Hospital practice (1995)最新文献

Objectives: Delirium may be associated with neuroinflammation and reduced blood-brain barrier (BBB) stability. ACE Inhibitors (ACEIs) and Angiotensin Receptor Blockers (ARBs) reduce neuroinflammation and stabilize the BBB, thus slowing the progression of memory loss in patients with dementia. This study evaluated the effect of these medications on delirium prevalence.

Methods: This was a retrospective study of data from all patients admitted to a Cardiac ICU between 1 January 2020-31 December 2020. The presence of delirium was determined based on the International Classification of Diseases (ICD) 10 codes and nurse delirium screening.

Results: Of the 1684 unique patients, almost half developed delirium. Delirious patients who did not receive either ACEI or ARB had higher odds (odds ratio [OR] 5.88, 95% CI 3.7-9.09, P < .001) of in-hospital death and experienced significantly shorter ICU lengths of stay (LOS) (P = .01). There was no significant effect of medication exposure on the time to delirium onset.

Conclusions: While ACEIs and ARBs have been shown to slow the progression of memory loss for patients with Alzheimer's disease, we did not observe a difference in time to delirium onset.

Introduction: Evidence suggests inappropriate oxygenation may be harmful to patients. To improve oxygen use in our hospital, we initiated a quality improvement project with a goal to reduce the percentage of inappropriate utilization of oxygen by 50% within a year.

Methods: Nasal cannula (NC) oxygen use data for medicine inpatients was abstracted weekly for chart review. A multidisciplinary team developed a guideline for use. Initiation of NC O2 with a baseline SPO2 > 92% was deemed inappropriate and 3+ consecutive SPO2 > 96% was defined as over-supplementation. Formal interventions included an oxygen use guideline, updated EMR order, unit-specific feedback, and magnetic placards. Progress was tracked by control charts.

Results: Baseline data revealed 40% of patients were inappropriately placed on oxygen and 55% of patients had one instance of excessive supplementation. Only half of all improper uses of oxygen had charted medical reasoning, and 30% had a corresponding order. Instances of proper oxygen use had orders 48% of the time. Run charts revealed inappropriate initiation was significantly reduced to 27.1% (p < 0.0001) and excessive oxygenation decreased significantly to 34.4% (p < 0.0001) following interventions with no effect on other variables.

Conclusions: Our interventions significantly decreased improper oxygen initiation and excessive supplementation.

Background: There is little evidence to guide the perioperative management of patients on a direct oral anticoagulant (DOAC) in the absence of a last known dose. Quantitative serum titers may be ordered, but there is little evidence supporting this.

Aims: This multi-center retrospective cohort study of consecutive surgical in-patients with a DOAC assay, performed over a five-year period, aimed to characterize preoperative DOAC assay orders and their impact on perioperative outcomes.

Materials and methods: Patients prescribed regular DOAC (both prophylactic and therapeutic dosing) with a preoperative DOAC assay were included. The DOAC assay titer was evaluated against endpoints. Further, patients with an assay were compared against anticoagulated patients who did not receive a preoperative DOAC assay. The primary endpoint was major bleeding. Secondary endpoints included perioperative hemoglobin change, blood transfusions, idarucizumab or prothrombin complex concentrate administration, postoperative thrombosis, in-hospital mortality and reoperation. Adjusted and unadjusted linear regression models were used for continuous data. Binary logistic models were performed for dichotomous outcomes.

Results: 1065 patients were included, 232 had preoperative assays. Assays were ordered most commonly by Spinal (11.9%), Orthopedics (15.4%), and Neurosurgery (19.4%). For every 10 ng/ml increase in titer, the hemoglobin decreases by 0.5066 g/L and the odds of a preoperative reversal increases by 13%. Compared to those without an assay, patients with preoperative DOAC assays had odds 1.44× higher for major bleeding, 2.98× higher for in-hospital mortality and 16.3× higher for receiving anticoagulant reversal.

Conclusion: A preoperative DOAC assay order was associated with worse outcomes despite increased reversal administration. However, the DOAC assay titer can reflect the patient's likelihood of bleeding.

Objectives: This systematic review was conducted to investigate the characteristics and effects of clinical decision support systems (CDSSs) on clinical and process-of-care outcomes of patients with kidney disease.

Methods: A comprehensive systematic search was conducted in electronic databases to identify relevant studies published until November 2020. Randomized clinical trials evaluating the effects of using electronic CDSS on at least one clinical or process-of-care outcome in patients with kidney disease were included in this study. The characteristics of the included studies, features of CDSSs, and effects of the interventions on the outcomes were extracted. Studies were appraised for quality using the Cochrane risk-of-bias assessment tool.

Results: Out of 8722 retrieved records, 11 eligible studies measured 32 outcomes, including 10 clinical outcomes and 22 process-of-care outcomes. The effects of CDSSs on 45.5% of the process-of-care outcomes were statistically significant, and all the clinical outcomes were not statistically significant. Medication-related process-of-care outcomes were the most frequently measured (54.5%), and CDSSs had the most effective and positive effect on medication appropriateness (18.2%). The characteristics of CDSSs investigated in the included studies comprised automatic data entry, real-time feedback, providing recommendations, and CDSS integration with the Computerized Provider Order Entry system.

Conclusion: Although CDSS may potentially be able to improve processes of care for patients with kidney disease, particularly with regard to medication appropriateness, no evidence was found that CDSS affects clinical outcomes in these patients. Further research is thus required to determine the effects of CDSSs on clinical outcomes in patients with kidney diseases.

Objectives: Vietnam is one of the countries in highly endemic areas of hepatitis B virus (HBV) infection in the world. Our study aims to determine the prevalence of HBV infection among different age groups of workers who had been included for annual general health checkups.

Methods: This cross-sectional study was conducted at the Health Screening Department, University Medical Center at Ho Chi Minh City, Vietnam, using anonymous data from employees who had health checkups from June 2017 to June 2018.

Results: A total of 5727 subjects were included, with an overall HBV prevalence of 9.0%. The prevalence of HBV infection was significantly higher in men and lowest in the age groups of 18-30. In multivariable analysis, the variables that were independently associated with HBV infection were male gender (Odd ratio (OR), 2.03; 95% confidence interval (CI), 1.58-2.60; p < 0.001), older than 30 years old (age group of 31-40: OR 1.7; 95% CI, 1.33-2.18; p < 0.001; of 41-50, OR 1.82; 95% CI, 1.37-2.43; p < 0.001); high total cholesterol (OR, 0.77; 95% CI, 0.64-0.94; p = 0.011), high triglyceride (OR, 0.53; 95% CI, 0.42-0.65; p < 0.001), and having significant fibrosis (OR, 2.7; 95% CI 1.85-3,95; p < 0.001).

Conclusions: The prevalence of HBV infection among employees on health assessments is still high (9%), even in the age group under 30 (7%). Male, age group older than 30, and significant liver fibrosis were the factors related to HBV infection. High cholesterol and level triglyceride were protective factors against HBV infection.

Diabetes prevalence increases with increasing age due to increased life expectancy. In older people with diabetes, frailty is an emerging diabetes-related complication. Although the literature is focused on the physical decline as the main manifestation of frailty, other domains such as cognitive and emotional dysfunction are commonly associated with physical frailty constituting a triad of impairment (TOI). The TOI is a better predictor of adverse outcomes than physical frailty alone. Previous diabetes studies focused on cardiovascular events as the main outcome with little data exploring the effect of glycemic control on frailty as a multidimensional perspective. Current evidence suggests that poor glycemic control may be associated with an increased risk of the three components of the TOI, however, the association of tighter glycemic control and the risk of TOI is inconsistent. In general HbA1c range of 6.5-7.9% appears to be less associated with TOI, while HbA1c > 8.0% is associated with a higher risk although most of the studies have limitations such as retrospective or cross-sectional design. So far, there is very little evidence from clinical trials to suggest that tight glycemic control would prevent or delay the development of frailty as a wide spectrum of physical, cognitive or emotional dysfunction. Therefore, future clinical trials are required to explore the effect of tight glycemic control on the multidimensional aspect of frailty as the main outcome. However, tight glycemic control in older people is associated with increased risk of hypoglycemia, which increases the risk of frailty. Therefore, novel hypoglycemic agents with intrinsic properties to reduce the risk of frailty, independent of glycemic control, are also required.

Objectives: The primary objective was to determine the financial resources allocated to docusate at a representative U.S. tertiary care center. Secondary objectives included comparing docusate utilization between two tertiary care centers, and exploring alternative uses for the funds spent on docusate.

Methods: The study population included all patients 18 years and older admitted to University Hospital in Newark, New Jersey. Every scheduled docusate prescription for the study population between January 1^st, 2015 and December 31^st, 2019 was collected. The annual total cost associated with docusate use per year was calculated. The 2015 data from this study and a 2015 McGill University Health Centre study were compared. Also, alternative uses for the money utilized on docusate were assessed.

Results: Over the study period, 37,034 docusate prescriptions and 265,123 docusate doses were recorded. The average cost of prescribing docusate was $25,624.14 per year and $49.37 per hospital bed per year. A comparison between the 2015 data of University Hospital and McGill showed that McGill prescribed 107 doses and spent $10.09 more per hospital bed than University Hospital. Finally, alternative uses for the average yearly spending on docusate equated to 0.35 the salary of a nurse, 0.51 the salary of a secretary, 20.66 colonoscopies, 27.00 upper endoscopies, 186.71 mammograms, 1,399.37 doses of polyethylene glycol 3350, 3,826.57 doses of lactulose, or 4,583.80 doses of psyllium.

Conclusion: A single average size tertiary care hospital spent about $25,000 yearly on docusate despite its lack of clinical effectiveness. While this amount is small compared to an overall hospital budget, when considering likely comparable docusate use at the U.S's 6,090 hospitals, the economic burden of docusate becomes significant. The funds currently being used on docusate could be redirected to alternative, more cost-effective purposes.

Background: This study was designed to assess the impact of postoperative atrial fibrillation (POAF) on short- and long-term outcomes after cardiac surgery.

Methods: We prospectively assessed POAF concerning outcomes in 379 adult patients who had undergone cardiac surgery in two heart surgery centers with a follow-up period of one year for every patient. The effects of POAF on postoperative events were evaluated using Logistic regression, Cox regression (adjusted for propensity score), and Kaplan-Meier analysis.

Results: The incidence of POAF was 27.2%. Multivariable logistic regression analysis revealed POAF was associated with an increased risk of 6-month (OR = 5.36; CI: 1.51-18.94; p = 0.009), and 1-year mortality (OR = 4.56; CI: 1.29-16.04; p = 0.018) as well as Major Adverse Cardiocerebral Events (MACEs; acute MI, cardiac arrest, low cardiac output after surgery, third-degree atrioventricular block or stroke; OR = 3.02; CI: 1.29-7.05; p = 0.011), Intensive Care Unit (ICU) stay > 3 days (OR = 2.39; CI: 1.14-5.00; p = 0.021), and postoperative stay > 14 days (OR = 3.12; CI: 1.65-5.90; p < 0.001). Multivariable Cox regression analysis showed POAF as an independent predictor of mortality at one year (HR = 2.86; CI: 1.05-7.75; p = 0.038). Discharge plans including statin and beta-blocker had an independent association with a reduced mortality at one year (HR = 0.22; CI: 0.05-0.96; p = 0.045; HR = 0.16; CI: 0.03-0.87; p = 0.034, respectively).

Conclusions: POAF is associated with an increased risk of morbidity, all-cause mortality, and hospital duration. Statins and beta-blockers that were included in discharge plans had an independent association with reduction in 1-year all-cause mortality.

Objective: In Japan, the benefits of hospitalist physician-led care after heart failure have not been sufficiently demonstrated. We evaluated quality of care by the general internal medicine hospitalist (GIM-H) system for patients after acute heart failure and compared it with care by cardiologists.

Methods: This retrospective cohort study enrolled adult patients from within a two-year period who were admitted to our institution for heart failure. Primary outcome measures were medico-economic indicators: length of hospital stay and medical costs. Secondary outcomes included readmission within 30 days of discharge, death within 30 days of admission, rate of prescription of ACEI/ARB and beta-blockers for heart failure with reduced left ventricular ejection fraction, and the percentage of patients receiving bespoke written treatment plans after discharge. This was thought to represent quality of heart failure-specific care. Outcomes between the groups were compared by adjusting for background factors using a propensity score.

Results: We enrolled 404 patients, and 81 were assigned to each group after matching (mean age: 86 years, female: 64.2%, mean left ventricular ejection fraction: 53.2%). The GIM-H-treated group had a significantly shorter hospital stay (13.7 days vs. 21.8 days, P < 0.001), a significantly lower total medical cost (618,805 JPY vs. 867,857 JPY, P < 0.05) but a higher medical cost per day (48,010 JPY vs 42,813 JPY, P < 0.05) than the cardiologist-treated group. Other indicators were not significantly different.

Conclusions: : GIM-H physicians in Japan are suggested to be useful and effective in care of patients with heart failure. The hospitalist system may positively impact the health economic outcomes of such patients.