Characteristics and outcomes of patients with heart failure discharged from different speciality units in Australia: an observational study.

BACKGROUND: Previous studies have reported differing clinical outcomes among hospitalized heart failure (HF) patients admitted under cardiology and general medicine (GM) without consideration of patients' frailty. AIMS: To explore outcomes in patients admitted under the two specialities after taking into account their frailty and other characteristics. METHODS: This retrospective study included all HF patients ≥18 years admitted between 1 January 2013 and 31 December 2019 at two Australian tertiary hospitals. Frailty was determined by use of the Hospital Frailty Risk Score (HFRS) and patients with HFRS ≥ 5 were classified as frail. Propensity score matching (PSM) was used to match 11 variables between the two specialities. The primary outcomes included the days-alive-and-out-of-hospital (DAOH90) at 90 days of discharge, 30-day mortality and readmissions. RESULTS: Of 4913 HF patients, mean age 76.2 (14.1) years, 51% males, 2653 (54%) were admitted under cardiology compared to 2260 (46%) under GM. Patients admitted under GM were more likely to be older females, with a higher Charlson index and poor renal function than those admitted under cardiology. Overall, 23.8% patients were frail and frail patients were more likely to be admitted under GM than cardiology (33.6% vs. 15.3%, P < 0.001). PSM created 1532 well-matched patients in each group. After PSM, the DAOH90 was not significantly different among patients admitted in GM when compared to cardiology (coefficient -5.36, 95% confidence interval -11.73 to 1.01, P = 0.099). Other clinical outcomes were also similar between the two specialities. CONCLUSIONS: Clinical characteristics of HF patients differ between GM and cardiology; however, clinical outcomes were not significantly different after taking into account frailty and other variables.

The Effect of Age upon the Interrelationship of BMI and Inpatient Health Outcomes.

OBJECTIVES: There is growing evidence that the relationship between body mass index (BMI - defined as weight in kilograms divided by height in metres squared) and patient outcomes is age-dependent; specifically, a raised BMI may have a protective effect in older adults. This has been demonstrated clearly in the community setting; less clear is the effect of age on this relationship in the inpatient setting. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: Retrospective analysis of 22,903 electronic records for patients discharged from two large public hospitals in South Australia between January 2015 and September 2018 inclusively. Records were retained if the patient's height and weight had been recorded during the admission, BMI was between 10-99 kg/m2 and it was the patient's first admission during that time. Patients were grouped by BMI (<18.5 kg/m2 ("underweight"), 18.5-24.9 kg/m2 ("normal weight"), 25-29.9 kg/m2 ("overweight"), >30 kg/m2 ("obese")) and age (18-59 years, 60-79 years, > 80 years); for each group we measured the relative stay index (RSI) (actual length of stay divided by predicted length of stay), death in hospital and composite adverse outcome after discharge (unplanned readmission within 30 days and/or death within 30 days). RESULTS: Underweight patients across all age groups generally experienced significantly poorer outcomes compared to those not underweight. In those aged 18-59 years there were no significant differences in outcomes between the normal weight, overweight and obese groups. In those aged 60-79 years overweight patients had a significantly reduced risk of RSI > 2 compared to those of normal weight (p=0.014), and both overweight and obese patients had a significantly reduced risk of adverse outcome after discharge when compared to those of normal weight (p=0.028 and p=0.009 respectively). In those aged 80 years or older, both overweight and obese patients had a significantly reduced risk of adverse outcome after discharge when compared to those of normal weight (p=0.028 and p=0.013 respectively), and obese patients had a significantly reduced risk of inpatient mortality and RSI >2 when compared to those of normal weight (p=0.027 and p=0.037 respectively). CONCLUSION: A BMI > 25 kg/m2 in older patients is associated with reduced risk of prolonged admission, inpatient mortality and adverse outcomes following discharge. This adds to growing evidence that age-specific BMI guidelines are required for adults because the healthiest BMI in the older hospital patient is seemingly not in the range 18.5-24.9 kg/m2.

Comparison of specialist and generalist care.

Objective The choice of whether to admit under a specialist or a generalist unit is often made with neither clear rationale nor understanding of its consequences. The present study compared the characteristics and outcomes of patients admitted with community-acquired pneumonia to either a general medicine or respiratory unit. Methods This study was a retrospective cross-sectional study using data from public hospitals in Adelaide, South Australia. Over 5 years there were 9775 overnight, unplanned appropriate adult admissions. Patient length of hospital stay, in-patient mortality rate and 30-day unplanned readmission rate were calculated, with and without adjustment for patient age and comorbidity burden. Results Over 80% of these patients were cared for by a general medicine unit rather than a specialist unit. Patients admitted to a general medicine unit were, on average, 4 years older than those admitted to a respiratory unit. Comorbidity burdens were similar between units at the same hospital. Length of in-patient stay was >1 day shorter for those admitted to a general medicine unit, without significant compromise in mortality or readmission rates. Between each hospital, general medicine units showed a range of mortality rates and length of hospital stay, for which there was no obvious explanation. Conclusions Compared with speciality care, general medicine units can safely and efficiently care for patients presenting to hospital with community-acquired pneumonia. What is known about the topic? Within the narrow range of any specific disease, generalist medical services are often cited as inferior in performance compared with a speciality service. This has implications for hospital resourcing, including both staffing and ward allocation. What does this paper add? This paper demonstrates that most patients admitted with a principal diagnosis of community-acquired pneumonia were admitted to a generalist unit and did not apparently fare worse than patients admitted to a specialist service; patients admitted to a generalist unit spent less time in hospital and there was no difference in mortality or readmission rate compared with patients admitted to a specialist service. What are the implications for practitioners? The provision of generalist services at urban hospitals in Australia provides a safe alternative admission option for patients presenting with pneumonia, and possibly for other common acute medical conditions.

Malnutrition in Acutely Unwell Hospitalized Elderly - "The Skeletons Are Still Rattling in the Hospital Closet".

INTRODUCTION: Malnutrition is common in hospitalized patients with prevalence rates of up to 30% in Australian hospitals with adverse consequences for both the patients and health care services. Despite formulation of nutritional screening protocols, not all hospitalized patients get nutritional screening. Real life screening rates of hospitalized elderly patients are unknown. AIM: The present study explored nutrition screening rate in acutely unwell elderly patients admitted in a large tertiary hospital and how these patients fared depending upon their nutrition status. METHODS: A prospective cross-sectional study involving 205 general medical patients ≥60years recruited between November 2014 and November 2015. The number of patients who missed nutrition screening were noted and all patients underwent nutritional assessment by a qualified dietitian using PG-SGA and quality of life was measured using EQ-5D 5L. A survival curve was plotted and multivariate cox proportional hazard model was used to adjust for confounders. RESULTS: Only 99 (49.7%) patients underwent nutritional screening. One hundred and six (53.5%) patients were confirmed as malnourished by PG-SGA. Malnourished patients had significantly longer length of hospital stay and had worse quality of life. Mortality was significantly higher in malnourished patients at one year (23 (21.7%) vs 4 (4.3%); p<0.001) and cox proportional hazard model suggests that malnutrition significantly affects survival even after adjustment for confounders like age, sex, Charlson index and polypharmacy. CONCLUSION: This study confirms that nutrition screening is still suboptimal in elderly hospitalized patients with adverse consequences and suggests need for review of policies to improve screening practices.

Investigation of the benefits of early malnutrition screening with telehealth follow up in elderly acute medical admissions.

BACKGROUND: The benefit of providing early nutrition intervention and its continuation post-discharge in older hospitalized patients is unclear. This study examined efficacy of such an intervention in older patients discharged from acute care. METHODS: In this randomized controlled trial, 148 malnourished patients were randomized to receive either a nutrition intervention for 3 months or usual care. Intervention included an individualized nutrition care plan plus monthly post-discharge telehealth follow-up whereas control patients received intervention only upon referral by their treating clinicians. Nutrition status was determined by the Patient Generated Subjective Global Assessment (PG-SGA) tool. Clinical outcomes included changes in length of hospital stay, complications during hospitalization, Quality of life (QoL), mortality and re-admission rate. RESULTS: Fifty-four males and 94 females (mean age, 81.8 years) were included. Both groups significantly improved PG-SGA scores from baseline. There was no between-group differences in the change in PG-SGA scores and final PG-SGA scores were similar at 3 months 6.9 (95% CI 5.6-8.3) vs. 5.8 (95% CI 4.8-6.9) (P = 0.09), in control and intervention groups, respectively. Median total length of hospital stay was 6 days shorter in the intervention group (11.4 (IQR 16.6) vs. 5.4 (IQR 8.1) (P = 0.01). There was no significant difference in complication rate during hospitalization, QoL and mortality at 3-months or readmission rate at 1, 3 or 6 months following hospital discharge. CONCLUSION: In older malnourished inpatients, an early and extended nutrition intervention showed a trend towards improved nutrition status and significantly reduced length of hospital stay.

Clinical outcomes for the obese hospital inpatient: An observational study.

OBJECTIVES: The prevalence of obesity presents a burden for Australian health care. The aim of this study was to determine whether severely obese hospital inpatients have worse outcomes. METHODS: This is an observational cohort study, using data from all adult patients admitted to hospital for all elective and emergency admissions of patients aged over 18 years to two large Australian urban hospitals. We measured their length of stay, intensive care unit admission rate, intensive care unit length of stay, mortality and readmission rates within 28 days of discharge and compared these outcomes in the severely obese and non-severely obese subjects using t-test or chi-square test as appropriate. RESULTS: Between February 2008 and February 2012, 120,872 were admitted to hospital 193,800 times; 2701 patients were identified as severely obese (2.23%) and 118,171 patients were non-severely obese. If admitted as an emergency, severely obese patients have worse outcomes and consume more resources than other patients. These outcomes are still worse, but less so, if the obese patient is admitted as an elective patient suggesting that anticipation of any obesity-specific problems can have a beneficial effect. CONCLUSION: Upon admission or discharge of severely obese hospital inpatients, health care plans should be even more carefully laid than usual to reduce the risk of readmission.

A newly designed observation and response chart's effect upon adverse inpatient outcomes and rapid response team activity.

BACKGROUND: Adverse inpatient events may diminish with earlier response to clinical deterioration. Observation and response charts with a tiered escalation response are recommended for use. AIMS: To examine the impact of an observation and response chart and altered calling criteria on rapid response team (RRT) calls, cardiac arrests and intensive care unit (ICU) admissions from the ward and hospital deaths. METHODS: Linked administrative and clinical data from an Australian, adult tertiary hospital for August 2007 to June 2013 (pre-chart) and July 2013 to December 2014 (post-chart) and analysed using interrupted time series analysis. RESULTS: Pre-chart RRT calls were increasing by 1.7 calls per 10 000 hospital admissions per month, whilst ICU admissions from the ward, deaths and cardiac arrests were decreasing by 0.3, 0.25 and 0.079 per 10 000 admissions per month respectively. Immediately upon chart introduction, the RRT call rate increased by 82% (66-98% CI; P < 0.01), the ward admissions to ICU rate increased by 41% (14-67% CI; P < 0.01) and the rates of deaths and cardiac arrests did not change. In the post chart period, both the pre-chart increasing trend in the rate of RRT and decreasing trend in the rate of ICU admissions changed significantly to become constant. The pre chart trends in the cardiac arrest rate and hospital mortality did not change. CONCLUSION: Observation and response charts increased RRT and ICU workload without improving cardiac arrest rate or mortality. Future chart evaluation should identify features beneficial to patient outcomes and refine those that consume critical care resources that are not associated with improved patient outcomes.

Seasonality of birth patterns in an Australian cohort of patients with biopsy-confirmed idiopathic inflammatory myopathy.

Environmental exposures in the foetal period may predispose to autoimmunity. Aim of this study is to investigate whether seasonality in birth patterns exists in idiopathic inflammatory myopathies (IIM). We used Stata (StataCorp USA, version 13.0) and the user-written routine command 'circsummarise' to assess birth seasonality among South Australian patients with histologically confirmed IIM subsequent to 1980 using their date of birth. There was no evidence for a seasonal birth pattern among IIM patients overall (n = 568), however there were some ethnic variances in birth patterns among non-Caucasian patients. There was evidence for birth seasonality among both Aboriginal (mean = 7 July, Rayleigh P = 0.04) and Asian patients (mean = 12 August, Rayleigh P-value = 0.038). Non-Caucasians born in the third quarter of the calendar year may have an increased risk of developing IIM. Large international studies of IIM patients of diverse ethnicity are required to clarify the role of perinatal exposures in disease susceptibility.

Impact of the emergency department streaming decision on patients' outcomes.

BACKGROUND: Streaming occurs in emergency department (ED) to reduce crowding, but misallocation of patients may impact patients' outcome. AIM: The study aims to determine the outcomes of patients misallocated by the ED process of streaming into likely admission or discharge. METHODS: This is a retrospective cohort study, at an Australian, urban, tertiary referral hospital's ED between January 2010 and March 2012, using propensity score matching for comparison. Total and partitioned ED lengths of stay, inpatient length of stay, in-hospital mortality and 7- and 28-day unplanned readmission rate were compared between patients who were streamed to be admitted against those streamed to be discharged. RESULTS: Total ED length of stay did not differ significantly for admitted patients if allocated to the wrong stream (median 7.6 h, interquartile range 5.7-10.6, cf. 7.5 h, 5.3-11.2; P = 0.34). The median inpatient length of stay was shorter for those initially misallocated to the discharge stream (1.8 days, 1.1-3.0, cf. 2.4 days, 1.4-3.9; P < 0.001). In-hospital mortality and 7- and 28-day readmission rates were not adversely affected by misallocation. When considering patients eventually discharged from the ED, those allocated to the wrong stream stayed in the ED longer than those appropriately allocated (5.2 h, 3.7-7.3, cf. 4.6 h, 3.3-6.4; P < 0.001). CONCLUSION: There were no significant adverse consequences for an admitted patient initially misallocated by an ED admission/discharge streaming process. Patients' discharge from the ED was slower if they had been allocated to the admission stream. Streaming carries few risks for patients misallocated by such a process.

Interpretation of an Extended Autoantibody Profile in a Well-Characterized Australian Systemic Sclerosis (Scleroderma) Cohort Using Principal Components Analysis.

OBJECTIVE: To determine the relationships between systemic sclerosis (SSc)-related autoantibodies, as well as their clinical associations, in a well-characterized Australian patient cohort. METHODS: Serum from 505 Australian SSc patients were analyzed with a commercial line immunoassay (EuroLine; Euroimmun) for autoantibodies to centromere proteins CENP-A and CENP-B, RNA polymerase III (RNAP III; epitopes 11 and 155), the 90-kd nucleolar protein NOR-90, fibrillarin, Th/To, PM/Scl-75, PM/Scl-100, Ku, topoisomerase I (topo I), tripartite motif-containing protein 21/Ro 52, and platelet-derived growth factor receptor. Patient subgroups were identified by hierarchical clustering of the first 2 dimensions of a principal components analysis of quantitative autoantibody scores. Results were compared with detailed clinical data. RESULTS: A total of 449 of the 505 patients were positive for at least 1 autoantibody by immunoblotting. Heatmap visualization of autoantibody scores, along with principal components analysis clustering, demonstrated strong, mutually exclusive relationships between CENP, RNAP III, and topo I. Five patient clusters were identified: CENP, RNAP III strong, RNAP III weak, topo I, and other. Clinical features associated with CENP, RNAP III, and topo I were consistent with previously published reports concerning limited cutaneous and diffuse cutaneous SSc. A novel finding was the statistical separation of RNAP III into 2 clusters. Patients in the RNAP III strong cluster had an increased risk of gastric antral vascular ectasia, but a lower risk of esophageal dysmotility. Patients in the other cluster were more likely to be male and to have a history of smoking and a history of malignancy, but were less likely to have telangiectasia, Raynaud's phenomenon, and joint contractures. CONCLUSION: Five major autoantibody clusters with specific clinical and serologic associations were identified in Australian SSc patients. Subclassification and disease stratification using autoantibodies may have clinical utility, particularly in early disease.

Variability in inpatient serum creatinine: its impact upon short- and long-term mortality.

BACKGROUND: Long-staying medical inpatients carry a significant burden of acute and chronic illness. Prediction of their in-hospital and longer-term mortality risk is important. AIM: The aim of this study was to determine to what extent creatinine variability predicts in-hospital and 1-year mortality in inpatients. DESIGN: Retrospective cohort analysis. METHODS: Patients were included if aged 18 years or older and if admitted for 7 days or longer. The main outcome variables were mortality in hospital and after discharge. RESULTS: Increasing age, the presence of heart failure and a reduced estimated glomerular filtration rate (eGFR) on admission (<60 ml/min/1.73 m(2)) all associated with death risk (both in hospital and within a year of discharge). The creatinine change was related to mortality risk for the patient whilst in hospital and within 1 year after discharge independently of these other factors. The threshold of creatinine change, above which the in-hospital mortality rose significantly was 25 µmol/l (P < 0.001). A creatinine change of >10 µmol/l predicted significantly higher mortality within a year of discharge (P < 0.001). Every 5 µmol/l change in creatinine was associated with an in-hospital mortality increase of 3% (P < 0.001) and a 1-year mortality increase of 1% (P < 0.007). CONCLUSIONS: Patients with a creatinine rise or fall of >10 µmol/l during admission are at higher risk of death after discharge than those with more stable creatinine. These patients therefore merit further attention that might include more focused nutritional assessment, cardiovascular risk factor management or advance care planning.

A comparison of educational interventions to improve prescribing by junior doctors.

BACKGROUND: Prescribing is a complex task with potential for many types of error to occur. Despite the introduction of a standard national medication chart for Australian hospital inpatients in 2006, simple prescribing errors are common. AIM: To compare the effect of quality improvement initiatives on the rate of simple prescribing errors. DESIGN: A prospective, multisite comparison of prescribing education interventions. METHODS: Using three hospital sites, we compared site-specific changes in prescribing error rates following use of an online education module alone (low intensity) with prescribing error rates following a high-intensity intervention (comprising the same online education module plus nurse education and academic detailing of junior prescribers). The study period was 4 months between May and August 2011. RESULTS: Full completion of the adverse drug reactions field did not improve after either intervention; however, there was better documentation of some elements following high-intensity intervention. Prescriber performance improved significantly for more elements in the regular prescription category than any other category of prescription. Legibility of medication name improved across all categories following interventions. Clarity of frequency, prescriber name and documentation of indication improved following both high- and low-intensity intervention. CONCLUSIONS: Improvements were seen in several prescription elements after the intervention but the majority of elements that improved were affected by both low- and high-intensity interventions. Despite targeted intervention, significant rates of prescribing breaches persisted. The prevalence of prescription breaches partially responds to an online education module. The nature of any additional intervention that would be effective is unclear.

Characteristics favouring a delayed disposition decision in the emergency department.

BACKGROUND: The working hours of a hospital affects efficiency of care within the emergency department (ED). Understanding the influences on ED time intervals is crucial for process redesign to improve ED patient flow. AIM: To assess characteristics that affect patients' transit through an ED. METHODS: Retrospective cohort study from 2004 to 2010 of 268 296 adult patients who presented to the ED of an urban tertiary-referral Australian teaching hospital. RESULTS: After adjustment for Australasian Triage Scale (ATS) category, every decade increase in age meant patients spent an additional 2 min in the ED waiting to be seen (P < 0.001) and an extra 29-min receiving treatment (P < 0.001). For every additional 10 patients in the ED, the 'waiting time' (WT) phase duration increased by 20 min (P < 0.001) and the 'Assessment and Treatment Time' (ATT) phase duration increased by 26 min (P < 0.001). When patients arrived outside working hours, the WT phase duration increased by 20 min (P < 0.001). When seen outside working hours, the ATT phase duration increased by 34.5 min (P < 0.001). CONCLUSION: Extrinsic to the patients themselves and in addition to ED overcrowding, the working hours of the hospital affected efficiency of care within the ED. Not only should the whole of the hospital be involved in improving efficient and safe transit of patients through an ED, but the whole of the day and every day of the week deserve attention.

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.

Prolonged pudendal nerve terminal motor latency is associated with decreased resting and squeeze pressures in the intact anal sphincter.

AIM: To determine the contribution of the pudendal nerve to the anal continence mechanism by determining the correlation between pudendal nerve terminal motor latency (PNTML) and resting and squeeze anal canal pressures. METHOD: In all, 1051 patients were investigated with anorectal physiology studies between January 1998 and July 2010. Of these, 213 patients had intact anal sphincters on endoanal ultrasound and had undergone PNTML testing and anal manometry with measurement of resting and squeeze pressures. The relationship between PNTML and mean resting and squeeze pressures was compared in these patients with an intact anal sphincter. Values were compared using a two-sample t test with equal variances. A P value of < 0.05 was considered significant. RESULTS: Of these patients 40.8% had normal PNTML bilaterally, 9.9% had slow PNTML bilaterally and 21.6% had a unilateral slow PNTML. Mean resting pressure was significantly reduced in patients with unilateral slow and bilateral slow PNTML compared with normal. The magnitude of the reduction was 28% and 19% respectively. Mean squeeze pressure was significantly reduced in patients with unilateral slow and bilateral slow PNTML compared with normal. The magnitude of the reduction was 18% and 23% respectively. CONCLUSION: In patients with an intact anal sphincter, either unilaterally or bilaterally prolonged PNTMLs are associated with significantly decreased resting and squeeze pressures. Our results suggest that both internal and external sphincter function is impaired with pudendal nerve injury. The inhibition of internal sphincter function may be due to damage of autonomic, principally sympathetic fibres carried in the pudendal nerve.

Do metastatic colorectal cancer patients who present with late relapse after curative surgery have a better survival?

BACKGROUND: Patients who relapse after potentially curative surgery for colorectal cancer tend to relapse within 5 years. There is, however, a group of patients who relapse beyond 5 years after resection and this late relapsing group may have a different behaviour and prognosis. METHODS: We analysed data from a prospective population-based registry to compare the characteristics and survival of relapsed patients with metachronous mCRC. Patients were categorised into relapse at <2, 2-5 and >5 years following their initial surgery. Univariate log-rank tests and multivariate Cox regression was performed to determine whether time to relapse (TTR) and other factors were associated with overall survival (OS). RESULTS: A total of 750 metachronous mCRC patients were identified. In all, 56% relapsed ≤2 years, 32.4% at 2-5 years and 11.6% >5 years. Median survival time from the time of diagnosis of mCRC for the three groups was 17.6, 26.1 and 27.5 months, respectively. Short TTR (<2 years) was significantly associated with survival (HR=0.75, 95% confidence interval (CI)=0.60-0.93 and HR=0.73, 95% CI=0.53-1.01, respectively, for 2-5 and >5 years vs <2 years, P<0.05). However, there was no significant difference in survival between patients who relapsed at 5 years or later compared with those who relapsed between 2 and 5 years (HR=0.98, 95% CI=0.69-1.38, P=0.90). CONCLUSION: TTR within 2 years is an independent predictor of shorter survival time for mCRC patients who experience a relapse. These data do not support the hypothesis that patients who have late relapse late (>5 years) have a 'better' biology or survival compared with patients with a TTR of 2-5 years.

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.