Emergency department lengths of stay: characteristics favouring a delay to the admission decision as distinct from a delay while awaiting an inpatient bed.

BACKGROUND: A prolonged stay for a patient within the emergency department (ED) can adversely affect the outcome of their ensuing hospital admission. AIMS: To investigate the characteristics of those eventual general medical hospital inpatients who stay in the ED awaiting a decision to be admitted and then await a bed. METHODS: Data from Flinders Medical Centre's patient journey database were analysed. The analysis was carried out on 19 476 patients admitted as an emergency under the General Medicine units. RESULTS: A less urgent Australian Triage Scale category significantly prolonged triage-to-admit time but did not affect boarding time. The decision to admit a patient took 29% longer for patients who presented to the ED outside of working hours. However, a decision to admit taken outside working hours meant the boarding time was over 3 h shorter than if the decision had been taken inside working hours. For every additional patient in the ED at the time of presentation, the admission decision was delayed by about half a minute. Every additional patient in the ED at the time of an admission decision increased boarding time by almost 10 min. CONCLUSION: Outside of working hours, patients presenting to ED have longer triage-to-admit times while patients for admission have shorter boarding times. ED congestion delays admission decisions only slightly and prolongs patients' boarding times to a greater extent. Strategies to reduce the time patients spend in ED should differ depending on whether a decision to admit the patient has been reached.

The survival of patients with not-for-resuscitation orders.

BACKGROUND: Studies have shown higher in-hospital mortality rates in patients with not-for-resuscitation (NFR) decisions. Long-term survival of these patients after their discharge from acute care is largely unknown as is communication of such decisions to primary care givers through letters or discharge summaries. AIM: To evaluate the in-hospital mortality and post-discharge survival of general medical patients with documented resuscitation decisions as well as the prevalence of these decisions being communicated to primary health care providers through discharge summaries. DESIGN: Retrospective cross-sectional study. METHODS: The medical records of 618 general medical patients admitted to an Australian tertiary referral teaching hospital between January and December 2007 were reviewed to determine the documentation of resuscitation decisions. Mortality rates in-hospital and up to 5 years post-discharge were assessed in relation to the nature of any resuscitation decisions. Communication of these decisions in the discharge summaries was also evaluated. RESULTS: One hundred and thirty-six (22%) patients had resuscitation decisions documented of whom 91 (67%) did not want resuscitation (NFR). For this NFR group, the in-hospital mortality rate was 20%, and their cumulative 1- and 5-year mortality rates were 53 and 85%, respectively. Of the 112 patients with resuscitation decisions who survived to discharge, 104 of them (93%) had discharge summaries completed but only 9 (8.4%) had resuscitation decisions documented in those discharge summaries. CONCLUSION: Many general medical patients with a documented NFR decision survive beyond 1 year after their index admission. The rate of communication of resuscitation decisions in hospital discharge summaries is low.

Characteristics and outcomes of discharges against medical advice among hospitalised patients.

BACKGROUND: Discharge against medical advice (DAMA) occurs when an in-patient chooses to leave the hospital before discharge is recommended by the treating clinicians. The long-term outcomes of patients who DAMA are not well documented. AIM: The objective of this long-term and hospital-wide study is to examine characteristics of patients who DAMA, their rates of readmission and mortality after self-discharge. METHODS: Administrative data of admissions to Flinders Medical Centre between July 2002 and June 2011 were used to compare readmissions and mortality among patients who DAMA with those who did not. The outcomes were adjusted for age, gender, emergency admission status, comorbidity, mental health diagnoses, and alcohol and substance abuse. RESULTS: In the study period, 1562 episodes (1.3%) of 121,986 admissions to Flinders Medical Centre were DAMA. Compared with those who did not leave against medical advice, these patients were younger, more often male, more likely of indigenous ethnicity and had less physical comorbidity, but greater mental health comorbidity. Half of the DAMA group stayed less than 3 days. In multivariate analysis, the relative risk for 7-day, 28-day and 1-year readmission in the DAMA group was 2.36 (95% confidence interval (CI), 1.99-2.81; P < 0.001), 1.66 (95% CI, 1.44-1.92; P < 0.001) and 1.31 (95% CI, 1.19-1.45; P < 0.001), respectively, compared with standard discharges. Furthermore, DAMA was associated with twofold (P = 0.02), 1.4-fold (P = 0.025) and 1.2-fold (P = 0.049) increase in 28-day, 1-year and up-to-9-year mortality, respectively, compared with non-DAMA. CONCLUSIONS: Patients who self-discharged against medical advice carry a significant risk of readmission and mortality. Patients with characteristics of 'at risk of DAMA' should have greater attention paid to their care before and especially after any premature discharge.

Relationship between in-hospital location and outcomes of care in patients of a large general medical service.

BACKGROUND: The discrepancy between the number of admissions and the allocation of hospital beds means that many patients admitted under the care of a general medical service can be placed in other departments' wards. These patients are called 'outliers', and their outcomes are unknown. AIMS: To examine the relation between the proportion of time each patient spent in their 'home ward' during an index admission and the outcomes of that hospital stay. METHODS: Data from Flinders Medical Centre's patient journey database were extracted and analysed. The analysis was carried out on the patient journeys of patients admitted under the general medicine units. RESULTS: Outlier patients' length of stay was significantly shorter than that of the inlier patients (110.7 h cf 141.9 h; P < 0.001).They had a reduced risk of readmission within 28 days of discharge from hospital. Outlier patients' discharge summaries were less likely to be completed within a week (64.3% cf 78.0%; P < 0.001). Being an outlier patient increased the risk-adjusted risk of in-hospital mortality by over 40%. Fifty per cent of deaths in the outlier group occurred within 48 h of admission. Outlier patients had spent longer in the emergency department waiting for a bed (6.3 h cf 5.3 h; P < 0.001) but duration of emergency department stay was not an independent predictor of mortality risk. CONCLUSION: Outlier patients had significantly shorter length of stay in hospital but significantly greater in-patient death rates. Surviving outlier patients had lower rates of readmission but lower rates of discharge summary completion.

The significance of reduced kidney function among hospitalized acute general medical patients.

BACKGROUND: Inpatient general medical units often look after older patients who have more complex co-morbidity including renal insufficiency. The consequences of renal insufficiency with respect to length of hospital stay (LOS) and mortality have not been well described in hospitalized general medical patients. AIM: To use a general medical inpatient population to evaluate the impact of reduced kidney function. DESIGN: Retrospective cross-sectional study. METHODS: We studied 504 acute medical admissions through an Acute Assessment Unit between February and November 2007. Patients were classified as having chronic kidney disease (CKD), acute kidney injury (AKI), neither (control) or both. LOS, in-hospital mortality and post-discharge survival were evaluated. RESULTS: Renal impairment was present in 151 patients. Ninety patients had CKD only and 61 had AKI with or without CKD. In-hospital mortality was increased in those with renal impairment compared with controls (9.3 vs. 3.4%; P = 0.006). Within 4 years of admission, 187 (39%) patients had died. Post-discharge mortality was significantly higher in all renal failure populations (hazard ratio: 2.57-4.38; P < 0.01). Adjustment for patient age, gender and Charlson index explained the increased mortality during and after hospital admission but did not explain increased LOS. Only a small proportion (13%) of admitted patients with renal insufficiency had renal disease documented in their discharge summaries. CONCLUSION: Many general medical inpatients (30%) have reduced kidney function at the time of admission. This study provides validation of the Modification of Diet in Renal Disease equation as a predictor of poor outcomes. Reduced renal function was associated with increased hospital LOS and mortality. Mortality rose with AKI and was explicable on the basis of the patients' age and co-morbidities. Renal insufficiency is documented infrequently in discharge summaries.

Quality of resuscitation orders in general medical patients.

BACKGROUND: Documentation of resuscitation status in hospitalized patients has relevance in the management of cardiopulmonary arrest. Its association with mortality, Length Of hospital Stay (LOS) and the patients' primary diagnosis has not been established in general medical inpatients in hospitals in Australia and New Zealand. AIM: To investigate the association of resuscitation orders with in-hospital mortality and LOS in a range of diagnoses, adjusting for severity of illness and other covariates. DESIGN: Retrospective study. METHODS: The admission notes of 1681 medical admissions to four tertiary care teaching hospitals across Australia and New Zealand were reviewed retrospectively for frequency and nature of resuscitation documentation and its association with mortality, LOS and primary diagnosis. RESULTS: Resuscitation orders were documented in 741 patients (44.7%). For the 232 patients with a Not For Resuscitation (NFR) order, the in-hospital mortality rate was higher than in control patients (14% vs. 1.2%, P<0.005). The mortality rate remained significantly higher in the NFR group after propensity matching of the controls for age and co-morbidity (14% vs. 5%, P<0.005). The death-adjusted LOS for the NFR group was also significantly higher compared to the control patients (9.7 days vs. 4.7 days, P<0.005) and this difference remained after propensity matching (9.7 days vs. 7.7 days, P<0.05). Those patients with a primary diagnosis of respiratory tract infection or cardiac failure were more likely to be documented NFR compared to those with cellulitis or urinary tract infection. CONCLUSIONS: The documentation of NFR in a patient's admission notes is associated with increased in-hospital mortality and LOS. This is only partly explicable in terms of these patients' greater age and co-morbidity.

Simple clinical score is associated with mortality and length of stay of acute general medical admissions to an Australian hospital.

BACKGROUND: In a rural Irish hospital, a simple clinical score (SCS) determined at the time of admission enabled stratification of acute general medical admissions into five categories that were associated incrementally with patients' immediate and 30-day mortality. The aim of this study was to examine the representative performance of this SCS in predicting the outcomes of general medical admissions to an Australian teaching hospital. METHODS: A retrospective chart review was undertaken of a representative sample from 480 admissions in 2007 to an urban university teaching hospital in Australia. The SCS was calculated and related to that patient's outcome in terms of mortality, length of stay, nursing home placement on discharge, the occurrence of medical emergency team call and intensive care unit transfer. These data were compared, where possible, with the outcomes reported in the Irish hospital. RESULTS: Four hundred and seventeen complete sets of data allowed calculation of the SCS. There were significant linear correlations of the SCS (divided into quintiles) and patients' in-hospital and 30-day mortality, their length of stay and their discharge to a nursing home. There was no association of the SCS and the patients' readmission rate, intensive care unit transfer rate or likelihood of a medical emergency team call. The significant trends replicated those from the Irish hospital. CONCLUSION: The SCS can predict significant outcomes for general medical admissions in an Australian hospital despite obvious differences to the hospital of its derivation. A wider study of Australasian hospitals and the performance of the SCS as a predictor of general medical admission outcomes is underway.

Resuscitation orders and their relevance to patients' clinical status and outcomes.

BACKGROUND: Documented resuscitation orders have relevance in the management of a pulseless, unresponsive patient. Although useful, the frequency of their documentation in the case notes of newly admitted medical patients is not well established. AIM: To investigate the frequency of early clear documentation of resuscitation orders in patients' admission notes. DESIGN: Retrospective audit. METHODS: The admission notes of 618 medical admissions to an Australian tertiary referral teaching hospital between January and December 2007 were reviewed to calculate the frequency of clear resuscitation documentation. Certain outcomes of each admission, such as in-hospital death, were obtained via hospital-based computerized records. RESULTS: Within the first 24 h of admission, discussions regarding resuscitation were not documented for 78% of patients. Of the 482 patients with no documented resuscitation orders, 5 patients died during their index admission. Of the 136 patients with documented resuscitation orders, 24 patients died during their index admission. As age or a measure of clinical debility increased, the absolute number and relative proportion of resuscitation discussions increased significantly (P<0.0001) and the number and proportion of patients deemed not for resuscitation also increased (P<0.0001). CONCLUSION: Those patients apparently targeted for discussion were older, more frail and acutely unwell. We propose widespread use of a clinical scoring system to identify those patients who need their resuscitation status clarified early in their admission prior to clinical deterioration.

The genetic epidemiology of body attitudes, the attitudinal component of body image in women.

BACKGROUND: There were four purposes of the current study, including the investigation of the: (i) adequacy of a multidimensional measure of body image; (ii) genetic and environmental epidemiology of this measure; (iii) shared variance between genetic and environmental risk factors for body mass index (BMI) and body image; and (iv) Equal Environment Assumption (EEA) as it related to body attitudes. METHOD: Six types of body attitudes, as measured by the Body Attitudes Questionnaire (BAQ) and reported by 894 complete female-female twin pairs (mean age 32.35 years, S.D. = 41.8) from the Australian Twin Registry, were analysed. RESULTS: Confirmatory factor analysis of the BAQ supported the adequacy of the measure. Additive genetic and unique environmental influences best accounted for the variance of all six of the BAQ subscales. The relationship between BMI and body attitudes was primarily due to shared genes rather than environment but the majority of genetic and environmental effects on body attitudes were independent of BMI, with the exception of the Feeling Fat subscale, which shared 53% of its genetic risk factors with BMI. One violation of the EEA was suggested, namely similarity of childhood treatment influenced similarity on Lower Body Fatness subscale. CONCLUSIONS: Findings support the notion that: (i) body image is a multidimensional concept; (ii) it is relatively independent of BMI; and (iii) both genetic and non-shared environment are influential determinants of body attitudes.

Individual psychotherapy in the outpatient treatment of adults with anorexia nervosa.

BACKGROUND: Anorexia nervosa is a disorder of high morbidity and significant mortality. It is commonest in young adult women, in whom the incidence may be increasing. The focus of treatment has moved to an outpatient setting and a number of differing psychotherapies are presently used in treatment. OBJECTIVES: The aim of the present review was to evaluate the evidence from randomised controlled trials for the efficacy of outpatient psychotherapies used in the treatment of older adolescents and adults with anorexia nervosa SEARCH STRATEGY: The strategy comprised database searches of MEDLINE, EXTRAMED, EMBASE,PSYCLIT, CURRENT CONTENTS, Cochrane Collaboration Controlled Trials Register and the Depression and Anxiety Neuroses Cochrane Group (CCDAN), a hand-search of The International Journal of Eating Disorders, and he reference lists of all papers selected. Personal letters were sent to identified notable researchers published in the area, requesting information on trials that are unpublished or in progress. SELECTION CRITERIA: All randomised controlled trials of adult individual outpatient therapy for anorexia nervosa as defined by the DSM-IV or similar international criterion. Quality ratings were made according to the CCDAN criteria and in addition, whether the trial had examined treatment integrity. DATA COLLECTION AND ANALYSIS: A range of outcome variables were selected, including physical state, severity of eating disorder attitudes and beliefs, interpersonal function, and general psychiatric symptom severity. Continuous outcome data comparisons were made with the standardized mean difference statistic, and binary outcome comparisons made with the relative risk statistic. Reliability of data extraction and quality ratings were made with the kappa statistic. Sensitivity analyses to evaluate the effects of trial quality and subgroup analyses to explore specific questions of treatment effects from different settings, frequency and duration of therapies were planned. MAIN RESULTS: Six small trials only, two of which included children or adolescents, were identified from the search and aggregation of data was not possible. Bias was possible due particularly to lack of blinding of outcome assessments. The results in two trials suggested that 'treatment as usual' or similar may be less efficacious than a specific psychotherapy. No specific treatment was consistently superior to any other specific approach. Dietary advice as a control arm had a 100% non-completion rate in one trial. REVIEWER'S CONCLUSIONS: No specific approach can be recommended from this review. It is unclear why 'treatment as usual' performed so poorly or why dietary advice alone appeared so unacceptable as the reasons for non-completion were not reported. There is an urgent need for large well-designed trials in his area.

Outcome in patients with eating disorders: a 5-year study.

BACKGROUND: Eating disorders are disabling, unpredictable, and difficult to treat. We did a prospective 5-year investigation of a representative sample of patients with eating disorders. Our aim was to identify predictors of outcome and to assess effects of available treatments. METHODS: We prospectively investigated 95 patients with anorexia nervosa, 88 with bulimia nervosa, and 37 with eating disorders not otherwise specified (EDNOS), who sought treatment in Adelaide, South Australia. We divided patients into those who had, and had not, received treatment in specialist units and reached a safe body weight. Individuals were then further classified dependent on intensity of any treatment received. We assessed clinical symptoms, body-related attitudes, and psychosocial function. FINDINGS: 216 (98%) patients were available for follow-up after 5 years. Three patients with anorexia nervosa and two with EDNOS died. 65 (74%) bulimic, 29 (78%) EDNOS, and 53 (56%) anorexic patients had no diagnosable eating disorder. A small proportion of patients in every group had poor Morgan-Russell-Hayward scores at outcome. Final outcome was predicted by extent and intensity, but not duration, of initial symptoms in patients with anorexia nervosa, and by initial body-related attitudes and impaired psychosocial functioning in bulimia patients. We were unable to predict EDNOS outcome. Treatment did not affect outcome for any group. INTERPRETATION: Deaths in the study confirm the serious nature of eating disorders. However, our results suggest that the efficacy of existing interventions is questionable.

Does the body image exist in three dimensions? The study of visual mental representation of a body and a nonbody object.

Do the mental images of 3-dimensional objects recreate the depth characteristics of the original objects? This investigation of the characteristics of mental images utilized a novel boundary-detection task that required participants to relate a pair of crosses to the boundary of an image mentally projected onto a computer screen. 48 female participants with body attitudes within expected normal range were asked to image their own body and a familiar object from the front and the side. When the visual mental image was derived purely from long-term memory, accuracy was better than chance for the front (64%) and side (63%) of the body and also for the front (55%) and side (68%) of the familiar nonbody object. This suggests that mental images containing depth and spatial information may be generated from information held in long-term memory. Pictorial exposure to views of the front or side of the objects was used to investigate the representations from which this 3-dimensional shape and size information is derived. The results are discussed in terms of three possible representational formats and argue that a front-view 2 1/2-dimensional representation mediates the transfer of information from long-term memory when depth information about the body is required.

Mental health status of the South Australian population.

OBJECTIVE: To determine, by the use of a telephone survey, the mental health status of SA adults (18+ years) using the GHQ-28, SF-12 and self-report as indicators of mental health, and to examine risk factors for mental health morbidity. SAMPLE: A random representative sample of South Australian adults selected from the Electronic White Pages. Overall, 2,501 interviews were conducted (74.0% response rate). RESULTS: Overall, 19.5% of respondents had a mental health problem as determined by the GHQ-28, 11.8% as determined by the mental health component summary score of the SF-12 and 11.9% self-reported a mental health condition. The percentage of people with a mental health problem who had used a psychologist or a psychiatrist in the previous 12 months was 9.6% for people diagnosed by the GHQ-28, 16.2% by SF-12 and 23.7% for self-report. The logistic regression analyses undertaken to describe people with a mental health problem as determined by the GHQ-28 and to describe people who visited a psychologist or psychiatrist produced different age categories, demographic and co-morbidity indicators. Variables found in both analyses included living in the metropolitan area, being economically inactive and being a high user of health services. CONCLUSIONS: One in five South Australian adults has a mental problem. Although the prevalence is higher for younger age groups, older adults are more likely to visit a psychologist or a psychiatrist. IMPLICATIONS: Telephone interviewing produces robust indicators of the prevalence of mental health problems and is a cost-effective way of identifying prevalence estimates or tracking changes over time.

[Personal behavior and mental state in anorexia nervosa]. / Osobennosti lichnostnogo reagirovaniia i psikhicheskogo sostoianiia pri nervnoi anoreksii.

Personality of the patients with anorexia nervosa is characterised by high neurotization and anxiety that resulted in diffuse anxiety in stress situation. Personal peculiarities included also high total hostility and intrapunitivity, inclination to obsessive-phobic and dysthymic reactions and tendency to somatization of anxiety. Such peculiarities promoted the choice of intrapunitivity type of reaction in situation of frustration. Its manifestation increases with an increase in the disease duration. The range of psychotic disorders in anorexia nervosa is restricted to anxious-depressive, obsessive and asthenic sphere.

Eating disorders revisited. II: Bulimia nervosa and related syndromes.

Bulimia nervosa and related syndromes are common, and occur in up to 5% of women who attend general practitioners. Young women in First World countries, particularly those who "diet", are at increased risk. Behaviours, such as binge eating and induced vomiting, are typically kept well hidden. Only a minority of those with these disorders present for treatment. General practitioners play a key role in primary and secondary prevention. Effective treatments include psychotherapies that focus on the patient's attitudes and relationships, not just the binge eating behaviour. About 50% of patients make a complete recovery, but the long term outcome is unknown.

Eating disorders revisited. I: Anorexia nervosa.

Anorexia nervosa is a serious psychiatric illness with a high morbidity and a significant lifetime mortality. Recurring themes in such patients centre on issues of self-worth and control. Treatment is difficult and prolonged, and may require hospitalisation. Therapy focuses on altering the misperceptions that patients have of themselves, both psychologically and physically. A multi-disciplinary team based in a specialised unit provides the treatment of choice, but if this is not available, a consistent, supportive relationship with an individual therapist familiar with the condition will be beneficial. Successful outcome should be based not simply on body weight but also on the resolution of anorexic thinking.

Recall of the visual body image using a novel boundary detection task.

A new task for eliciting a pictorial mental image of the body or other objects is described. The task involved relating a pair of crosses to the boundary of a mental image 'projected' onto a computer screen. Responses were assessed for accuracy defined as identifying a relationship between a cross and an image that would hold when a photograph (of the same object) was substituted for the mental image. A group of 30 female students achieved between 70 to 80% accuracy when using this task to assess mental images of their own faces, torsos, or a familiar nonbody object. Accuracy was similar for body and nonbody objects. The presence of some kind of quasipictorial representation of the body is confirmed. Its characteristics await further elucidation.