[Specialized home care of medical diseases in an urban tertiary university hospital. Coordination between the medical services of the hospital and the primary health care]. / Atención especializada domiciliaria de patologías médicas desde un hospital universitario terciario urbano. Coordinación entre los servicios médicos del hospital y la Atención Primaria de salud del territorio.

INTRODUCTION: The experience of an urban Tertiary University Hospital in the design and implementation of Hospital at Home Program (HaHP) integrated in a Department of Internal Medicine and highly coordinated with Medical Services of the Hospital and the Primary Health Care, that contemplates the like main objectives of the promotion of specialized home care medical diseases and the improvement of the coordination with the primary health care. PATIENTS AND METHOD: Systematic collection in all the patients admitted between April 2006 and March 2007 in the HaHP of the following variables: age, gender, service of origin, main diagnosis, Barthel and Charlson index, number of visits per day to doctors and nurses, destination on discharge and medical team. The descriptive statistical analysis was made in April 2007. The results are presented globally and differentiated by teams (internal medicine, respiratory and nutritional support teams). RESULTS: 506 admissions in 390 patients with a mean age of 66.5 (18) years, 53% being women. The Charlson index was 2 (2.2) and the Barthel index 63.5 (40,4). Average stay was 7.9 (8.2) days. The main reasons for admission were the infections and domiciliary intravenous antibiotic therapy in 153 (30.5%) cases, followed by patients with chronic obstructive pulmonary disease or cardiac failure in 107 (21%) cases, and home enteral and parenteral nutrition in 102 (20%) cases. Two hundred (39.5) patients were subsequently controlled by their primary care team after discharger, 241 (47.5) patients were followed-up in the hospital consultations, and 45 (9%) of the patients had to return directly to the hospital. CONCLUSIONS: The creation of a HaHP, for medical diseases, in internal medicine department that is highly coordinated with medical services of the hospital, especially with emergency, respiratory, and nutritional support teams, and with the primary health care, facilitates specialized home care of medical diseases and improves coordination with the primary health care.

Safety and efficacy of home intravenous antimicrobial infusion therapy in older patients: a comparative study with younger patients.

BACKGROUND: Home intravenous antimicrobial infusion therapy has proved its safety and efficacy in a great number of infections. Despite this there are few published studies about this way of managing in the elderly patient. OBJECTIVE: To study the safety and efficacy of home intravenous antimicrobial infusion therapy in elderly patients. STUDY DESIGN: A prospective and comparative study of an elderly group of patients > or =70 years old vs. a cohort of younger adult patients as a control group. All patients were followed until 3 months after discharge. SETTING: Hospital at Home Programme (HHP) as part of the Internal Medicine Department at Valle de Hebrón Hospital, Barcelona, Spain. PATIENTS: All patients admitted to HHP diagnosed of infections requiring intravenous antibiotic therapy between March 2006 and March 2007. RESULTS: We included 145 patients, 90 of whom were 70 years or older. Diabetes mellitus, heart failure and respiratory tract infection were more frequent in these elderly patients. In this group 14 (12%) developed some type of adverse event during treatment, phlebitis being the most common. The majority of those in the elderly patients group were discharged because of satisfactory clinical evolution and only 7 (7%) were re-admitted to hospital. Another 13 (14%) were re-admitted to hospital 3 months after discharge from HHP, mostly for chronic diseases. There were no significant differences between these results and those obtained from the control group. CONCLUSION: Home intravenous antimicrobial infusion therapy in elderly patients is safe and effective.

Atención especializada domiciliaria de patologías médicas desde un hospital universitario terciario urbano. Coordinación entre los servicios médicos del hospital y la Atención Primaria de salud del territorio / Specialized home care of medical diseases in an urban tertiary university hospital. Coordination between the medical services of the hospital and the primary health care

Introducción. Se presenta la experiencia de un hospital universitario terciario urbano en el diseño e implementación de una unidad de hospitalización a domicilio (UHaD) integrada en un Servicio de Medicina Interna y altamente coordinada con los servicios médicos del hospital y la Atención Primaria de salud del entorno hospitalario, que contempla como principales objetivos la promoción de la atención especializada domiciliaria de patologías médicas y la mejora de la coordinación con la Atención Primaria de salud. Pacientes y métodos. Recogida sistemática en todos los pacientes ingresados entre abril 2006 y marzo 2007 en la UHaD de las siguientes variables: edad, sexo, lugar y servicio de procedencia, diagnóstico principal, índice de Barthel y de Charlson, número de visitas al día de enfermería y médicas, destino al alta y equipo médico responsable. El análisis estadístico descriptivo se realizó en abril de 2007. Los resultados se presentan de forma global y diferenciados por equipos (Medicina Interna, Neumología y soporte nutricional). Resultados. Quinientos seis ingresos que correspondían a 390 pacientes con una edad media de 66,5 (18) años, y un 53% mujeres. El índice de Charlson fue de 2 (2,2) y el índice de Barthel de 63,5 (40,4). La estancia media fue de 7,9 (8,2) días. Los principales motivos de ingreso fueron las infecciones y tratamiento antibiótico por vía intravenosa en 153 (30,5%) casos, las agudizaciones de enfermedad pulmonar obstructiva crónica o insuficiencia cardíaca en 107 (21%) casos y la nutrición enteral o parenteral domiciliaria en 102 (20%) casos. Doscientos (39,5%) pacientes al finalizar el ingreso fueron controlados por sus equipos de Atención Primaria, 241 (47,5%) fueron seguidos en consultas del hospital y 45 (9%) retornaron directamente al hospital. Conclusión. La creación de una UHaD para patologías médicas desde el Servicio de Medicina Interna, altamente coordinada con servicios médicos del hospital, especialmente con Urgencias, Neumología y Soporte Nutricional y con la Atención Primaria del entorno hospitalario, facilita la atención especializada domiciliaria de patologías médicas y mejora la coordinación con la Atención Primaria de salud

Introduction. The experience of an urban Tertiary University Hospital in the design and implementation of Hospital at Home Program (HaHP) integrated in a Department of Internal Medicine and highly coordinated with Medical Services of the Hospital and the Primary Health Care, that contemplates the like main objectives of the promotion of specialized home care medical diseases and the improvement of the coordination with the primary health care. Patients and method. Systematic collection in all the patients admitted between April 2006 and March 2007 in the HaHP of the following variables: age, gender, service of origin, main diagnosis, Barthel and Charlson index, number of visits per day to doctors and nurses, destination on discharge and medical team. The descriptive statistical analysis was made in April 2007. The results are presented globally and differentiated by teams (internal medicine, respiratory and nutritional support teams). Results. 506 admissions in 390 patients with a mean age of 66.5 (18) years, 53% being women. The Charlson index was 2 (2.2) and the Barthel index 63.5 (40,4). Average stay was 7.9 (8.2) days. The main reasons for admission were the infections and domiciliary intravenous antibiotic therapy in 153 (30.5%) cases, followed by patients with chronic obstructive pulmonary disease or cardiac failure in 107 (21%) cases, and home enteral and parenteral nutrition in 102 (20%) cases. Two hundred (39.5) patients were subsequently controlled by their primary care team after discharger, 241 (47.5) patients were followed-up in the hospital consultations, and 45 (9%) of the patients had to return directly to the hospital. Conclusions. The creation of a HaHP, for medical diseases, in internal medicine department that is highly coordinated with medical services of the hospital, especially with emergency, respiratory, and nutritional support teams, and with the primary health care, facilitates specialized home care of medical diseases and improves coordination with the primary health care

[Fast specialized ambulatory care of medical disease in an urban tertiary university hospital. Fast care consultation]. / Atención especializada ambulatoria rápidade patologías médicas desde un hospital universitario terciario. Consulta de atención inmediata.

INTRODUCTION: The experience of an urban tertiary university hospital in the design and establishment of Specialized Ambulatory Consultation (SAC) of Internal Medicine is presented. The purpose of this consultation is fast specialized ambulatory care of medical diseases, decrease of inappropriate hospitalizations and improvement of coordination with primary health care. PATIENTS AND METHOD: Systematic collection of the following variables in all the patients who visited the SAC between March 2006 and February 2007: origin, syndromic diagnosis and reason for consultation, age and gender, number of visits, examinations made, and destination on discharge. The descriptive statistical analysis was made in March 2007. RESULTS: A total of 744 patients with 1248 visits were seen (successive/first ratio of 0.67). Mean age was 62.56 (18.6) years and 50.6% were women. The hospital origin/primary origin went from 3.5 - 4 in the first quarter to between 2.6 - 2.8 in the last quarter. The main reasons for consultation due to patient with constitutional or anemic syndromes with suspicion of serious disease and patients with decompensation of chronic diseases or infectious disease. Half of the patients returned to primary care and the rest were distributed among different hospital resources. It stands out that 30% were sent to the hospital consultations and 10% required hospitalization or transfer to the emergency room. CONCLUSIONS: The SAC is a Fast Consultation Care (diagnosis and treatment) of general internal medicine located in a tertiary university hospital with a good capacity of resolution. It facilitates Specialized Ambulatory Care of medical diseases, decreasing inappropriate hospitalization and improving coordination with the Primary Health Care.

Atención especializada ambulatoria rápidade patologías médicas desde un hospital universitario terciario. Consulta de atención inmediata / Fast specialized ambulatory care of medical disease in an urban tertiary university hospital. Fast care consultation

Introducción. Se presenta la experiencia de un hospital universitario terciario urbano en el diseño e implementación de una consulta de atención inmediata (CAI) de medicina interna que tiene como objetivo la atención especializada ambulatoria rápida de patologías médicas, la disminución de ingresos inadecuados y la mejora de la coordinación con la Atención Primaria de salud. Material y métodos. Recogida sistemática en todos los pacientes visitados en la CAI entre marzo de 2006 y febrero de 2007 de las siguientes variables: procedencia, orientación sindrómica y motivo de consulta, edad y sexo, número de visitas, exploraciones realizadas y destino al alta. El análisis estadístico descriptivo se realizó en marzo de 2007. Resultados. Se han visitado 744 pacientes, realizándose un total de 1.248 vistas (ratio sucesivas/primeras de 0,67). La edad media fue de 62,56 (18,6) años y un 50,6% fueron mujeres. La ratio procedencia hospital/procedencia primaria pasó de 3,5 a 4 en el primer trimestre a 2,6-2,8 en el último trimestre. Los principales motivos de consulta fueron pacientes con síndromes constitucionales o anémicos con sospecha de enfermedad grave y pacientes con agudizaciones de procesos crónicos o infecciones. La mitad de los pacientes volvieron a la primaria y el resto se distribuyó entre diferentes recursos hospitalarios, destacando un 30% que fueron remitidos a las consultas del hospital y un 10% que precisó ingreso hospitalario o traslado a Urgencias. Discusión. La CAI es una consulta de atención (diagnóstico y tratamiento) inmediata de medicina interna general ubicada en un hospital universitario terciario con una buena capacidad de resolución, facilitando la atención especializada ambulatoria de patologías médicas, disminuyendo los ingresos inadecuados y mejorando la coordinación con la Atención Primaria de salud (AU)

Introduction. The experience of an urban tertiary university hospital in the design and establishment of Specialized Ambulatory Consultation (SAC) of Internal Medicine is presented. The purpose of this consultation is fast specialized ambulatory care of medical diseases, decrease of inappropriate hospitalizations and improvement of coordination with primary health care. Patients and method. Systematic collection of the following variables in all the patients who visited the SAC between March 2006 and February 2007: origin, syndromic diagnosis and reason for consultation, age and gender, number of visits, examinations made, and destination on discharge. The descriptive statistical analysis was made in March 2007. Results. A total of 744 patients with 1248 visits were seen (successive/first ratio of 0.67). Mean age was 62.56 (18.6) years and 50.6% were women. The hospital origin/primary origin went from 3.5 - 4 in the first quarter to between 2.6 - 2.8 in the last quarter. The main reasons for consultation due to patient with constitutional or anemic syndromes with suspicion of serious disease and patients with decompensation of chronic diseases or infectious disease. Half of the patients returned to primary care and the rest were distributed among different hospital resources. It stands out that 30% were sent to the hospital consultations and 10% required hospitalization or transfer to the emergency room. Conclusions. The SAC is a Fast Consultation Care (diagnosis and treatment) of general internal medicine located in a tertiary university hospital with a good capacity of resolution. It facilitates Specialized Ambulatory Care of medical diseases, decreasing inappropriate hospitalization and improving coordination with the Primary Health Care (AU)

Geriatrización de los Servicios de Urgencias / Geriatrization of Emergency Services

No disponible

[Geriatric physical performance assessment in an emergency department]. / Valoración geriátrica de la función física en un Servicio de Urgencias.

BASIS: Premorbid situation with regard to daily life activities is an important prognostic factor in elderly people who needs medical care. This work analyzes the way the parameter evaluation of core processes of daily life (CPDL) is made in patients over 70 years cared in an Emergency Service because of diverse medical conditions. PATIENTS AND METHODS: A prospective study, carried out in a third level medical institution, on 200 patients over 70 years cared in the Emergency medical Service, with questioning a group of 60 physicians on duty (POD) about the informal or subjective assessments of five parameters of CPDL (to get dressed, to be fed, sphincter control, walking, and transfer). POD evaluation is compared with evaluation carried out formally by the research physician. Assessments are evaluated, grouping the patients according to the degree of dependency, age, or sex. RESULTS: 82% of most dependent patients and 53% of those older than 80 years were poorly assessed, and both parameters were statistically significant. The analysis with multiple linear regression showed that the intensity of these errors is only determined by a variable: the greater degree of dependency. CONCLUSIONS: Correct performance assessment of elderly patients in emergency services, especially of those older and most dependent, requires a specific training of professionals in this regard and the use of formal instruments of evaluation.

Valoración geriátrica de la función física en un Servicio de Urgencias / Geriatric physical performance assessment in an emergency department

Fundamento. Entre la población anciana que precisa atención médica, la situación premórbida, respecto a las actividades de la vida diaria, tiene un importante factor pronóstico. Este trabajo analiza cómo se realiza la evaluación de parámetros de actividades básicas de la vida diaria en pacientes de más de 70 años que acuden por patología médica a un Servicio de Urgencias. Pacientes y métodos. Estudio prospectivo, realizado en un hospital de tercer nivel, con 200 pacientes de más de 70 años atendidos en el Servicio de Urgencias médicas, interrogando a un grupo de 60 médicos de guardia de medicina las valoraciones informales o subjetivas de 5 parámetros de actividades básicas de la vida diaria (vestirse, alimentarse, control de esfínteres, deambulación y transferencias). Se compara la evaluación de los médicos de guardia con la realizada de manera formal por el médico investigador. Se evalúan las valoraciones, agrupando a los pacientes según el grado de dependencia, edad o sexo. Resultados. El 82% de los pacientes con más dependencia y el 53% de los mayores de 80 años estaban mal valorados; ambos hallazgos eran estadísticamente significativos. El análisis con regresión lineal múltiple detecta que la gravedad de dichos errores sólo está determinada por una variable: el mayor grado de dependencia. Conclusiones. La correcta valoración funcional de los pacientes ancianos en los servicios de urgencias, especialmente de los más mayores y más dependientes, exige la formación de los profesionales en este sentido y el uso de instrumentos formales de evaluación (AU)

Basis. Premorbid situation with regard to daily life activities is an important prognostic factor in elderly people who needs medical care. This work analyzes the way the parameter evaluation of core processes of daily life (CPDL) is made in patients over 70 years cared in an Emergency Service because of diverse medical conditions. Patients and methods. A prospective study, carried out in a third level medical institution, on 200 patients over 70 years cared in the Emergency medical Service, with questioning a group of 60 physicians on duty (POD) about the informal or subjective assessments of five parameters of CPDL (to get dressed, to be fed, sphincter control, walking, and transfer). POD evaluation is compared with evaluation carried out formally by the research physician. Assessments are evaluated, grouping the patients according to the degree of dependency, age, or sex. Results. 82% of most dependent patients and 53% of those older than 80 years were poorly assessed, and both parameters were statistically significant. The analysis with multiple linear regression showed that the intensity of these errors is only determined by a variable: the greater degree of dependency. Conclusions. Correct performance assessment of elderly patients in emergency services, especially of those older and most dependent, requires a specific training of professionals in this regard and the use of formal instruments of evaluation (AU)

[Predictors factors about functional decline in community-dwelling older persons]. / Factores predictores del deterioro funcional geriátrico.

OBJECTIVES: The goal of this work was to prove the usefulness of simple standard geriatrics tools as a predictors of basic daily activities or quality of life decline in one year in older patients apparent healthy to apply in primary care. DESIGN: Prospective study of a randomised sample of 100 patients. SETTING: Urban primary care center. PATIENTS: A systematic sample of 100 patients of 75 years old or older, with Barthel index > or =90, Karnofsky scale > or =70 and without any neoformation process evaluated prospectively. MEASUREMENTS: A comprehensive geriatric assessment was done that include: physical performance, neural-psychologist performance, organic assessment, social assessment. After 12 month were assessed again basic activities of daily living (Barthel) and quality of life (Karnofsky). To estimate the odds ratio (OR) of association we used logistic regression models. RESULTS: The alterations in cognition trials (Pfeiffer >2) and in instrumental activities of daily living (Lawton <7) showed predictors about decline in basic activities of daily living (OR=4.66; CI, 1.33-16.22), (OR=4.89; CI, 1.65-14.48). The alterations in instrumental activities of daily living (Lawton <7) and in performance tests (abbreviated Guralnik test <4) showed predictors about decline in quality of life (OR=4.31; CI, 1.62-11.44), (OR=7.41; CI, 1.54-35.62). CONCLUSION: In primary care geriatric assessment tools based in instrumental activities of daily living, cognition and performance tests predict decline in basic activities of daily living and quality of life.

Factores predictores del deterioro funcional geriátrico / Predictors factors about functional decline in community-dwelling older persons

Objetivo. Demostrar la utilidad de sencillos instrumentos geriátricos como predictores del deterioro de las actividades básicas de la vida diaria (ABVD) o pérdida de calidad de vida al año en ancianos con un estado de salud previo aparentemente bueno, para poder ser aplicado en atención primaria de la salud (APS).Diseño. Estudio prospectivo. Emplazamiento. Centro de atención primaria urbano. Participantes. Muestra sistemática de 100 ancianos con edad >= 75 años, índice de Barthel (IB) >= 90, escala de Karnofsky (EK) >= 70 y ausencia de proceso neoplásico. Mediciones principales. Se les aplicó un protocolo de valoración geriátrica integral que incluía variables biopsicosociales y funcionales. Tras 12 meses se revaloraron las ABVD (IB) y la calidad de vida (EK).Se realizó la estimación de las odds ratio (OR) de asociación mediante modelos de regresión logística múltiples. Resultados. Las alteraciones en las pruebas de cognición (test de Pfeiffer > 2) y en las actividades instrumentales de la vida diaria (AIVD) (índice de Lawton [IL] < 7) se mostraron predictoras del deterioro en las ABVD (OR = 4,66; intervalo de confiaza [IC], 1,33-16,22, y OR = 4,89; IC, 1,6514,48, respectivamente).Las alteraciones en las AIVD (IL < 7) y las alteraciones en las pruebas de rendimiento (test de Guralnik abreviado < 4) se mostraron predictores del deterioro de la calidad de vida (OR = 4,31; IC, 1,62-11,44, y OR = 7,41; IC, 1,54-35,62, respectivamente).Conclusiones. En APS, los instrumentos de valoración geriátrica centrados en las AIVD, la cognición y las pruebas de rendimiento predicen el deterioro en las ABVD y en calidad de vida (AU)

[The risk factors for Clostridium difficile infection in elderly patients. A case-control study]. / Factores de riesgo de infección por Clostridium difficile en pacientes ancianos. Estudio de casos y controles.

BACKGROUND: To study the main risk factors associated with Clostridium difficile infection in a geriatric unit. PATIENTS AND METHOD: Retrospective case-control study. RESULTS: In a multivariate analysis, tube feeding (OR = 6.73; IC 95%, 1.01-45.35) and length of antibiotic therapy (OR = 1.15; IC, 95% 1.01-1.28) were independent variables which associated with C. difficile infection. CONCLUSIONS: Antibiotic treatment, tube feeding and fragility are associated with C. difficile infection.

[Comorbidity, hospitalization, and drug use for non-exacerbated chronic disease in the elderly population]. / Comorbilidad, ingreso hospitalario y consumo de fármacos por enfermedad crónica no reagudizada en población anciana.

OBJECTIVES: To evaluate the prevalence of comorbidity among elderly hospitalized patients and its influence on discharge diagnosis and medication due to non-exacerbated chronic disease (NECD). To evaluate the impact of hospital admission on the use of drugs due to NECD since admission to the month of discharge. METHODS: A study was made of 85 patients aged 65 years or older collected during two consecutive months. The study protocol consisted of a questionnaire on comorbidity, study of drug consume, discharge diagnosis and follow-up for one month post discharge. RESULTS: Patients had a mean of 6.4 chronic diseases; significant differences were observed regarding discharge report (mean: 2.1). The number of drugs due to NECD prior to admission (mean: 2.9), at discharge (1.5) and one month after discharge (1.9) showed significant differences between those prior to admission, at discharge, and one month after discharge (p < 0.0001). Hospital admission involved a decrease (p < 0.0001) in the number of patients with polypharmacy criteria (more than four drugs), which persisted one month after discharge (p < 0.01), and in the prescription of polyvitaminic compounds, nonsteroid antiinflammatory drugs, antiaggregants, peripheral vasodilators and antacids (p < 0.03). CONCLUSIONS: A relevant under-reporting of chronic diseases in the discharge report, particularly of those without exacerbations, as well as quantitative (decrease) and qualitative changes in the prescription due to NECD, maintained by the general practitioner one month after discharge. A higher awareness regarding chronic disease is necessary, as well as chronic disease is necessary, as well as establishing communication channels between Primary and Specialized Care.

[Hemorrhagic complications and thrombotic phenomena in oral anticoagulation of elderly patients]. / Complicaciones hemorrágicas y fenómenos trombóticos en la anticoagulación oral de pacientes ancianos.

OBJECTIVE: To retrospectively analyze the hemorrhagic complications and thrombotic events associated with aging and the degree of anticoagulation in a series of ambulatory patients treated with acenocumarol and controlled in a specialized anticoagulant therapy unit. PATIENTS AND METHODS: A total of 1,613 ambulatory patients were studied. Patients were divided into two groups (group 1, 645 patients > 65 years old, mean age 71.7 +/- 4.5 years; INR, 2.1-2.8; group 2, 968 patients < or = 65 years, mean age 53.7 +/- 10 years; INR, 2.8-4.2) for a time period of twelve months. The prevalence of hemorrhagic complications and severity according to a validated international index (Bleeding Severity Index), as well as the thrombotic events occurred despite anticoagulation therapy. RESULTS: Fifty-two hemorrhagic events (8/100 patients-year) were recorded in the older group (group 1). Twenty-six cases were considered banal episodes, 24 minor hemorrhages and two major hemorrhages. Ten patients (1.5/100 patients-year) had thrombotic complications. In the younger group (group 2) 150 bleeding episodes were recorded (15 patients-year), of which 11 were banal, 39 minor hemorrhages and no major hemorrhages. Only eight patients 0.8/100 patients-year) had thrombosis. The presence of local factors predisposing to bleeding was more common in group 1 (p < 0.001). Older patients had in general more complications than younger patients (p < 0.001), but no significant differences were observed between the occurrence of hemorrhages or thrombosis independently analyzed between both groups. The rate in the therapeutic range was greater among the youngest individuals (p < 0.05). CONCLUSIONS: Our results support the idea that patients with advanced age can benefit from a less aggressive anticoagulation. A statistical trend was observed, although not significant, towards the presence of major hemorrhages and thrombosis in this group of patients. The presence of local or predisposing factors to hemorrhage (underlying disease and NSAIDs use) is more relevant in patients with advanced age.