The effect of a rotating night-float coverage scheme on preventable and potentially preventable morbidity at a level 1 trauma center.

BACKGROUND: The effect of resident work-hour restriction on patient outcome remains controversial. METHODS: Demographic data, mechanism of injury, length of hospital stay length of intensive care unit (ICU) stay, ventilator days, mortality, and complication data were prospectively collected for 11 months before and 11 months after institution of a rotating night-float system. Seven attending surgeons reviewed all complications and categorized each as preventable, potentially preventable, or nonpreventable. RESULTS: Both study periods were comparable with respect to demographic data, mean Injury Severity Score, mechanism of injury, and admissions. Limitation of resident work hours had no effect on length of hospital or ICU stay, ventilator days, or mortality. Work-hour restrictions did not increase or decrease the total number of complications nor did it alter the distribution of those determined to be preventable or potentially preventable. CONCLUSIONS: Resident work-hour restrictions were not associated with significant improvement or deterioration in patient outcome.

Night-shift discharge from intensive care unit increases the mortality-risk of ICU survivors.

UNLABELLED: Intensive Care (ICU) survivors discharged from ICU to the general ward at night have a higher mortality. We sought to clarify which factors, including night-shift discharge, influence outcome following ICU discharge in a metropolitan hospital, using a cohort study of critically-ill patients between 1/1/1999-30/4/2003. Patients were excluded from analysis if they (a) died in ICU, (b) were transferred to another hospital, (c) had an ICU length of stay <8 hours, or (d) age <16 years. Logistic regression was used to derive a predictive model based on the following variables: patient demographics, severity of illness following ICU admission (APACHE II mortality-risk, p(m)), final diagnosis, discharge timing including premature or delayed (>4 hours) ICU discharge, and "limitation of medical treatment" orders. The outcome measures were patient status at hospital discharge and ICU readmission rate. Of the 1870 ICU survivors, 92 (4.9%) died after discharge from ICU. Patients discharged to the ward during the night-shift (2200-0730 hours) had a higher APACHE II score and crude mortality. The difference in APACHE II p(m) did not reach statistical significance. No significant calendar or seasonal pattern was identified. Logistic regression identified night-shift discharge (RR=1.7; 95% CI 1.03-2.9; P=0.03), limited medical treatment order (RR=5.1; 95% CI 2.2-12) and admission APACHE II p(m) (RR=3.3; 95% CI 1.3-7.6) as independent predictors of patient outcome following ICU transfer to the ward. CONCLUSION: At the time of ICU discharge to the ward three factors are predictive of hospital outcome: timing of ICU discharge, limited medical treatment orders and initial illness severity.

Cognitive deficit and the prediction of rehabilitation success in a chronic psychiatric group.

This paper describes the second stage (years 4, 5 and 6) of a prospective follow-up of a sample of chronic patients which was designed to investigate the in service use. It also tested the relative predictive power of variables which included demographic, symptomatic and behavioural factors as well as a novel reaction time variable which reflects response processing time. During the six years of the study 91% of the patients in the sample changed either the degree of their day and/or night care. Many moved to more independence but, a number did also become more dependent on psychiatric services. There were no differences in outcome between a schizophrenic group and patients with other diagnoses. These results suggest a level of flexibility in outcome even in a severely disabled chronic group. The main predictor of future service use at each stage of the follow-up for the whole group was chronicity at entry to the study. But, when the group was divided into schizophrenic patients and 'others', the response processing measure was a significant predictor of service use in the schizophrenic group and accounted for between 17% and 30% of the variance. For the 'other' diagnostic group, the age of the patient seemed to be the major determinant of care. The reaction time variable seems to be an extra class correlate of a strict diagnosis of schizophrenia. It may also be a stable or episodic vulnerability factor, but as well as these promising hypotheses, which have yet to be justified, this measure does seem to have pragmatic value in predicting outcome in a rehabilitation network.

[Development of semi-inpatient care]. / Entwicklung der semistationären Betreuung.

Changes in the concepts of psychiatric care have led to a relaxation of the strict division of care into out-patient and inpatient care. The complex care of patients, the demand for more diagnosis-specific care of good quality require more multifarious kinds of care. Concerning patients which are not in need of the comprehensive care performances necessary to bedridden patients for other specialized fields. As can be seen from literature, this kind of care has not yet taken its due place in practice despite good experience over a period of more than 50 years. This would require unisonous views of semi-in-patient care, its documentation and mode of accounting up to issues of social insurance.

[Full inpatient versus partial inpatient psychiatric after-care--a comparative retrospective study]. / Vollstationäre versus halbstationäre psychiatrische Anschlussbehandlung--Eine vergleichende retrospektive Studie.

In a retrospective study 80 inpatients (Sociotherapy, Therapeutic Community) were compared to 160 outpatients (80 patient Day Clinic, 80 patients Night Clinic). With a mean treatment duration of 4-5 1/2 month a significant decrease was found for each group in the frequency and duration of further hospital admissions after end of therapy. Day and Night Clinic patients tending to a better outcome than the inpatients. Advantages of the Day and Night Clinic are seen e.g. in a higher degree of acceptance by patients and family doctors, disadvantages in the increased rate of suicide found in our sample.

[Reduction of complete inpatient treatment by a system of partial hospitalization, ambulatory and complementary services]. / Zur Reduktion vollstationärer Behandlung durch ein System teilstationärer, ambulanter und komplementärer Dienste.

This study aimed at investigating whether psychiatric care and especially partial hospitalisation programmes would achieve a reduction in time and cost of inpatient care. Frequency and duration of hospital treatments were studied in chronic psychotic patients (mean duration of illness = 8.7 years) before and after admission to a comprehensive community care system. The system includes partial hospitalisation programmes, out-patient care and various community services. Frequency and duration of hospital treatments were found to be lowered to less than 50%. However, since there were long periods of partial hospitalisation in addition to in-patient treatment, the remaining time of out-patient care was reduced. This result can be found mainly during the first year after admission and applies in particular to elderly and particularly chronic patients. In discussing the findings, treatment costs were also considered.

[Experience with psychotherapeutic work with schizophrenics in an adolescent psychotherapy department]. / Opyt psikhoterapevticheskoi raboty s bol'nymi shizofreniei v usloviiakh podrostkovogo psikhoterapevticheskogo otdeleniia.

Organization of and experience gained so far by the Psychotherapy Department for adolescents, a unique establishment of this type in the Soviet Union, are described. This department has a multi-stage structure, and its activities are based on a complete non-constraint of patients' behavior. The therapeutic complex that includes psychotherapeutic management, therapeutic education and the climate of the Department is conventionally called as "joy therapy". The therapeutic and rehabilitation facilities of the Department proved adequate in diagnosing patients suffering from schizophrenia.