Hospitalisation in short-stay units for adults with internal medicine diseases and conditions

Emergency department direct discharge compared to short-stay unit admission for selected patients with acute heart failure: analysis of short-term outcomes

Short stay unit (SSU) is an alternative to conventional hospitalization in patients with acute heart failure (AHF), but the prognosis is not known compared to direct discharge from the emergency department (ED). To determine whether direct discharge from the ED of patients diagnosed with AHF is associated with early adverse outcomes versus hospitalization in SSU. Endpoints, defined as 30-day all-cause mortality or post-discharge adverse events, were evaluated in patients diagnosed with AHF in 17 Spanish EDs with an SSU, and compared by ED discharge vs. SSU hospitalization. Endpoint risk was adjusted for baseline and AHF episode characteristics and in patients matched by propensity score (PS) for SSU hospitalization. Overall, 2358 patients were discharged home and 2003 were hospitalized in SSUs. Discharged patients were younger, more frequently men, with fewer comorbidities, had better baseline status, less infection, rapid atrial fibrillation and hypertensive emergency as the AHF trigger, and had a lower severity of AHF episode. While their 30-day mortality rate was lower than in patients hospitalized in SSU (4.4% vs. 8.1%, p < 0.001), 30-day post-discharge adverse events were similar (27.2% vs. 28.4%, p = 0.599). After adjustment, there were no differences in the 30-day risk of mortality of discharged patients (adjusted HR 0.846, 95% CI 0.637-1.107) or adverse events (1.035, 0.914-1.173). In 337 pairs of PS-matched patients, there were no differences in mortality or risk of adverse event between patients directly discharged or admitted to an SSU (0.753, 0.409-1.397; and 0.858, 0.645-1.142; respectively). Direct ED discharge of patients diagnosed with AHF provides similar outcomes compared to patients with similar characteristics and hospitalized in a SSU.

Structure and processes of emergency observation units with a geriatric focus: a scoping review

BACKGROUND

Combining observation principles and geriatric care concepts is considered a promising strategy for risk-stratification of older patients with emergency care needs. We aimed to map the structure and processes of emergency observation units (EOUs) with a geriatric focus and explore to what extent the comprehensive geriatric assessment (CGA) approach was implemented in EOUs.

METHODS

The revised scoping methodology framework of Arksey and O'Malley was applied. Manuscripts reporting on dedicated areas within hospitals for observation of older patients with emergency care needs were eligible for inclusion. Electronic database searches were performed in MEDLINE, EMBASE and CINAHL in combination with backward snowballing. Two researchers conducted data charting independently. Data-charting forms were developed and iteratively refined. Data inconsistencies were judged by a third researcher or discussed in the research team. Quality assessment was conducted with the Methodological Index for Non-Randomized Studies.

RESULTS

Sixteen quantitative studies were included reporting on fifteen EOUs in seven countries across three continents. These units were located in the ED, immediately next to the ED or remote from the ED (i.e. hospital-based). All studies reported that staffing consisted of at least three healthcare professions. Observation duration varied between 4 and 72 h. Most studies focused on medical and functional assessment. Four studies reported to assess a patients' medical, functional, cognitive and social capabilities. If deemed necessary, post-discharge follow-up (e.g. community/primary care services and/or outpatient clinics) was provided in eleven studies.

CONCLUSION

This scoping review documented that the structure and processes of EOUs with a geriatric focus are very heterogeneous and rarely cover all elements of CGA. Further research is necessary to determine how complex care principles of 'observation medicine' and 'CGA' can ideally be merged and successfully implemented in clinical care.

Morbidity diagnosed in an internal medicine department of a secondary care center (Msaken, Sousse, Tunisia)

INTRODUCTION

Internal Medicine is an essential component of the clinical platform of regional hospitals (relay between district hospitals and reference university hospitals).

OBJECTIVE

To describe the morbidity diagnosed at Medicine department of the regional hospital of Msaken (Sousse, Tunisia), taken as a tracer of intermediate hospitals.

METHODS

This descriptive study covered all of the patients hospitalized, during the year 2015, in the Internal Medicine department of the Msaken regional hospital. The data were disseminated through a "Minimum Clinical Summary". Morbidity was classified according to ICD-10. Hospital readmission was tested with reference to <28 days.

RESULTS

A total of 594 patients were hospitalized in Internal Medicine, with a sex ratio of 0.95 and a median age of 67 years [54-78]. "Diseases of the respiratory system" were the first category of diagnosed morbidity (58%), dominated by acute bronchitis, followed by "endocrine, nutritional and metabolic diseases" in women (including insulin-dependent diabetes) and category of infectious diseases in men (including erysipelas). The former patients of the service (49%) were twice as numerous among people ≥60 years old (57% vs 30% in those under 60 years). The readmission rate was 19% (29% for men versus 8% for women). The mean length of stay was 7 ± 5.7 days. The transfer rates and hospital mortality were 11.3% and 1.2%, respectively.

CONCLUSION

The morbidity diagnosed at the Internal Medicine department of the Msaken regional hospital was dominated by the triad: acute bronchitis, diabetes mellitus and erysipelas, particularly in the elderly. Hence the need to strengthen the training of future family doctors in pulmonology, diabetology and infectious diseases.

[Abdominal Wall Surgery After SARS-CoV-2: Time to Reestablish Postponed Non-essential Procedures?]

La pandemia por el COVID-19 nos ha encontrado desprotegidos ante la dificultad para dar una respuesta sanitaria adecuada y rápida. La red de hospitales del sistema sanitario público ha dispuesto la mayoría de los recursos para el tratamiento de los pacientes afectos por la infección. Las cirugías no esenciales (no prioritarias) han sido aplazadas. El reinicio óptimo y proporcionado de estas cirugías no prioritarias puede representar un problema. En el presente artículo se ofrece una perspectiva técnica y no técnica del reinicio de las cirugías no prioritarias desde la óptica de la cirugía de la pared abdominal.

Hospitalisation in short-stay units for adults with internal medicine diseases and conditions

BACKGROUND

Short-stay units are hospital units that provide short-term care for selected patients. Studies have indicated that short-stay units might reduce admission rates, time of hospital stays, hospital readmissions and expenditure without compromising the quality of care. Short-stay units are often defined by a target patient category, a target function, and a target time frame. Hypothetically, short-stay units could be established as part of any department, but this review focuses on short-stay units that provide care for participants with internal medicine diseases and conditions.

OBJECTIVES

To assess beneficial and harmful effects of short-stay unit hospitalisation compared with usual care in people with internal medicine diseases and conditions.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers up to 13 December 2017 together with reference checking, citation searching and contact with study authors to identify additional studies. We also searched several grey literature sources and performed a forward citation search for included studies.

SELECTION CRITERIA

We included randomised trials and cluster-randomised trials, comparing hospitalisation in a short-stay unit with usual care (hospitalisation in a traditional hospital ward or other services). We defined a short-stay unit to be a hospital ward where the targeted length of stay in hospital for patients was five days or less. We included both multipurpose and specialised short-stay units. Participants were adults admitted to hospital with an internal medicine disease or condition. We excluded surgical, obstetric, psychiatric, gynaecological, and ambulatory participants. Trials were included irrespective of publication status, date, and language.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently extracted data and assessed the risk of bias of each included trial. We measured intervention effect sizes by meta-analyses for two primary outcomes, mortality and serious adverse events, and one secondary outcome, hospital readmission. We narratively reported the following important outcomes: quality of life, activities of daily living, non-serious adverse events, and costs. We used risk ratio differences of 15% for mortality and of 20% for serious adverse events for minimal relevant clinical consideration. We rated the certainty of the evidence and the strength of recommendations of the outcomes using the GRADE approach.

MAIN RESULTS

We included 19 records reporting on 14 randomised trials with a total of 2872 participants. One trial was ongoing. Thirteen trials evaluated short-stay unit hospitalisation for six specific conditions (acute decompensated heart failure (one trial), asthma (one trial), atrial fibrillation (one trial), chest pain (seven trials), syncope (two trials), and transient ischaemic attack (one trial)) and one trial investigated participants presenting with miscellaneous internal medicine disease and conditions. The components of the intervention differed among the trials as dictated by the trial participants' condition. All included trials were at high risk of bias.The certainty of the evidence for all outcomes was very low. Consequently, it is uncertain whether hospitalisation in short-stay units compared with usual care reduces mortality (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.47 to 1.15) 5 trials (seven additional trials reporting on 1299 participants reported no deaths in either group)); serious adverse events (RR 0.95, 95% CI 0.59 to 1.54; 7 trials (one additional trial with 108 participants reported no serious adverse events in either group)), and hospital readmission (RR 0.80, 95% CI 0.54 to 1.19, 8 trials (one additional trial with 424 participants did not report results for participants)). There was not enough information to confirm or refute that short-stay unit hospitalisation had relevant effects on quality of life, activities of daily living, non-serious adverse events, and costs.

AUTHORS' CONCLUSIONS

Overall, the quantity and the certainty of the evidence was very low. Consequently, it is uncertain whether there are any beneficial or harmful effects of short-stay unit hospitalisation for adults with internal medicine diseases and conditions - more trials comparing the effects of short-stay units with usual care are needed. Such trials ought to be conducted with low risk of bias and low risks of random errors to improve the overall confidence in the evidence.