The association between geriatric treatment and 30-day readmission risk among medical inpatients aged ≥75 years with multimorbidity

Background Readmission to hospital is frequent among older patients and reported as a post-discharge adverse outcome. The effect of treatment in a geriatric ward for acutely admitted older patients on mortality and function is well established, but less is known about the possible influence of such treatment on the risk of readmission, particularly in the oldest and most vulnerable patients. Our aim was to assess the risk for early readmission for multimorbid patients > 75 years treated in a geriatric ward compared to medical wards and to identify risk factors for 30-day readmissions. Methods Prospective cohort study of patients acutely admitted to a medical department at a Norwegian regional hospital. Eligible patients were community-dwelling, multimorbid, receiving home care services, and aged 75+. Patients were consecutively included in the period from 1 April to 31 October 2012. Clinical data were retrieved from the referral letter and medical records. Results We included 227 patients with a mean (SD) age of 86.0 (5.7) years, 134 (59%) were female and 59 (26%) were readmitted within 30 days after discharge. We found no statistically significant difference in readmission rate between patients treated in a geriatric ward versus other medical wards. In adjusted Cox proportional hazards regression analyses, lower age (hazard ratio (95% confidence interval) 0.95 (0.91–0.99) per year), female gender (2.17 (1.15–4.00)) and higher MMSE score (1.03 (1.00–1.06) per point) were significant risk factors for readmission. Conclusions Lower age, female gender and higher cognitive function were the main risk factors for 30-day readmission to hospital among old patients with multimorbidity. We found no impact of geriatric care on the readmission rate.

Obesity as a mortality risk factor in the medical ward: a case control study

Background Research regarding the association between severe obesity and in-hospital mortality is inconsistent. We evaluated the impact of body mass index (BMI) levels on mortality in the medical wards. The analysis was performed separately before and during the COVID-19 pandemic. Methods We retrospectively retrieved data of adult patients admitted to the medical wards at the Mount Sinai Health System in New York City. The study was conducted between January 1, 2011, to March 23, 2021. Patients were divided into two sub-cohorts: pre-COVID-19 and during-COVID-19. Patients were then clustered into groups based on BMI ranges. A multivariate logistic regression analysis compared the mortality rate among the BMI groups, before and during the pandemic. Results Overall, 179,288 patients were admitted to the medical wards and had a recorded BMI measurement. 149,098 were admitted before the COVID-19 pandemic and 30,190 during the pandemic. Pre-pandemic, multivariate analysis showed a “J curve” between BMI and mortality. Severe obesity (BMI > 40) had an aOR of 0.8 (95% CI:0.7–1.0, p = 0.018) compared to the normal BMI group. In contrast, during the pandemic, the analysis showed a “U curve” between BMI and mortality. Severe obesity had an aOR of 1.7 (95% CI:1.3–2.4, p < 0.001) compared to the normal BMI group. Conclusions Medical ward patients with severe obesity have a lower risk for mortality compared to patients with normal BMI. However, this does not apply during COVID-19, where obesity was a leading risk factor for mortality in the medical wards. It is important for the internal medicine physician to understand the intricacies of the association between obesity and medical ward mortality.

Comment on Ramos-Rincon et al. Palliative Sedation in COVID-19 End-of-Life Care. Retrospective Cohort Study. Medicina 2021, 57, 873

We read with interest the article by Ramos-Rincon and colleagues about patients with COVID-19 dying in acute medical wards in a Spanish University hospital [...]

The evidence for introducing case-finding for delirium and dementia in older medical inpatients in a New Zealand hospital

Objective The aim of this project was to make the case to the managers of a large urban teaching hospital in New Zealand for the introduction of systematic case-finding for pre-existing cognitive impairment/dementia in older hospital inpatients that screen positive for delirium. Method Two hundred consecutive acute admissions aged 75+ in four medical wards were assessed using the 4AT assessment tool for delirium and the Alzheimer Questionnaire (AQ) for pre-existing cognitive impairment/dementia. Length of stay and mortality at 1 year were also collected. Results Over a third of the sample screened positive for delirium and nearly two-thirds of these also screened positive for dementia. The median length of stay was 5 days for delirium without dementia and 7 days for delirium with dementia, compared to 3 days for those who screened negative for both. After adjustment for age, gender and ethnic group, people who screened positive for delirium (with or without dementia) had 50% longer length of stay ( p < 0.05) and at least double the risk of death ( p < 0.05). Conclusion Older hospital inpatients that screen positive for delirium and dementia using 4AT and AQ have longer lengths of stay and higher mortality. Identification may lead to more timely interventions that help to improve health outcomes and reduce hospital costs.

Comparison between Dexamethasone and Methylprednisolone Therapy in Patients with COVID-19 Pneumonia Admitted to Non-Intensive Medical Units

(1) Background: Data on different steroid compounds for the treatment of hospitalized COVID-19 (coronavirus disease 2019) patients are still limited. The aim of this study was to compare COVID-19 patients admitted to non-intensive units and treated with methylprednisolone or dexamethasone. (2) Methods: This was a single-center retrospective study that included consecutive patients with COVID-19 hospitalized in medical wards during the second wave of the pandemic. Thirty-day mortality and the need for intensive or semi-intensive care were the main clinical outcomes analyzed in patients receiving methylprednisolone (60 mg/day) compared with dexamethasone (6 mg/day). Secondary outcomes included complication rates, length of hospital stay, and time to viral clearance. (3) Results: Two-hundred-forty-six patients were included in the analysis, 110 treated with dexamethasone and 136 with methylprednisolone. No statistically significant differences were found between the two groups of patients regarding 30-day mortality (OR 1.35, CI95% 0.71–2.56, p = 0.351) and the need for intensive or semi-intensive care (OR 1.94, CI95% 0.81–4.66, p = 0.136). The complication rates, length of hospital stay, and time to viral clearance did not significantly differ between the two groups. (4) Conclusions: In patients hospitalized for COVID-19 in non-intensive units, the choice of different steroid compounds, such as dexamethasone or methylprednisolone, did not affect the main clinical outcomes.

Nurses and physicians attitudes towards factors related to hospitalized patient safety

Introduction The attitudes of healthcare staff towards patients’ safety, including awareness of the risk for adverse events, are significant elements of an organization’s safety culture. Aim of research To evaluate nurses and physicians’ attitudes towards factors influencing hospitalized patient safety. Materials and methods The research included 606 nurses and 527 physicians employed in surgical and medical wards in 21 Polish hospitals around the country. The Polish adaptation of the Safety Attitudes Questionnaire (SAQ) was used to evaluate the factors influencing attitudes towards patient safety. Results Both nurses and physicians scored highest in stress recognition (SR) (71.6 and 80.86), while they evaluated working conditions (WC) the lowest (45.82 and 52,09). Nurses achieved statistically significantly lower scores compared to physicians in every aspect of the safety attitudes evaluation (p<0.05). The staff working in surgical wards obtained higher scores within stress recognition (SR) compared to the staff working in medical wards (78.12 vs. 73.72; p = 0.001). Overall, positive working conditions and effective teamwork can contribute to improving employees’ attitudes towards patient safety. Conclusions The results help identify unit level vulnerabilities associated with staff attitudes toward patient safety. They underscore the importance of management strategies that account for staff coping with occupational stressors to improve patient safety.

Burden and outcome of community-acquired pneumonia in adult patients admitted to National Referral Hospital, Bhutan

ABSTRACT Introduction: Community acquired pneumonia is one of the leading causes of morbidity and mortality globally with the highest burden being reported from Asia. In Bhutan, community acquired pneumonia was reported to be one of the top five causes of mortality and one of the top ten causes of morbidity. Methods: This was an observational study done in a cohort of adult patients with community acquired pneumonia who were admitted to National Referral Hospital of Bhutan from February 2020 – February 2021 using purposive sampling. The Research Ethics Board of Health, Bhutan, gave ethical approval. We evaluated the burden and outcome of the community acquired pneumonia, and assessed the predictive capability of CURB-65 score to predict mortality as an outcome in these patients. Results: The inpatient burden of community acquired pneumonia was found to be 4.7% among patients admitted to medical wards. The mortality was 7.8%. 15.7 % of patients were managed in the intensive care unit out of which 5.9% patients needed mechanical ventilation. The mean hospital length of stay of these patients was 13 days. The sensitivity, specificity, PPV and NPV of CURB-65 score to predict death as an outcome in these patients were 87.5%, 43.6%, 11.7% and 97.6% respectively. Conclusion: The inpatient burden of Community Acquired Pneumonia in the National Referral Hospital is of concern. The CURB-65 score can be used a supplement to clinical judgement to assess the severity of the disease and make appropriate management decisions.

Pseudomonas aeruginosa Susceptibility in Spain: Antimicrobial Activity and Resistance Suppression Evaluation by PK/PD Analysis

Pseudomonas aeruginosa remains one of the major causes of healthcare-associated infection in Europe; in 2019, 12.5% of invasive isolates of P. aeruginosa in Spain presented combined resistance to ≥3 antimicrobial groups. The Spanish nationwide survey on P. aeruginosa antimicrobial resistance mechanisms and molecular epidemiology was published in 2019. Based on the information from this survey, the objective of this work was to analyze the overall antimicrobial activity of the antipseudomonal antibiotics considering pharmacokinetic/pharmacodynamic (PK/PD) analysis. The role of PK/PD to prevent or minimize resistance emergence was also evaluated. A 10,000-subject Monte Carlo simulation was executed to calculate the probability of target attainment (PTA) and the cumulative fraction of response (CFR) considering the minimum inhibitory concentration (MIC) distribution of bacteria isolated in ICU or medical wards, and distinguishing between sample types (respiratory and non-respiratory). Ceftazidime/avibactam followed by ceftolozane/tazobactam and colistin, categorized as the Reserve by the Access, Watch, Reserve (AWaRe) classification of the World Health Organization, were the most active antimicrobials, with differences depending on the admission service, sample type, and dose regimen. Discrepancies between EUCAST-susceptibility breakpoints for P. aeruginosa and those estimated by PK/PD analysis were detected. Only standard doses of ceftazidime/avibactam and ceftolozane/tazobactam provided drug concentrations associated with resistance suppression.

The opinions and experiences of nurses on frailty screening among older hospitalized patients. An exploratory study

Background Routine screening for frailty at admission by nurses may be useful to detect geriatric risks and problems at an early stage. However, the added value of this screening is not clear yet. Information about the opinions and attitudes of nurses towards this screening is also lacking. As they have a crucial role in conducting this screening, an exploratory study was performed to examine hospital nurses’ opinions and perspectives about this screening and how it influences their daily work. Methods A qualitative, exploratory approach was employed, using semi-structured interviews with 13 nurses working on different general medical wards (surgical and internal medicine) in three Dutch hospitals. Frailty screening had been implemented for several years in these hospitals. Results The participating nurses reported that frailty screening can be useful to structure their work, create more awareness of frail older patients and as starting point for pro-active nursing care. At the same time, they assess their clinical view as more important than the results of a standard screening tool. The nurses hardly used the overall screening scores, but were particularly interested in information regarding specific items, such as delirium or fall risk. Screening results are partly embedded systematically and in daily nursing care, e.g., in team briefings or during transfer of patients to other wards. The majority of the nurses had received little training about the background of frailty screening and the use of screening tools. Conclusions Most nurses stated that frailty screening tools are helpful in daily practice. However, nurses did not use the frailty screening tools in the referred way; tools were particularly used to evaluate patients on separate items of the tool instead of the summative score of the tool. When frailty screening tools are implemented in daily practice, training needs to be focused on. Additional research in this field is necessary to gain more insight into nurses’ opinions on frailty screening.

Improving the quality of weekend medical handover on non-receiving medical hospital wards

IntroductionHandover is the system by which the responsibility for immediate and ongoing care is transferred between healthcare professionals and can be an area of risk. The Royal College of Physicians (RCP) has recommended improvement and standardisation of handover. Locally, national training surveys have reported poor feedback regarding handover at Glasgow Royal Infirmary.AimTo improve and standardise handover from weekday to weekend teams.MethodsThe Plan–Do–Study–Act (PDSA) quality improvement framework was used. Interventions were derived from a driver diagram after consultation with relevant stakeholders. Four PDSA cycles were completed over a 4-month period:PDSA cycle 1—Introduction of standardised paper form on three wards.PDSA cycle 2—Introduction of electronic handover system on three wards.PDSA cycle 3—Expansion of electronic handover to seven wards.PDSA cycle 4—Expansion of electronic handover to all non-receiving medical wards.The outcome of interest was the percentage of patients with full information handed over based on a six-point scale derived from the RCP. Data were collected weekly throughout the study period.Results18 data collection exercises were performed including 525 patients. During the initial phase there was an improvement in handover quality with 0/28 (0%) at baseline having all six points completed compared with 13/48 (27%) with standardised paper form and 21/42 (50%) with the electronic system (p<0.001). When the electronic handover form was expanded to all wards, the increased quality was maintained, however, to a lesser extent compared with the initial wards.ConclusionA standardised electronic handover system was successfully introduced to downstream medical wards over a short time period. This led to an in improvement in the quality of handover in the initial wards involved. When expanded to a greater number of wards there was still an improvement in quality but to a lesser degree.