Using machine learning models to predict falls in hospitalised adults

BACKGROUND

Identifying patients at high risk of falling is crucial in implementing effective fall prevention programs. While the integration of information systems is becoming more widespread in the healthcare industry, it poses a significant challenge in analysing vast amounts of data to identify factors that could enhance patient safety.

OBJECTIVE

To determine fall-associated factors and develop high-performance prediction tools for at-risk patients in acute and sub-acute care services in Australia.

METHODS

A retrospective study of 672,400 patients admitted to acute and sub-acute care services within a large metropolitan tertiary health service in Victoria, Australia, between January 1, 2019, and December 31, 2021. Data were obtained from four sources: the Department of Health Victorian Admitted Episodes Dataset, RiskManTM, electronic health records, and the health workforce dataset. Machine learning techniques, including Random Forest and Deep Neural Network models, were used to analyse the data, predict patient falls, and identify the most important risk factors for falls in this population. Model performance was evaluated using accuracy, F1-score, precision, recall, specificity, Matthew's correlation coefficient, and the area under the receiver operating characteristic curve (AUC).

RESULTS

The deep neural network and random forest models were highly accurate in predicting hospital patient falls. The deep neural network model achieved an accuracy of 0.988 and a specificity of 0.999, while the RF achieved an accuracy of 0.989 and a specificity of 1.000. The top 20 variables impacting falls were compared across both models, and 12 common factors were identified. These factors can be broadly classified into three categories: patient-related factors, staffing-related factors, and admission-related factors. Although not all factors are modifiable, they must be considered when planning fall prevention interventions.

CONCLUSION

The study demonstrated machine learning's potential to predict falls and identify key risk factors. Further validation across diverse populations and settings is essential for broader applicability.

Cancer Decedents' Hospital End-of-Life Care Documentation: A Retrospective Review of Patient Records

Objective: International standards of end-of-life care (EOLC) intend to guide the delivery of safe and high-quality EOLC. Adequately documented care is conducive to higher quality of care, but the extent to which EOLC standards are documented in hospital medical records is unknown. Assessing which EOLC standards are documented in patients' medical records can help identify areas that are performed well and areas where improvements are needed. This study assessed cancer decedents' EOLC documentation in hospital settings. Methods: Medical records of 240 cancer decedents were retrospectively evaluated. Data were collected across six Australian hospitals between 1/01/2019 and 31/12/2019. EOLC documentation related to Advance Care Planning (ACP), resuscitation planning, care of the dying person, and grief and bereavement care was reviewed. Chi-square tests assessed associations between EOLC documentation and patient characteristics, and hospital settings (specialist palliative care unit, sub-acute/rehabilitation care settings, acute care wards, and intensive care units). Results: Decedents' mean age was 75.3 years (SD 11.8), 52.0% (n = 125) were female, and 73.7% lived with other adults or carers. All patients (n = 240; 100%) had documentation for resuscitation planning, 97.6% (n = 235) for Care for the Dying Person, 40.0% for grief and bereavement care (n = 96), and 30.4% (n = 73) for ACP. Patients living with other adults or carers were less likely to have a documented ACP than those living alone or with dependents (OR 0.48; 95% CI 0.26-0.89). EOLC documentation was significantly greater in specialist palliative care settings than that in other hospital settings (P < .001). Conclusion: The process of dying is well documented among inpatients diagnosed with cancer. ACP and grief and bereavement support are not documented enough. Organizational endorsement of a clear practice framework and increased training could improve documentation of these aspects of EOLC.

Recognising and Responding to Clinical Deterioration in Adult Patients in Isolation Precautions for Infection Control: A Retrospective Cohort Study

BACKGROUND

Patient isolation is widely used as a strategy for prevention and control of infection but may have unintended consequences for patients. Early recognition and response to acute deterioration is an essential component of safe, quality patient care and has not been explored for patients in isolation. Primary aims of this study were to: i) describe the timing, frequency, and nature of clinical deterioration during hospital admission for patients with isolation precautions for infection control and ii) compare the characteristics of patients who did and did not deteriorate during their initial period of isolation precautions for infection control.

METHODS

This retrospective cohort study was conducted across three sites of a large Australian health service. The study sample were adult patients (≥18 years) admitted into isolation precautions within 24-hours of admission from 1 July to 31 December 2019.

RESULTS

There were 634 patients who fulfilled the study inclusion criteria. One in eight patients experienced at least one episode of clinical deterioration during their time in isolation with most episodes of deterioration occurring within the first two days of admission. Timely Medical Emergency Team calls occurred in almost half the episodes of deterioration; however, the same proportion (47.2%) of deterioration episodes resulted in no Medical Emergency Team activation (afferent limb failure). In the 24-hours preceding each episode of clinical deterioration (n=180), 81.6% (n=147) of episodes were preceded by vital signs fulfilling pre-Medical Emergency Team criteria.Patients who deteriorated during isolation for infection control were older (median age 74.0 vs 71.0 years, P=0.042); more likely to live in a residential care facility (21.0% vs 7.2%, P=0.006); had a longer initial period of isolation (4.0 vs 2.9 days, P=<000.1) and hospital length of stay (median 4.9 vs 3.2 days, P=<0.001) and were more likely to die in hospital (12.3% vs 4.3%, P<0.001).

CONCLUSION

Patients in isolation precautions experienced high Medical Emergency Team afferent limb failure and most fulfilled pre-Medical Emergency Team criteria in the 24-hours preceding episodes of deterioration. Timely recognition and response to clinical deterioration continue to be essential in providing safe, quality patient care regardless of the hospital-care environment.

Service use by older very frequent emergency department users: A retrospective cohort study

BACKGROUND

Frequent Emergency Department (ED) attendance is a common occurrence, across all patient age groups. Older frequent users of ED are an at-risk group who often have complex, chronic health needs with many requiring out-of-hospital services to support their care. The aim of this study is to identify the characteristics, outcomes and health service use of older, very frequent emergency department (ED) users.

METHODS

A retrospective cohort study, at three Australian EDs, comparing first and last ED attendances, by older people (≥65 years) with frequent ED use (≥8 attendances/year).

RESULTS

There were 1387 ED attendances in 12 months by 115 patients (median=11). The median age-adjusted Charlson comorbidity score increased between attendances (5 vs 6, p<0.001). From first to last visit, hospital stays exceeding 7 days increased (12% vs 20%, p=0.013), while both ED re-attendances within 28 days (58% vs 20%, p≤0.001) and hospital readmissions within 30 days (39% vs 23%, p=0.016) decreased. In-patient mortality was 11% (n=10/88). There was no change in out-of-hospital services in place at both ED attendances (55% vs 61%, p=0.185).

CONCLUSIONS

Out-of-hospital service use did not change despite frequent ED attendance. Older very frequent ED users had increasing co-morbidities over time and often required hospital admission.

Emergency department management of exacerbation of chronic obstructive pulmonary disease: audit of compliance with evidence-based guidelines

BACKGROUND

Emergency departments (ED) play a key role in management of exacerbation of chronic obstructive airways disease (COPD). Current guidelines for management of exacerbation of COPD showed highest levels of evidence (Level A and B) were related to use of medications and non-invasive positive pressure ventilation (NIPPV).

AIMS

The aim of this study was to examine compliance with high level evidence for management of exacerbation of COPD during the first 4 h of ED care.

METHODS

A retrospective medical record audit was conducted at four public and one private ED in Melbourne, Australia. Participants were adult patients with COPD presenting to the ED with a primary complaint of shortness of breath from July 2006 to July 2007. Outcome measures were compliance with evidence-based recommendations regarding use of bronchodilators, methylxanthines, steroids and NIPPV.

RESULTS

Of 273 patients in this study, 72.4% received short-acting beta-agonist bronchodilators, 37.8% received an inhaled short-acting anticholinergic medication and 56.6% received systemic steroid therapy. NIPPV was used in 21 patients, 15 of whom had documentation of acidosis and/or hypercapnia).

CONCLUSIONS

There was variation in the use of high level evidence for the ED management of exacerbation of COPD. The highest rate of compliance was non-use of methylxanthines and the greatest deficit was poor compliance with evidence related to NIPPV. There was also scope for improvement in the use of bronchodilators and systemic steroids.

The influence of economic incentives on treatment patterns in a third-party funded dental service

OBJECTIVE

To investigate the response of dental practitioners to administration and remuneration adjustments to the Dental Treatment Services Scheme (DTSS) in the Republic of Ireland.

DESIGN

Following the introduction of a series of administration and fee adjustments by a third party payments system in December 1999 the pattern of extractions and restorations are examined to determine whether the adjustments had influenced provider behaviour, in particular whether a substitution effect from extractions to restorations would result from a relative fee increase of 62% for amalgam fillings.

DATA AND METHODS

Data on patient and provider characteristics from June 1996 to April 2005, collected by the Health Service Executive (HSE) National Shared Services Primary Care Reimbursement Service to facilitate remuneration to dentists providing services in the DTSS, was used in this analysis. A graphical analysis of the data revealed a structural break in the time-series and an apparent substitution to amalgam fillings following the introduction of the fee increases. To test the statistical significance of this break, the ratio of amalgams to restorations was regressed on the trend, growth and level dummy variables, using Ordinary Least Squares (OLS) regression. The diagnostics of the model were assessed using the Jarque-Bera normality test and the LM to test for serial correlation.

RESULTS

The initial results showed no evidence of a structural break. However on further investigation, when a pulse dummy was included to account for the immediate impact of the fee adjustment the results suggest a unit root process with a structural break in December 1999. This implies that the amalgam fee increase of December 1999 influenced the behaviour patterns of providers.

CONCLUSIONS

System changes can be used to change the emphasis from a scheme that was principally exodontia/emergency based to a scheme that is more conservative and based on restoration/prevention.

Evaluation of Nasopharyngeal Oxygen, Nasal Prongs and Facemask Oxygen Therapy Devices in Adult Patients: A Randomised Crossover Trial

Nasopharyngeal oxygen (NPO) therapy may overcome some of the difficulties associated with nasal prongs and facemask oxygen delivery devices. In response to a lack of published studies of NPO therapy in adults, we conducted a prospective randomised crossover trial to compare the effectiveness of NPO, nasal prongs (NP) and facemasks (FM) when used in an adult population (n=37) from the intensive care unit and general hospital wards. We measured oxygen saturation (SpO 2 using pulse oximetry, oxygen flow (litres per minute), respiration rate (per minute) and comfort using a horizontal visual analogue scale. All three devices were effective in maintaining a Sp0 2 of ≥95% (NP 97.0±1.9, NPO 97.7±1.7, FM 98.8±1.3%). NPO therapy consumed less oxygen than NP and FM therapy (NP 2.6±1.0, NPO 2.2±0.9, FM 6.1 ±0.4 l/min, P <0.001). There was no significant difference in patients’ respiratory rates (NP 19.9±3.2, NPO 19.9±3.0, FM 19.8±3.1 per minute, P=0.491). In terms of comfort, patients rated NP higher than NPO and FM using a horizontal visual analogue scale (100 mm=most comfortable) (NP 65.5±14.3, NPO 62.8±19.4, FM 49.4 ± 21.4 mm, P <0.001). We conclude that for adult patients, nasal prongs and nasopharyngeal oxygen therapy consume less oxygen and provide greater comfort than facemasks while still maintaining Sp0 2 ≥95%.

An assessment of the cost effectiveness of a postal toothpaste programme to prevent caries among five-year-old children in the North West of England

OBJECTIVE

To assess the cost effectiveness of a postal toothpaste programme to prevent caries in 5-year-old children in the north west of England.

PARTICIPANTS

Birth cohorts of children aged 12 months were recruited from high caries risk populations in nine health districts.

DESIGN

The results of a randomised controlled trial to measure the effects of a postal toothpaste programme are used and related to the costs of running a similar programme. Children in the trial received free toothpaste on four occasions a year and a toothbrush once a year for four years from age 12 months to 5 years. When aged 5-6 years children were examined by trained, calibrated examiners using BASCD standards. Those who received toothpaste containing 1450 ppm F were found to have a significantly lower mean dmft than those who had not. The costs that would be incurred by a public dental service running such a postal toothpaste programme are identified, measured and related to the likely health improvement that could be achieved.

MAIN OUTCOME MEASURES

The cost per tooth saved and the cost per child saved from caries experience and extraction experience.

RESULTS

The estimated cost per tooth saved from carious attack was pounds sterling 80.83 and the cost per child of preventing caries experience was pounds sterling 424.38 and avoiding any extractions was pounds sterling 679.01. Analysis resulted in an overestimation of costs and underestimation of benefits.

CONCLUSION

The programme achieved a significant caries reduction in children who received the 1450 ppm F toothpaste and the costs are now available to those considering provision of treatment services in areas where children are at high caries risk.

Clinical decisions using the National Triage Scale: how important is postgraduate education?

Triage is the formal nursing assessment of all patients who present to an Emergency Department (ED). The National Triage Scale (NTS) is used in most Australian EDs. Triage decision making involves the allocation of every patients presenting to an ED to one of the five NTS categories. The NTS directly relates a triage category to illness or injury severity and need for emergency care. Triage nurses' decisions not only have the potential to impact on the health outcomes of ED patients, they are also used, in part, to evaluate ED performance and allocate components of ED funding. This study was a correlational study that used survey methods. Triage decisions were classified as 'expected triage', 'overtriage' or 'undertriage' decisions. Participant's qualifications were allocated to five categories: 'nil'; 'emergency nursing'; 'critical care nursing'; 'midwifery'; and 'tertiary' qualifications. There was no correlation between triage decisions and length of experience in emergency nursing or triage. 'Expected triage' decisions were more common when the predicted triage category was Category 3 (P < 0.001) and 'overtriage' decisions were less common when the predicted triage category was Category 2 (P < 0.0010). The frequency of 'undertriage' decisions decreased significantly when the predicted triage category was Category 3 (P < 0.001) or Category 4 (P < 0.001). There was no correlation between triage decisions and qualifications in the 'nil', 'emergency nursing' or 'critical care nursing' categories. A midwifery qualification demonstrated a positive correlation with 'expected triage' decisions (P = 0.048) and a negative correlation with 'undertriage' decisions (P = 0.012). There was also a positive correlation between a tertiary qualification and 'expected triage' decisions (P = 0.012).

Triage nurses' decisions using the National Triage Scale for Australian emergency departments

The initiation of emergency care primarily depends on the decisions made by the triage nurse. Triage decisions can therefore have a profound effect on the health outcomes of patients who present for emergency care. If the National Triage Scale (NTS) was effective in providing a standardized approach to triage, a patient with a specific problem should be allocated to the same triage category, irrespective of the institution to which they present or the personnel performing the role of triage. This study examines triage nurses' level of agreement in their allocation of triage categories to patients with specific presenting problems using the NTS. Relationships between demographic characteristics of participants and triage decisions are examined and implications of any variation for triage practice and patient outcomes are explored.

A study of the effects of the appointment of a clinical nurse educator in one Victorian emergency department

The Clinical Nurse Educator (CNE) project saw the appointment and evaluation of a CNE position in the Emergency Department at Dandenong Hospital, Australia. The study aimed to identify the educational needs of nursing staff, the self reported levels of knowledge of nursing staff, the perceptions of nursing staff surrounding education and clinical support and to compare responses over the 6 month period to identify any statistically significant changes. Data was collected at three intervals during the study period and the responses compared using the Kruskal-Wallis test(H). Since the appointment of the CNEs, the reported levels of knowledge increased for all areas of emergency nursing included in the study. Tutorials, in-service education sessions, direct clinical support and self-directed learning packages were reported to be useful educational methods. There were increases in the reported adequacy of in-service education (P = 0.0000), level of clinical support and satisfaction with current level of knowledge in emergency nursing. Nursing staff found the process of basic and advanced life support assessment less intimidating (P = 0.0031), more important and less affected by workload constraints of the ED (P = 0.0002). The reported thoroughness of orientation of new employees (P = 0.0005) and levels of clinical support and education when orientated to the triage role (P = 0.0225) also increased.

The treatment of superficial bladder tumours under local anaesthetic using suction diathermy electrodes

Daycase cystoscopy under local anaesthetic is commonly used in screening patients with superficial transitional cell carcinoma of the bladder. Treatment of any lesions found, however, often requires a further cystoscopy under general or regional anaesthesia. Recent reports suggest that small lesions can be diathermied without anaesthesia with only mild patient discomfort. Suction diathermy electrodes, introduced for the treatment of small superficial bladder tumours, have significant advantages over conventional methods. Firstly, most of the superficial tumour fronds can be removed painlessly by suction alone. Diathermy, the uncomfortable component of treatment, is sparingly used to treat the tumour base. Larger tumours can therefore be treated by suction diathermy, with less patient discomfort, than by standard cystodiathermy methods. Secondly, by eliminating tumour debris within the bladder during treatment and reducing tissue damage due to diathermy, suction diathermy minimizes the risk of tumour recurrence due to implantation. In this preliminary report the ease and efficacy of using suction diathermy electrodes under local anaesthesia is assessed.

Cystoscopic suction diathermy for the treatment of superficial bladder tumours

The treatment of superficial bladder tumours (Ta, T1) is a time-consuming exercise for urological surgeons and patients. A method of treating the tumours, whether primary or recurrent, by endoscopic suction diathermy has been developed. The technique significantly reduces the amount of tumour debris within the bladder during treatment as well as the amount of diathermy employed. By removing the free tumour cells in the irrigation fluid the risk of tumour cell implantation may be kept to a minimum.

Xanthogranulomatous pyelonephritis. A reappraisal and immunohistochemical study

The clinicopathologic features of 17 patients with xanthogranulomatous pyelonephritis are described, together with results on a number of histochemical and immunohistochemical techniques that were used to demonstrate the variety of cells involved. Based on our clinicopathologic data and review of the literature, we believe that xanthogranulomatous pyelonephritis should be regarded as a destructive, and, at times, tumefactive inflammatory process that may complicate chronic pyelonephritis. The initiation of this process remains an enigma. However, there appears to be three main features that are associated with xanthogranulomatous pyelonephritis: pelvicalyceal obstruction, ulceration of the pelvicalyceal urothelium, and bacterial infection.

Ectopic beta-human chorionic gonadotropin production by bladder urothelial neoplasia

Endocrine manifestations are rarely observed in bladder urothelial neoplasia. To our knowledge, only 11 cases of choriocarcinoma have been reported in this site, and recently the production of beta-human chorionic gonadotropin has been demonstrated in these tumors by applying the immunoperoxidase technique. Of 104 transitional cell neoplasms of the bladder, we demonstrated by the indirect immunoperoxidase technique beta-human chorionic gonadotropin production in 12 neoplasms, 11 of which were grade 3 and 4 transitional cell carcinomas.

Idiopathic hydronephrosis. Light microscopic features and pathogenesis

A histological study of surgical specimens of idiopathic hydronephrosis demonstrated an abnormal muscle arrangement at the ureteropelvic junction in 18 of 26 cases. We believe this abnormality to be the cause in these cases. At this junction, the muscle bundles, instead of displaying the normal interwoven (braided) pattern, are arranged into an outer circular and an inner longitudinal layer. This abnormal muscle arrangement can be attributed to local failure of the physiological uncoiling during growth and development.

Transitional cell carcinoma of the upper renal tract in rubber workers

We report two patients where transitional cell carcinoma of the upper urinary tract developed after occupational exposure to known carcinogens, in the rubber industry. Although carcinoma of the bladder is well recognized in this context, to our knowledge, this association has not been reported previously.

Physical Aspects of Fruit Growth: STRESS DISTRIBUTION AROUND LENTICELS

The skin around a lenticel on a soft fruit has been modelled as a thin elastic plate with a rigid circular inclusion and applied tensile loads at the edges. A solution for the stress distribution in the skin has then been found using the linear theory of elasticity. From that solution the severity of the stress concentration and the location and form of initial cuticular failure have been deduced, the latter two being in broad agreement with observed crack initiation in the cuticle of grapes.

Physical Aspects of Fruit Growth : THEORETICAL ANALYSIS OF DISTRIBUTION OF SURFACE GROWTH FORCES IN FRUIT IN RELATION TO CRACKING AND SPLITTING

The theory of shells has been applied to some aspects of the physics of fruit growth. Four form and structural attributes are identified which may intensify mechanical stress in the skin of a growing fruit and alter the distribution of that stress. One is a radius-related factor introduced by deviation of shape from that of a sphere and the other three are related to attachment of a fruit to a plant and to provision of a vascular system: core diameter, core tensile strength, and structure of the core/skin interface. The last factor also applies in principle to a hole which may be introduced for example at the style canal. These factors either alone or in combination can cause stresses far in excess of those predicted for a spherical shell of similar volume and wall thickness. They are considered in relation to their effect on fruit morphogenesis and the occurrence of disorders such as rainfall-induced splitting and cracking.