OBJECTIVE: To find the pathogenies and risk factors related to surgical intensive care unit (SICU) readmission for patients who underwent hepatobiliary-pancreatic surgery, and to develop a predictive model for determining patients who are likely to be readmitted to SICU. METHODS: The patients who admitted to SICU of the Affiliated Hospital of Qingdao University from January 2013 to August 2018; who first stayed in SICU after hepatobiliary-pancreatic surgery; who were assessed and discharged from SICU by surgeons and SICU physicians after treatment, and then transferred to SICU again because of the change of their condition were enrolled. The unintended return to SICU within 3 days and 7 days were recorded. Patients who returned to SICU within 7 days were studied for the pathogenies, risk factors and predictive model of returning to SICU, and non-returning patients were enrolled according to 1:1 as the controls. A total of 43 indicators were divided into five categories, including general clinical data, medical history, surgical indicators before first admission of SICU, length of first SICU stay, and other indicators on the day of first discharge from the SICU. Logistic regression was used to screen the risk factors associated with SICU readmission, then the Nomogram diagram was drawn by using the R 3.4.1 software for predicting SICU readmission, and the classification performance of Nomogram was evaluated by self-help sampling test. RESULTS: Of the 763 patients discharged from the SICU, 2.10% (16/763) of them were readmitted within 3 days and 3.28% (25/763) were readmitted within 7 days to the SICU unexpectedly. The pathogenies of SICU readmission within 7 days included infection [56.00% (14/25)], heart failure [16.00% (4/25)], infarction [12.00% (3/25)], bleeding [12.00% (3/25)], and sutures splitting [4.00% (1/25)]. The pathogenies of SICU readmission within 3 days included infection [56.25% (9/16)], heart failure [18.75% (3/16)], infarction [12.50% (2/16)], and bleeding [12.50% (2/16)]. Nomogram analysis showed that the risk factors associated with unplanned SICU readmission were length of first SICU stay, history of hypertension, and activity of daily living (ADL) score, white blood cell count (WBC), arterial partial pressure of oxygen (PaO₂), prothrombin time (PT), fibrinogen (FIB) on the day of first SICU discharge. Self-help sampling test was carried out on the Nomogram map, and the results showed that the coherence index (C-index) was 0.962 [95% confidence interval (95%CI) = 0.869-1.057]. The classification performance of the model was good. CONCLUSIONS The common pathogenies of SICU readmission for patients who underwent hepatobiliary-pancreatic surgery were infection, heart failure, infarction and bleeding. Risk factors of readmission after SICU discharge included the length of first SICU stay, history of hypertension, and ADL score, WBC, PaO₂, PT, FIB on the day of first SICU discharge. The model consisted of above risk factors showed a good performance in predicting the probability of readmission after SICU discharge for patients who underwent hepatobiliary-pancreatic surgery.
Biliary Tract Diseases/surgery* ; Digestive System Surgical Procedures/adverse effects* ; Humans ; Intensive Care Units ; Liver Diseases/surgery* ; Models, Statistical ; Pancreatic Diseases/surgery* ; Patient Readmission/statistics & numerical data* ; Postoperative Complications/therapy* ; Risk Factors

INTRODUCTION: Atrial fibrillation (AF) with rapid ventricular rate (RVR) is a common diagnosis in the Emergency Department (ED) requiring evaluation and treatment. We present the characteristics and outcomes of patients presenting with primary or secondary AF in a tertiary hospital ED. MATERIALS AND METHODS: This retrospective cohort study included consecutive patients ≥21 years old, with a primary or secondary diagnosis of AF with RVR in the ED over a 1-year period from 1 January 2016 to 31 December 2016. Primary AF is defined as AF with no precipitating cause and secondary AF as AF secondary to a precipitating cause. RESULTS: A total of 464 patients presented to the ED from 1 January to 31 December 2016 with primary and secondary diagnosis of AF with RVR; 44.8% had primary diagnosis of AF whereas 55.2% had secondary AF. Overall admission rate from ED was high at 91.8% (primary 84.6% vs secondary 97.7%). Patients with primary AF were younger (68 vs 74 years, <0.001), had lower rates of cardiovascular risk factors, and shorter length of stay (median 4 vs 5 days). Within 30 days of discharge, they had lower ED reattendance (16.3% vs 25.8%, <0.001) and lower readmission (16.3% vs 25.8%, <0.001). There was no mortality in the primary AF group (0% vs 9.8%, <0.001). CONCLUSION Currently, majority of patients with AF with RVR are admitted from the ED. Other study suggests patients with uncomplicated primary AF have lower adverse outcomes and some could potentially be treated as outpatients.
Aged ; Atrial Fibrillation ; diagnosis ; epidemiology ; therapy ; Emergency Service, Hospital ; statistics & numerical data ; Female ; Humans ; Male ; Middle Aged ; Outcome and Process Assessment (Health Care) ; Patient Care Management ; methods ; statistics & numerical data ; Patient Readmission ; statistics & numerical data ; Retrospective Studies ; Risk Factors ; Singapore ; epidemiology ; Tachycardia, Ventricular ; diagnosis ; epidemiology ; therapy ; Tertiary Care Centers ; statistics & numerical data

PURPOSE: Readmission and mortality rates of patients with heart failure are good indicators of care quality. To determine whether hospital resources are associated with care quality for cardiac patients, we analyzed the effect of number of physicians and the combined effects of number of physicians and beds on 30-day readmission and 1-year mortality. MATERIALS AND METHODS: We used national cohort sample data of the National Health Insurance Service (NHIS) claims in 2002–2013. Subjects comprised 2345 inpatients (age: >65 years) admitted to acute-care hospitals for heart failure. A multivariate Cox regression was used. RESULTS: Of the 2345 patients hospitalized with heart failure, 812 inpatients (34.6%) were readmitted within 30 days and 190 (8.1%) had died within a year. Heart-failure patients treated at hospitals with low physician volumes had higher readmission and mortality rates than high physician volumes [30-day readmission: hazard ratio (HR)=1.291, 95% confidence interval (CI)=1.020–1.633; 1-year mortality: HR=2.168, 95% CI=1.415–3.321]. Patients admitted to hospitals with low or middle bed and physician volume had higher 30-day readmission and 1-year mortality rates than those admitted to hospitals with high volume (30-day readmission: HR=2.812, 95% CI=1.561–5.066 for middle-volume beds & low-volume physicians, 1-year mortality: HR=8.638, 95% CI=2.072–36.02 for middle-volume beds & low-volume physicians). CONCLUSION: Physician volume is related to lower readmission and mortality for heart failure. Of interest, 30-day readmission and 1-year mortality were significantly associated with the combined effects of physician and institution bed volume.
Aged ; Aged, 80 and over ; Cohort Studies ; Female ; Heart Failure/diagnosis/*mortality/therapy ; Hospitalization ; *Hospitals, High-Volume/statistics & numerical data ; *Hospitals, Low-Volume/statistics & numerical data ; Humans ; Male ; Middle Aged ; Patient Readmission/*statistics & numerical data ; Physicians/economics/*supply & distribution ; Proportional Hazards Models ; Quality Improvement ; Quality Indicators, Health Care/*statistics & numerical data ; Time Factors ; Treatment Outcome

OBJECTIVETo evaluate the effect of a clinical pathway for Crohn disease (CD) complicated with intestinal obstruction.

METHODSCD patients complicated with intestinal obstruction in Inflammatory Bowel Disease(IBD) Center of Jinling Hospital were enrolled. One hundred and nineteen CD patients from March 2014 to September 2015 received treatment with the clinical pathway (CP), which was developed based on medical evidence and experience of the IBD center in February 2014, as CP group. The other 108 CD patients from September 2012 to February 2014 received treatment according to the management strategy made by individual attending physician as non-CP group. Rate of operation, rate of stoma, morbidity of surgical complications, hospital stay, hospital cost, and 6-month unplanned re-admission were compared between two groups.

RESULTSThe baseline data were similar between the two group (all P > 0.05). No significant differences were noted between these the two groups in terms of rate of operation (73.9% vs. 77.8%, P = 0.605), rate of stoma (15.9% vs. 25.0%, P = 0.197), and morbidity of surgical complications (23.9% vs. 27.4%, P = 0.724). However, the mean postoperative hospital stay was shorter (10.9 d vs. 13.2 d, P = 0.000), the mean hospital cost was less (78 325 Yuan vs. 85 310 Yuan, P = 0.031) and the rate of 6-month unplanned re-admission was lower(3.4% vs. 11.1%, P = 0.035) in CP group.

CONCLUSIONTreatment based on this CP for CD patients complicated with intestinal obstruction can reduce the rate of 6-month unplanned re-admission, shorten the postoperative hospital stay and decrease the hospital cost in patients requiring surgery.

Critical Pathways ; Crohn Disease ; complications ; therapy ; Female ; Hospital Costs ; statistics & numerical data ; Humans ; Intestinal Obstruction ; complications ; therapy ; Intraoperative Complications ; epidemiology ; Length of Stay ; statistics & numerical data ; Male ; Patient Readmission ; statistics & numerical data ; Postoperative Complications ; epidemiology ; Surgical Stomas ; statistics & numerical data ; Treatment Outcome

INTRODUCTION72-hour emergency department (ED) reattendance is a widely-used quality indicator for quality of care and patient safety. It is generally assumed that patients who return within 72 hours of ED discharge (72-hour re-attendees) received inadequate treatment or evaluation. The current literature also suggests considerable variation in probable causes of 72-hour ED reattendances internationally. This study aimed to understand the characteristics of these patients at the ED of a Singapore tertiary hospital.

METHODSWe conducted a retrospective cohort study on all ED visits between 1 January 2013 and 31 December 2013. 72-hour re-attendees were compared against non-re-attendees based on patient demographics, mode of arrival, patient acuity category status (i.e. P1/P2/P3/P4), seniority ranking of doctor-in-charge and medical diagnoses. Multivariate analysis using the generalised linear model was conducted on variables associated with 72-hour ED re-attendance.

RESULTSAmong 104,751 unique patients, 3,065 (2.93%) were in the 72-hour re-attendees group. Multivariate analysis showed that the following risk factors were associated with higher risk of returning within 72 hours: male gender, older age, arrival by ambulance, triaged as P2, diagnoses of heart problems, abdominal pain or viral infection (all p < 0.001), and Chinese ethnicity (p = 0.006). There was no significant difference in the seniority ranking of the doctor-in-charge between both groups (p = 0.419).

CONCLUSIONSeveral patient and event factors were associated with higher risk of being a 72-hour re-attendee. This study forms the basis for hypothesis generation and further studies to explore reasons behind reattendances so that interventions can be developed to target high-risk groups.

Abdominal Pain ; Adult ; Aged ; Aged, 80 and over ; China ; Data Mining ; Electronic Health Records ; Emergency Medicine ; methods ; statistics & numerical data ; Emergency Service, Hospital ; statistics & numerical data ; Female ; Humans ; Male ; Middle Aged ; Multivariate Analysis ; Patient Discharge ; Patient Readmission ; Patient Safety ; Quality of Health Care ; Retrospective Studies ; Risk ; Singapore ; Tertiary Care Centers ; Triage ; methods ; Young Adult

PURPOSE: Myocardial infarction can occur due to known risk factors and lifestyle choices. The difficulties that patients experience after discharge can lead to readmission and nonadherence to lifestyle change. The purpose of this study was to analyze the difficulties experienced by patients after hospitalization due to myocardial infarction and to identify the predictors of readmission and unchanged lifestyles. METHODS: The study used a mixed-methods design across 106 patients who had experienced a first episode of acute myocardial infarction. The data were collected from two patient interviews and the patients' medical records. A logistic regression was used to predict unchanged lifestyle and readmission. RESULTS: In the first interview, 74.5% of the patients reported receiving information prior to discharge. Six months after discharge, 80.2% mentioned that they had changed their lifestyles, but only 59.4% reported that their health had improved, and 75.5% continued to have concerns regarding their health. Patients described difficulties with regard to psychological problems, family dynamics, professional issues, problems with managing cardiovascular symptoms, and complications associated with hospital interventions. A follow-up assessment revealed that 12.3% of patients had been readmitted for cardiovascular disease. CONCLUSIONS: The analysis revealed significant predictors of readmission amongst patients with hypertension and three-vessel disease. Specifically, the number of people in the household, per capita income, and a lack of information/education provided at discharge as well as problems related to mental health after discharge predicted unchanged lifestyle. An educational program might be advantageous to clarify doubts and involve patients in their own disease management.
Activities of Daily Living ; Adult ; Attitude to Health/ethnology ; Female ; Follow-Up Studies ; Health Education/methods ; Healthy Lifestyle ; Humans ; Male ; Middle Aged ; Myocardial Infarction/ethnology/psychology/*therapy ; Patient Readmission/statistics & numerical data ; Portugal/ethnology ; Risk Factors ; Self Care

PURPOSE: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity in many countries, and it has high rate of hospital readmissions due to recurrent exacerbations of the disease. Many previous studies have suggested further examination of the factors that contribute to hospital readmissions of COPD patients. However, evidence on the effects of nurse staffing by registered nurses (RNs) on the readmission of COPD patients is lacking in Korea. The aim of our study was to evaluate the effects of nurse staffing on hospital readmissions of COPD patients. METHODS: We used National Health Insurance claim data from 2002 to 2012. A total of 1,070 hospitals and 339,379 hospitalization cases were included in the analysis. We divided the number of RNs per 100 beds and the proportion of RNs on staff to one of three groups (Q1: low; Q2: moderate; Q3: high). A generalized estimating equation model was used to evaluate the associations between readmission and nurse staffing. RESULTS: A higher number of RNs was associated with lower readmission rates of 8.9% (Q2) and 7.9% (Q3) respectively. A similar effect was observed as the proportion of RNs among the total nursing staff gradually increased, resulting in lower readmission rates of 7.7% (Q2) and 8.3% (Q3). CONCLUSIONS: Our results suggest notable positive effects of nurse staffing by RNs on patient outcomes. In addition, the magnitude of impact differed between different sizes of hospitals. Thus, human resource planning to solve staffing shortages should carefully consider the qualitative aspects of the nursing staff composition.
Aged ; Female ; Health Facility Size/statistics & numerical data ; Hospitals, General/statistics & numerical data ; Humans ; Male ; Nurses/*supply & distribution ; Nursing Staff, Hospital/*supply & distribution ; Patient Outcome Assessment ; Patient Readmission/*statistics & numerical data ; Personnel Staffing and Scheduling ; Pulmonary Disease, Chronic Obstructive/*nursing ; Quality of Health Care ; Recurrence ; Republic of Korea ; Retrospective Studies

BACKGROUND: It is debatable whether a managed care model would affect the quality of care and length of hospital stay in the treatment of hip fractures in elderly patients. METHODS: This prospective study was undertaken to determine whether or not a managed care critical pathway tool shortened hospital stay in a group of 102 senior patients with fractures of the hip during follow-up. We compared our study findings with two equivalent populations of senior hip fracture patients not treated using a critical care pathway concerning specific markers of quality. RESULTS: The managed care group had a 9% mortality rate, 95% return to prefracture living and 63% return to ambulatory status. The rates compared favorably with previous studies. The quality of care provided before and after the critical pathway was equivalent, while the post-pathway length of stay dropped 30%. CONCLUSIONS: The proposed care protocol is recommended to shorten hospital stay in elderly patients with hip fractures.
Aged ; Aged, 80 and over ; Female ; Hip Fractures/*epidemiology/mortality/*therapy ; Humans ; Length of Stay/*statistics & numerical data ; Los Angeles/epidemiology ; Male ; Managed Care Programs/*statistics & numerical data ; Middle Aged ; Patient Readmission ; Postoperative Complications ; Prospective Studies ; Quality of Health Care

Aged ; Disease Progression ; Exercise Therapy ; Hospitalization ; Humans ; Male ; Patient Readmission ; statistics & numerical data ; Physical Therapy Modalities ; Pulmonary Disease, Chronic Obstructive ; rehabilitation ; Retrospective Studies ; Singapore ; Treatment Outcome ; Walk Test

PURPOSE: The objectives of this study were to find factors related to medical intensive care unit (ICU) readmission and to develop a prediction index for determining patients who are likely to be readmitted to medical ICUs. MATERIALS AND METHODS: We performed a retrospective cohort study of 343 consecutive patients who were admitted to the medical ICU of a single medical center from January 1, 2008 to December 31, 2012. We analyzed a broad range of patients' characteristics on the day of admission, extubation, and discharge from the ICU. RESULTS: Of the 343 patients discharged from the ICU alive, 33 (9.6%) were readmitted to the ICU unexpectedly. Using logistic regression analysis, the verified factors associated with increased risk of ICU readmission were male sex [odds ratio (OR) 3.17, 95% confidence interval (CI) 1.29-8.48], history of diabetes mellitus (OR 3.03, 95% CI 1.29-7.09), application of continuous renal replacement therapy during ICU stay (OR 2.78, 95% CI 0.85-9.09), white blood cell count on the day of extubation (OR 1.13, 95% CI 1.07-1.21), and heart rate just before ICU discharge (OR 1.03, 95% CI 1.01-1.06). We established a prediction index for ICU readmission using the five verified risk factors (area under the curve, 0.76, 95% CI 0.66-0.86). CONCLUSION: By using specific risk factors associated with increased readmission to the ICU, a numerical index could be established as an estimation tool to predict the risk of ICU readmission.
Aged ; Aged, 80 and over ; Cohort Studies ; Female ; Humans ; Intensive Care Units/*statistics & numerical data ; Male ; Medical Records ; Middle Aged ; Odds Ratio ; Patient Readmission/*statistics & numerical data ; Predictive Value of Tests ; Regression Analysis ; Republic of Korea ; Retrospective Studies ; Risk Factors