overhead. Both higher quality and lower cost would be achieved if complex procedures were done in fewer centers. Hospitals with a geographic or prestige monopoly receive higher payments than warranted. As physicians are increasingly employed by hospitals rather than independent, costs go up with no added benefit to patients. The United States has too many specialists and too few primary care physicians. Practice guidelines are slanted to favor expensive treatments, often with little solid evidence behind the recommendations.