Admission decisions to a medical intensive care unit are based on functional status rather than severity of illness. A single center experience.

BACKGROUND: Few data exist on Medical Intensive Care Unit (MICU) triage practices. We assessed MICU triage practices in our medical center. METHODS: We collected data on all MICU consultations for one year, including each patient's APACHE II score at time of consultation. We assessed functional impairment at baseline and at time of MICU consultation. RESULTS: A total of 54% out of 572 consultations resulted in admission. Patients were less likely to be admitted if baseline functional status was poor (OR, 0.29; 95% CI 0.17-0.50), if a do-not-resuscitate order was present (OR, 0.44; 95% CI, 0.21-0.89), and if the MICU attending spent more than 25% of professional time in MICU (OR, 2.44; 95% CI, 1.37-4.32). Patients were more likely to be admitted if functional status at time of MICU consultation was poor (OR, 2.30; 95% CI 1.46-3.48). Patients' age, insurance, ethnicity, severity of illness, presence of malignancy, or whether patient's primary physician was on staff were not independently associated with MICU admission decisions. MICU attendings rarely cited functional status as reason for MICU refusal on the consult forms. CONCLUSION: MICU admission decisions are implicitly based on patients' baseline functional status rather than severity of illness.

Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures. The Antibiotic Prophylaxis Study Group.

BACKGROUND: Twenty-five percent of all nosocomial infections are wound infections. Professional guidelines support the timely use of preoperative prophylaxis for prevention of postoperative wound infections. Barriers exist in implementing this practice. IPRO, the New York State peer review organization, as part of the Health Care Financing Administration's Health Care Quality Improvement Program, sought to determine the proportion of patients receiving timely antibiotic prophylaxis for aortic grafts, hip replacements and colon resections in 44 hospitals in New York State. METHODS: IPRO conducted a retrospective medical record review of 44 hospitals through out New York State stratified for teaching, nonteaching status. A sample was drawn of 2651 patients, 2256 from Medicare and 395 from Medicaid, undergoing either abdominal aortic aneurysm repair, partial or total hip replacement or large bowel resection. The study determined the proportion of patients who had documentation of receiving antibiotics and those who received antibiotics timely, that is less than or equal to 2 hours preoperatively. RESULTS: Eighty-six percent of patients had documentation of receiving an antibiotic. Forty-six percent of aneurysm repairs and 60% of hip replacements had evidence of receiving timely antibiotic prophylaxis, that is within 2 hours prior to surgery. For colon resections, 73% of cases had either oral prophylaxis or timely parenteral therapy. An increased proportion of patients had received parenteral antibiotics prematurely as the surgical start time occurred later in the day. A total of 44 different antibiotics were recorded for prophylaxis. CONCLUSIONS: Antibiotic prophylaxis was performed in 81% to 94% of cases, however, anywhere from 27% to 54% of all cases did not receive antibiotics in a timely fashion. By delegating implementation of ordered antibiotic prophylaxis to the anesthesia team, timing may be improved and the incidence of postoperative wound infections may decrease.

Inpatient treatment patterns of human immunodeficiency virus-associated Pneumocystis carinii pneumonia in New York State Medicare patients.

Hospital charts were reviewed to ascertain the frequency with which patients with human immunodeficiency virus (HIV)-associated Pneumocystis carinii pneumonia (PCP) were being managed in accordance with current guidelines or recommendations in New York State for the calendar year 1993. Comparisons were made between hospitals that are designated by the New York State Department of Health as comprehensive treatment centers--designated acquired immunodeficiency syndrome (AIDS) centers--and all other hospitals. For patients who had been on PCP prophylaxis before admission, 34% had documentation of positive histologic evidence for PCP infection during the studied hospitalization period. Of all patients not on PCP prophylaxis at the time of admission, 94% had at least one of the diagnostic tests for PCP done during the PCP hospitalization. Eighty-one percent of all patients had either pulse oximetry or an arterial blood gas determination. Seventy-seven percent of all patients with a PO2 equal to or less than 70 mm Hg received steroids. All eligible patients received one of nine possible treatment combinations, which included either single drug therapy, multiple drug therapy, or participation in a clinical trial. Sixteen percent of eligible patients had no documentation of receiving PCP medication at discharge. Proportions receiving diagnostic or treatment interventions were usually higher in designated AIDS centers than in non-designated AIDS centers.

The outcomes of patients newly admitted to nursing homes after hip fracture.

OBJECTIVES: The outcomes of elderly, hospitalized patients discharged to nursing homes after hip fracture were examined. METHODS: For 2624 hip fracture patients admitted to any of 43 proprietary nursing homes between 1984 and 1988, admission assessments were examined in relation to 1-month outcomes. RESULTS: Mean patient age was 82 +/- 7 y; 85% of the sample were female. Within 1 month after discharge, 24% had returned home, 12% had been rehospitalized, 3% had died, and 61% remained in the nursing home. Characteristics significantly associated with morality included disorientation, functional dependency, neurologic diagnoses, and use of cardiac medications, antidepressants, or narcotics. Rehospitalization was significantly associated with age, gender, living with someone, being ambulatory, and functional dependency. Returning home was associated with younger age, living with someone, being ambulatory, and having no disorientation, functional dependency, or psychiatric or neurologic diagnoses, nor any pressure sores. CONCLUSIONS: Better-functioning persons and those with social support returned home; physically and cognitively impaired persons and those taking narcotics, cardiac medications, or antidepressants were likely to die; and younger men, those with social support, those with functional dependency, and those who were free of disorientation were more likely to be rehospitalized.

Evaluating the predictive validity of nursing home pre-admission screens.

This article demonstrates a method for evaluating the predictive validity of nursing home pre-admission screens (PAS) by using measures of predictive validity adapted from the field of epidemiology. Our approach estimates how well as PAS performs in identifying the "who but for" population of the Medicaid home and community-based services waiver programs for the frail elderly. The methodology's usefulness in screen revision is also illustrated.

Efficacy of nursing home preadmission screening.

This study evaluates the efficacy of four state nursing home preadmission screening instruments. Using data from three community-based services demonstration experiments, the screens were compared on measures of sensitivity, specificity, and proportions of false negatives and false positives. Results indicate that the more restrictive screens tended to have lower sensitivity but higher specificity, and to generate a higher proportion of false negative decisions than the more liberal screens. Overall rates of correct prediction were higher for the more restrictive screens. Results highlight differences in eligibility restrictiveness across states as well as possible tradeoffs of cost containment and access in designing a preadmission screen.