Appropriateness of bed usage for inpatients admitted as emergencies to internal medicine services.

OBJECTIVE: To establish the appropriateness of bed usage for acute care within the medical directorates of two district general hospitals using a validated assessment tool, the Emergency Admission Review (EAR). This tool assesses the appropriateness of day of care against strict criteria and allows classification of care as either acute or non-acute. DESIGN: Prospectively, 200 medical emergency admissions, 100 in each of the hospitals, were selected. Following identification patients were assessed every two days during the first fortnight of admission or until discharge. Those patients staying longer than two weeks were then assessed weekly until conclusion of the audit period or discharge whichever was reached first. SETTING: The medical directorates of two District General Hospitals within one acute NHS trust. SUBJECTS: All patients admitted as medical emergencies, who were 14 years or older and had a length of stay of 24 hours or more. RESULTS: A total of 787 acute in-patient bed days were analysed in Hospital A of which 363 (46%) were deemed inappropriate for acute care. In Hospital B 810 bed days were analysed and 44% (363) were deemed inappropriate. In Hospital A the most common reason for bed-days not meeting the acute care criteria was short-term waiting, accounting for 60% (217 days) of the total bed days deemed non-acute. In Hospital B the most common reason for patients receiving non-acute care was that they were having active rehabilitation. This accounted for 29% (105 days) of the total number of non-acute care days. In Hospital B three patients accounted for 28% of the total occupied bed days. CONCLUSIONS: The use of the EAR is a systematic and objective approach to the assessment of appropriateness of acute care. It applies strict criteria to determine the reason for a patient's continued hospital stay. From the results it is clear that a significant proportion of medical emergency admissions in both Hospital A and B remain in hospital for care that is deemed non-acute and therefore in theory could be performed in another setting. This information has significant potential in identifying the opportunities for streamlining services within hospitals to reduce short-term delays and also to inform the development of intermediate care services both within and outwith the acute hospital setting.

Use of a fibrous dressing in exuding leg ulcers.

In a multicentre, prospective, randomised trial of 44 patients with exuding leg ulcers, a new hydrofibre dressing was compared with an alginate dressing in terms of dressing performance, patient comfort, safety and cost-effectiveness. The groups were well matched with regard to sex and age. A statistically significant difference between treatment groups was observed in mean wear time, with a longer wear time of four days observed in the hydrofibre dressing group compared to three days in the alginate group. The hydrofibre dressing group therefore demonstrated a significantly lower frequency of dressing changes required per week. Significantly more patients achieved a seven-day wear time with the hydrofibre dressing than with the alginate dressing. There was no difference with regard to percentage change in ulcer area. Cost-effectiveness was based on the cost of dressings, compression therapy and nursing time to achieve a healed wound. However, because of small patient numbers, it was difficult to make an accurate comparison. This study suggests that the hydrofibre dressing may have clinical benefits that merit further investigation with larger patient numbers.

Noncompliance with post-transplant immunosuppression.

Two cases from an adolescent dialysis group are presented to illustrate the limitations of the generally used models of patient compliance and noncompliance with medical treatment. Understanding the noncompliance of these two young men required awareness of their psychological development and of the interpersonal matrix in which they lived. Their noncompliance was the result of a failure to master a transition from dependence to autonomy which probably could not have been predicted in advance, but which might have detected as it developed and might have been avoided through appropriate interventions with the patients and their families.

Sexual experimentation by adolescents while babysitting.

This paper deals with the sexual experiences an adolescent might have as a result of babysitting. The impact of babysitters in our culture has been ignored in the literature, and yet we find it practiced widely by teenagers in the United States. Parents and society in general have few guidelines in sitter selection and in recognizing the potential impact of the sitter on their children.

Children with terminal illness: a selected review.

This brief review consdiers the psychiatric aspect of a child's dying from terminal illness. Much of the literature is largely theoretical, illustrated by case histories and clinical observations. Only recently has research been published based on empirical analyses of grief reactions in the child. There is no corresponding empirical research on the grief reactions of parents and siblings, or of the medical staff that cares for the terminally ill child. A review in this area points out the need for more integration of theoretical, clinical, and empirical work, including all aspects of a dying child's environment.

Effects of patient racial attribution on black clinicians' inferences.

This study was done to determine the impact of patient racial attribution on black practitioners' clinical judgments. Fifty-five professionals indicated their clinical reactions to a bogus case description of a sexually maladjusted male patient identified as black or white and also completed a traditional social beliefs scale. Relatively untraditional clinicians evaluated the black-designated patient more favorably than the white-designated patient. The less traditional practitioners also evaluated the black-designated patient more favorably than did the traditional clinicians. Effects of patient race were found for both clinical impressions and treatment decisions and were not attenuated in the more highly experienced subsample. Implications and limitations of the findings are discussed.

Character defenses and biofeedback. The problems of symptom chronicity and symptom removal.

One aspect of biofeedback treatment with chronically incapacitated persons concerns their resistance to getting better. In effect, the removal of their symptom is equivalent to undercutting a characteristic way of relating to themselves and to the world, and hence, is opposed. Even though many biofeedback procedures are impressively effective, the therapist must watch for another symptom reemerging in the place of the older somatic complaint, or for psychologically regressive attempts to preserve one's character defenses.