The Use of Risk Scores for Thromboprophylaxis in Medically Ill Patients-Rationale and Design of the RICO trial.

Background Venous thromboembolism (VTE) in hospitalized medically ill patients is a significant cause of morbidity and mortality. Guidelines suggest that VTE and bleeding risk assessment models (RAMs) should be integrated into the clinical decision-making process on thromboprophylaxis. However, poor evidence is available comparing the use of a RAM versus clinical judgement in evaluating VTE and bleeding occurrence. Methods Reducing Important Clinical Outcomes in hospitalized medical ill patients (RICO) is a multicenter, cluster-randomized, controlled clinical trial (ClinicalTrials.gov Identifier: NCT04267718). Acutely ill patients hospitalized in Internal Medicine wards are randomized to the use of RAMs-namely the Padua Prediction Score and the International Medical Prevention Registry on Venous Thromboembolism Bleeding Score-or to clinical judgement. The primary study outcome is a composite of symptomatic objectively confirmed VTE and major bleeding at 90-day follow-up. Secondary endpoints include the evaluation of clinical outcomes at hospital discharge and the assessment of VTE prophylaxis prescription during the study period. In order to demonstrate a 50% reduction in the primary outcome in the experimental group and assuming an incidence of the primary outcome of 3.5% in the control group at 90-day; 2,844 patients across 32 centers will be included in the study. Discussion The RICO trial is a randomized study of clinical management assessing the role of RAMs in hospitalized medical ill patients with the aim of reducing VTE and bleeding occurrence. The study has the potential to improve clinical practice since VTE still represents an important cause of morbidity and mortality in this setting.

Prediction of in-hospital bleeding in acutely ill medical patients: External validation of the IMPROVE bleeding risk score.

INTRODUCTION: Pharmacological thromboprophylaxis slightly increases bleeding risk. The only risk assessment model to predict bleeding in medical inpatients, the IMPROVE bleeding risk score, has never been validated using prospectively collected outcome data. METHODS: We validated the IMPROVE bleeding risk score in a prospective multicenter cohort of medical inpatients. Primary outcome was in-hospital clinically relevant bleeding (CRB) within 14 days of admission, a secondary outcome was major bleeding (MB). We classified patients according to the score in high or low bleeding risk. We assessed the score's predictive performance by calculating subhazard ratios (sHRs) adjusted for thromboprophylaxis use, positive and negative predictive values (PPV, NPV), and the area under the receiver operating characteristic curves (AUC). RESULTS: Of 1155 patients, 8 % were classified as high bleeding risk. CRB and MB within 14 days occurred in 0.94 % and 0.47 % of low-risk and in 5.6 % and 3.4 % of high-risk patients, respectively. Adjusted for thromboprophylaxis, classification in the high-risk group was associated with an increased risk of 14-day CRB (sHR 4.7, 95 % confidence interval [CI] 1.5-14.5) and MB (sHR 4.9, 95%CI 1.0-23.4). PPV was 5.6 % and 3.4 %, while NPV was 99.1 % and 99.5 % for CRB and MB, respectively. The AUC was 0.68 (95%CI 0.66-0.71) for CRB and 0.73 (95%CI 0.71-0.76) for MB. CONCLUSION: The IMPROVE bleeding risk score showed moderate to good discriminatory power to predict bleeding in medical inpatients. The score may help identify patients at high risk of in-hospital bleeding, in whom careful assessment of the risk-benefit ratio of pharmacological thromboprophylaxis is warranted.

Undertaking risk and relational work to manage vulnerability: Acute medical patients' involvement in patient safety in the NHS.

Over the last decade a wealth of studies have explored the way that patients are involved in patient safety internationally. Most begin from the premise that patients can and should take on the role of identifying and reporting safety concerns. Most give little attention, however, to the impact of the patient's health status and vulnerability on their ability to participate in their safety. Drawing on qualitative interviews with 28 acute medical patients, this article aims to show how patients' contributions to their safety in the acute medical context are less about involvement as a deliberate intervention, and more about how patients manage their own vulnerability in their interactions with staff. Our analysis is underpinned by theories of vulnerability and risk. This enables us to provide a deeper understanding of how vulnerability shapes patients' involvement in their safety. Acute medical patients engage in reassurance-seeking, relational and vigilance work to manage their vulnerability. Patients undertake reassurance seeking to obtain evidence that they can trust the organisation and the professionals who work in it and relational and vigilance work to manage the vulnerability associated with dependence on others and the unpredictability of their status as acute medical patients. Patients are made responsible for speaking up about their care but simultaneously, by virtue of the expectations of the sick role and their relational vulnerability, encouraged to remain passive, compliant or silent. We show how risk frames the extent to which patients can activate their role in creating patient safety at the point of care. Foregrounding the theory of vulnerability, the concept of the sick role and the relationship of both to risk offers new insights into the potentials and limits of patient involvement in patient safety in the acute care context.

From expected to actual barriers and facilitators when implementing a new screening tool: A qualitative study applying the Theoretical Domains Framework.

AIM AND OBJECTIVES: To identify determinants for using a new screening tool to identify older patients eligible for targeted nurse-led intervention, as perceived by healthcare professionals implementing the tool, and to examine how these perceptions changed over time. DESIGN: A cross-sectoral longitudinal qualitative study based on semi-structured interviews with healthcare professionals in a Danish hospital and two collaborating municipalities. METHODS: In three focus groups, seven single interviews and a workshop, we examined the healthcare professionals' perceptions of and attitudes towards the new screening tool before, during and after the implementation. The Theoretical Domains Framework was used to identify the healthcare professionals' perception of barriers and facilitators, followed by content analysis. The results were further discussed using the COM-B system as an analytic framework. This qualitative study is reported according to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist. RESULTS: 'Professional role', 'Goals' and 'Environmental context' were the domains most talked about by the healthcare professionals across the three time points. The content analysis identified four determinants for using the new screening tool:Making time for the project, External motivation and management, Expectations and reality, and Professional identity. The healthcare professionals' perception of the determinants changed during the implementation, influencing their behaviour and, consequently, the implementation's sustainability. CONCLUSION: Perception of barriers and facilitators to the interventions were time- and context-sensitive. Beliefs and motivational factors changed during the project, which points out the importance of following implementation processes systematically to understand the outcome of an intervention. RELEVANCE FOR CLINICAL PRACTICE: Perceptions and attitudes towards a new initiative may change over time, emphasising the importance of following barriers and facilitators during the implementation of an intervention and working with an implementation plan that can be adapted along the way.

Effects of a transitional care intervention on readmission among older medical inpatients: a quasi-experimental study.

PURPOSE: To evaluate the effect of a transitional care intervention (TCI) on readmission among older medical inpatients. METHODS: This non-randomised quasi-experimental study was conducted at Horsens Regional Hospital in Denmark from 1 February 2017 to 31 December 2018. Inclusion criteria were patients ≥ 75 years old admitted for at least 48 h. First, patients were screened for eligibility. Then, the allocation to the intervention or control group was performed according to the municipality of residence. Patients living in three municipalities were offered the hospital-based intervention, and patients living in a fourth municipality were allocated to the control group. The intervention components were (1) discharge transportation with a home visit, (2) a post-discharge cross-sectorial video conference and (3) seven-day telephone consultation. The primary outcome was 30-day unplanned readmission. Secondary outcomes were 30- and 90-day mortality and days alive and out of hospital (DAOH). RESULTS: The study included 1205 patients (intervention: n = 615; usual care: n = 590). In the intervention group, the median age was 84.3 years and 53.7% were females. In the control group, the median age was 84.9 years and 57.5% were females. The 30-day readmission rates were 20.8% in the intervention group and 20.2% in the control group. Adjusted relative risk was 1.00 (95% confidence interval: 0.80, 1.26; p = 0.99). No significant difference was found between the groups for the secondary outcomes. CONCLUSION: The TCI did not impact readmission, mortality or DAOH. Future research should conduct a pilot test, address intervention fidelity and consider real-world challenges. TRIAL REGISTRATION: Clinical trial number: NCT04796701. Registration date: 24 February 2021.

VTE Prophylaxis Therapy: Clinical Practice vs Clinical Guidelines.

Introduction: Venous thromboembolism (VTE) is the most preventable complication in hospitalized patients. The main objective of this study was to evaluate the adherence of current clinical practice to the established guidelines at a Palestinian teaching hospital. Methods: This cross-sectional, retrospective, observational study was conducted at a Palestinian Teaching Hospital. The medical records of patients admitted to the medical floor over 18 years of age and hospitalized for longer than 24 hours between January 1 and May 31, 2019, were included. Patients taking anticoagulants with incomplete or duplicated medical records were excluded from the study. A data collection sheet was developed, and clotting and bleeding risks were assessed using the Padua and IMPROVE risk assessment models (scores). The data were analyzed using IBM SPSS (version 25). Results: In total, 408 patients were included in the study, 222 of whom received thromboprophylaxis (54.4%). Of the hospitalized patients, 112 (27.5%) had a high risk of developing VTE (Padua score ≥ 4), and 73 patients were eligible for VTE pharmacological prophylaxis; however, only 44 (60.3%) received the appropriate prophylaxis. In addition, 296 patients had low Padua scores, indicating that pharmacological prophylaxis was not indicated. However, 144 (48.6%) patients received prophylaxis. The mean Padua and IMPROVE risk scores were 2.25 ± 2.08 and 4.44 ± 2.72, respectively. Among the patients, 17.6% had a high risk of bleeding (IMPROVE score ≥ 7). Conclusion: VTE prophylaxis among hospitalized medically ill patients was mostly inappropriate; 80.18% of the patients received inappropriate prophylaxis, and only 60.3% of eligible patients received appropriate prophylaxis. Adapting assessment models or checklists in clinical practice based on clinical guidelines for VTE risk stratification is a practical and effective method to improve VTE prophylaxis management and select the appropriate therapy to prevent toxicity or complication.

Age-dependent differences in energy metabolism in the acute phase of critical illness.

OBJECTIVES: Resting energy expenditure (REE) declines with age in healthy individuals, independent of the age-related decrease in lean body mass. The aim of this study was to evaluate whether this holds true in critically ill medical patients. Moreover, we assessed how measured REE compares with energy requirements calculated by prediction equations in different age groups. METHODS: In this retrospective cohort study, 200 critically ill medical patients with need for mechanical ventilation underwent indirect calorimetry within 72 h of admission after an overnight fast to determine REE. REE was adjusted for body weight (REEaBW). Patients were divided into age quartiles (I: 18-35, n = 21; II: 36-52, n = 43; III 53-69, n = 93; IV = 70-86 y, n = 43). Sex, Simplified Acute Physiology Score II, temperature at time of measurement, height, weight, and body mass index were assessed. We calculated energy requirements by Harris-Benedict and Mifflin-St. Jeor equations. Kruskal-Wallis test was used for group comparisons. Parameters that were significant in univariate regression entered the multivariate regression model. RESULTS: REE (P = 0.009) and REEaBW (P < 0.001) declined with age in our study population. Multivariate regression reveals age (R = -8.49 (95% CI -8.30- -1.83), P = 0.003), P = 0.004) and body temperature (R = 92.52 (95% CI 40.08-135.97, P < 0.001) as independent predictors for REE. CONCLUSION: REE and REEaBW decrease with age in critically ill medical patients. Age and body temperature are independent predictors of both REE and REEaBW. Prediction equations underestimate energy requirements in critically ill medical patients.

Phase Angle Is a Stronger Predictor of Hospital Outcome than Subjective Global Assessment-Results from the Prospective Dessau Hospital Malnutrition Study.

This prospective cohort study of 16,943 consecutive patients compared phase angle (PhA, foot-to-hand at 50 kHz) and subjective global assessment (SGA) to predict outcomes length of hospital stay (LOS) and in-hospital mortality in patients at risk of malnutrition (NRS-2002 ≥ 3). In 1505 patients, the independent effects on LOS were determined by competing risk analysis and on mortality by logistic regression. In model I, including influence factors age, sex, BMI, and diagnoses, malnourished (SGA B and C) patients had a lower chance for a regular discharge (HR 0.74; 95%CI 0.69−0.79) and an increased risk of mortality (OR 2.87; 95%CI 1.38−5.94). The association of SGA and outcomes regular discharge and mortality was completely abrogated when PhA was added (model II). Low PhA reduced the chance of a regular discharge by 53% in patients with a PhA ≤ 3° (HR 0.47; 95%CI 0.39−0.56) as compared to PhA > 5°. Mortality was reduced by 56% for each 1° of PhA (OR 0.44; 95%CI 0.32−0.61). Even when CRP was added in model III, PhA ≤ 3° was associated with a 41% lower chance for a regular discharge (HR 0.59; 95%CI 0.48−0.72). In patients at risk of malnutrition, the objective measure PhA was a stronger predictor of LOS and mortality than SGA.

Feasibility and implementation fidelity of a co-designed intervention to promote in-hospital mobility among older medical patients-the WALK-Copenhagen project (WALK-Cph).

BACKGROUND: Mobility interventions can prevent functional decline among older patients, but implementation of such interventions may be complicated by barriers in the clinical setting. The WALK-Copenhagen project (WALK-Cph) is aimed at promoting a 24-h mobility among older medical patients during hospitalization. The WALK-Cph intervention was co-designed by researchers and stakeholders to tailor the intervention to the clinical context. The aim of this study was to investigate the feasibility and implementation fidelity of the WALK-Cph intervention before evaluating clinical effectiveness in a randomized controlled trial (ClinicalTrials.gov NCT03825497). METHODS: The WALK-Cph intervention consisted of six components: a welcome folder explaining the importance of in-hospital activity, a WALK-plan prescribing up to three daily walking sessions during and after hospitalization, a WALK-path in the hallway that patients were motivated to use daily, exercise posters in the hallways and bedrooms, self-service on beverages and clothes, and discharge with a WALK-plan. The present study reports on phase 2 of WALK-Cph and consists of a feasibility and a fidelity component. The study was conducted at the two WALK-Cph intervention departments after the initiation of the WALK-Cph intervention. A cohort of older medical patients (+65) was recruited for the feasibility study to assess recruitment and data collection procedures and the method for assessment of activity. Simultaneously, implementation fidelity was assessed by observing clinical practice and intervention delivery at the intervention departments. RESULTS: A feasibility cohort of 48 patients was included. Inclusion was considered feasible with recruitment rates between 62% and 70% of all eligible patients. Also, data collection was conducted without obstacles, and all patients accepted to wear activity monitors. The fidelity observations showed that three of the six intervention components were partially implemented as planned whereas three components were not implemented as planned. CONCLUSION: The WALK-Cph intervention was found feasible, and although the intervention was not implemented with fidelity, the level of fidelity was considered sufficient to continue with further testing of the WALK-Cph intervention in a large-scale trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT03825497 (retrospectively registered). Protocol PubMed ID (PMID): 29523569.

Depression in internal medicine inpatients at the time of hospital discharge and referral to primary care

Background and objectives. This is the first multi-center study intended to document the prevalence, characteristics, and associations of depression in Medicine patients at the time of hospital discharge and their referral to Primary Care (PC). Methods. Adult patients randomly selected among consecutive admissions to Medicine wards in 8 hospitals in Spain, covering health districts, were examined in a two-phase 'case-finding' procedure. Standardized, Spanish versions of instruments were used, including the Standardized Polyvalent Psychiatric Interview (SPPI) and Cumulative Illness Rating Scale (CIRS). Cases of depression were diagnosed according to ICD-10 general hospital research criteria. Results. Three hundred and twelve patients with treatable depression and 777 non-depressed controls were identified. In a conservative estimate, the global prevalence of major depression was 7.1%, dysthymia 4.2% and adjustment depression 7.1%, and 51.9% of cases were of moderate/ severe intensity. Depression was more frequent in women, the differences being significant in all categories of depression. The prevalence of depression was lower in individuals aged 85 or more years, the differences being significant in cases of both dysthymia and adjustment depression. A clear pattern of decreasing prevalence with age was observed in women. The depressed had as an average five medical systems affected, and higher CIRS scores compared with the controls, the differences being significant in cases of both major depression and dysthymia. Conclusions. This is the first report showing a considerable prevalence of treatable cases of depression in Medicine patients at the time of hospital discharge and referral to PC. Depression is associated with the severity of the medical condition, and differences observed by age and sex have clinical implications. Paper read at the 3rd Annual Meeting of the European Association of Psychosomatic Medicine, Nuremberg 2015.

Intersectoral Ward Rounds on Patients Admitted to Temporary Twenty-Four-Hour Accommodations in Denmark: Case Study.

INTRODUCTION: Temporary twenty-four-hour accommodations (TTAs) are municipal beds for elderly patients discharged from the hospital with acute treatment, care and/or rehabilitation needs that cannot be met in their own homes. TTAs are staffed by nurses and nursing assistants who are not authorized to prescribe or modify medications. At North Zealand Hospital one third of the many readmissions from a TTA within eight days after discharge have been assessed as preventable. DESCRIPTION: A hospital-based team rounded on 268 patients at TTAs from May 2017 to October 2019 to promote integrated care. This study aimed to assess the efficacy of the rounding by auditing patient cases. A physician, a nurse, and a pharmacist from the hospital; a general practitioner; and one or two TTA nurses audited 17 cases. DISCUSSION: Obtaining access to all electronic patient records and reconstructing information shared across sectors were not feasible in all cases. CONCLUSION: An overview of the course of treatment was provided in most casesThe patient's health was enhanced in most cases and to a considerable or determining degree in half of casesMedication was optimized in most casesThe succeeding course of treatment was enhanced in more than half of the casesReadmission was prevented in some cases.

Optimal authoritative risk assessment score of Cancer-associated venous thromboembolism for hospitalized medical patients with lung Cancer.

BACKGROUND: Cancer-associated venous thromboembolism (VTE) is common in patients with primary lung cancer. It has been understudied which authoritative risk assessment score of cancer-associated VTE is optimal for the assessment of VTE development in hospitalized medical patients with lung cancer. METHODS: Patients with lung cancer who had undergone computed tomography pulmonary angiography (CTPA), compression ultrasonography (CUS) of lower and upper extremities, and/or planar ventilation/perfusion (V/Q) scan to confirm the presence or absence of VTE during a medical hospitalization were retrospectively reviewed. Based on the actual prevalence of VTE among all patients, the possibility of VTE were reassessed with the Khorana score, the PROTECHT score, the CONKO score, the ONKOTEV score, the COMPASS-CAT score, and the CATS/MICA score, to compare their assessment accuracy for VTE development. RESULTS: A total of 1263 patients with lung cancer were incorporated into the final analysis. With respect to assessment efficiency for VTE occurrence, the scores with adjusted agreement from highest to lowest were the ONKOTEV score (78.6%), the PROTECHT score (73.4%), the CONKO score (72.1%), the COMPASS-CAT score (71.7%), the Khorana score (70.9%), and the CATS/MICA score (60.3%). The ONKOTEV score had the highest Youden index which was 0.68, followed by the PROTECHT score (0.58), the COMPASS-CAT score (0.56), the CONKO score (0.55), the Khorana score (0.53), and the CATS/MICA score (0.23). CONCLUSIONS: Among the Khorana score, the PROTECHT score, the CONKO score, the ONKOTEV score, the COMPASS-CAT score, and the CATS/MICA score which are approved by authoritative guidelines, the ONKOTEV score is optimal for the assessment of VTE development in hospitalized medical patients with lung cancer.

Mixed effect of increasing outflow of medical patients from an emergency department.

BACKGROUND AND AIM: Since 2014, the annual number of patients entering our emergency department (ED) has increased significantly. These were primarily Internal Medicine (IM) patients, and of these, 25-30% were admitted. The present governmental policy presents a deterrent to adding IM beds for these patients, and Emergency and IM departments cope with ever-increasing number of IM patients. We describe a quality improvement intervention to increase outflow of IM patients from the ED to the IM departments. METHODS: We conducted a quality improvement intervention at the Shaare Zedek Medical Center from 2014 to 2018. The first stage consisted of an effort to increase morning discharges from the IM departments. The second stage consisted of establishing a process to increase the number of admissions to the IM departments from the ED. RESULTS: Implementation of the first stage led to an increased morning discharge rate from a baseline of 2-4 to 18%. The second stage led to an immediate mean (± SD) morning transfer of 35 ± 7 patients to the medical departments (8-12 per department), providing significant relief for the ED. However, the additional workload for the IM departments' medical and nursing staff led to a rapid decrease in morning discharges, returning to pre-intervention rates. Throughout the period of the new throughput intervention, morning admissions increased from 30 to > 70%, and were sustained. The number of patients in each department increased from 36 to 38 to a new steady state of 42-44, included constant hallway housing, and often midday peaks of 48-50 patients. Mean length of stay did not change. IM physician and nurse dissatisfaction led to increased number of patients being admitted during the evening and night hours and fewer during the morning. CONCLUSION: We describe a quality improvement intervention to improve outflow of medical patients from the ED in the morning hours. The new ED practices had mixed effects. They led to less ED crowding in the morning hours but increased dissatisfaction among the IM department medical and nursing staff due to an increased number of admissions in a limited number of hours. The present governmental reimbursement policy needs to address hospital overcrowding as it relates to limited community healthcare beds and an aging population.

Challenges in co-designing an intervention to increase mobility in older patients: a qualitative study.

PURPOSE: The aim of this study is to explore and discuss key challenges associated with having stakeholders take part in co-designing a health care intervention to increase mobility in older medical patients admitted to two medical departments at two hospitals in Denmark. DESIGN/METHODOLOGY/APPROACH: The study used a qualitative design to investigate the challenges of co-designing an intervention in five workshops involving health professionals, patients and relatives. "Challenges" are understood as "situations of being faced with something that needs great mental or physical effort in order to be done successfully and therefore tests a person's ability" (Cambridge Dictionary). Thematic content analysis was conducted with a background in the analytical question: "What key challenges arise in the material in relation to the co-design process?". FINDINGS: Two key challenges were identified: engagement and facilitation. These consisted of five sub-themes: recruiting patients and relatives, involving physicians, adjusting to a new researcher role, utilizing contextual knowledge and handling ethical dilemmas. RESEARCH LIMITATIONS/IMPLICATIONS: The population of patients and relatives participating in the workshops was small, which likely affected the co-design process. PRACTICAL IMPLICATIONS: Researchers who want to use co-design must be prepared for the extra time required and the need for skills concerning engagement, communication, facilitation, negotiation and resolution of conflict. Time is also required for ethical discussions and considerations concerning different types of knowledge creation. ORIGINALITY/VALUE: Engaging stakeholders in co-design processes is increasingly encouraged. This study documents the key challenges in such processes and reports practical implications.

Accuracy of the calculated serum osmolarity to screen for hyperosmolar dehydration in older hospitalised medical patients.

BACKGROUND AND AIMS: Simple hyperosmolar dehydration, also termed water-loss dehydration (HD), is common in older hospitalised patients, thus increasing the risk of morbidity and mortality. Directly measured serum osmolality is the reference standard to determine HD; however, it is not a routine test due to its complexity and cost. Thus, a simple valid objective diagnostic tool to detect HD is needed. Consequently, we aimed to validate the agreement between measured s-osmolality (mOsm/kg) and calculated s-osmolarity (mOsm/L). METHODS: Patients aged >65 were included from the emergency medical department at Herlev Hospital, Copenhagen, Denmark. Exclusion criteria were: eGFR< 30 mmol/L, severe heart failure, decompensated cirrhosis, alcohol intake or initiated rehydration treatment. We obtained data for measured s-osmolality as well as calculated osmolarity, using the by ESPEN recommended equation [1.86x (Na+ + K+)+1.15 ∗glucose + urea+14]. To determine accuracy, we used cut-off values of >295 mOsm/L versus >300 mOsm/kg. RESULTS: A total of 90 patients (female 53%), age median 78 yrs (72-86 yrs) were included. According to the measured mOsm/kg, impending HD was evident in 32% (n = 10), of these 11% (n = 10) had current HD. There was a significant association between calculated mOsm/L and measured Osm/kg (r2 = 0.7513, p < 0.0001). A sensitivity of 90% (95% CL: 56%-100%), a specificity of 68% (95% CL: 56%-78%), Positive predictive value (PPV) of 26% (95% CL: 12%-43%), and Negative predictive value (NPV) of 98% (95% CL: 90%-100%) were observed. Notably, only 20% (n = 2) of the patients who were dehydrated according to the measured Osm/kg were correctly clinically diagnosed with dehydration. CONCLUSIONS: The equation recommended by ESPEN to calculate osmolarity was found to be an accurate objective diagnostic tool to assess HD in older hospitalised medical patients. The method is markedly superior to the current clinical practice.

Screening Pediatric Medical Patients for Suicide Risk: Is Depression Screening Enough?

PURPOSE: Medically ill youth are at increased risk for suicide. For convenience, hospitals may screen for suicide risk using depression screening instruments, though this practice might not be adequate to detect those at risk for suicide. This study aims to determine whether depression screening can detect suicide risk in pediatric medical inpatients who screen positive on suicide-specific measures. METHODS: A convenience sample of medical inpatients ages 10-21 years were recruited as part of a larger instrument validation study. Participants completed the Ask Suicide-Screening Questions, the Suicidal Ideation Questionnaire/Suicidal Ideation Questionnaire-Junior, and the Patient Health Questionnaire-Adolescent Version (PHQ-A). Univariate and multivariate statistics were calculated to examine the relationship between screening positive for depression and suicide risk. RESULTS: The sample consisted of 600 medical inpatients (59.2% female; 55.2% white; mean age 15.2 ± 2.84 years). Of participants who screened positive for suicide risk (13.5%; 81/600), 39.5% (32/81) did not screen positive for depression, and more than half (45/81) did not endorse PHQ-A item 9, which queries for thoughts of harming oneself or being better off dead. Twenty-six participants (32%) who screened negative for depression and on PHQ-A item nine were at risk for suicide. CONCLUSIONS: In this sample, depression screening alone failed to detect nearly a third of youth at risk for suicide. Although depression and suicide risk are strongly related, a significant portion of pediatric medical inpatients at risk for suicide may pass through the healthcare system unrecognized if depression screening is used as a proxy for identifying suicide risk.

Mobility levels of acute medical patients: Is behavioural mapping comparable to accelerometry?

OBJECTIVE: To (1) determine agreement between behavioural mapping and accelerometry for measuring mobility levels in an acute medical inpatient setting and to (2) explore and compare the required resources and costs for both methods. DESIGN: Observational cross-sectional study. SETTING: Tertiary referral teaching hospital in Brisbane, Australia. SUBJECTS: Adult patients admitted to two acute medical wards. MAIN MEASURES: Mobility levels were recorded by behavioural mapping, and thigh and chest-worn accelerometers (ActivPAL). The level of agreement between the two methods was evaluated using the Intraclass Correlation Coefficients for each mobility level (i.e. lying, sitting, upright, standing and walking). RESULTS: Nineteen patients (10 male (53%); mean(SD) age of 72(14) years) were included in the agreement analysis. The Intraclass Correlation Coefficients were high for 'lying' (ICC = 0.87), 'sitting' (ICC = 0.84) and 'upright' (ICC = 0.93), indicating good to excellent agreement between the two methods. For these mobility levels, mean differences between the two methods were small (<2%), with large standard deviations (up to 18%). Agreement was poor for 'standing' (ICC = 0.00) and 'walking' (ICC = 0.35). Both methods were labour-intensive, with labour costs of A$1,285/€798 (34 hours) for behavioural mapping and A$1,055/€655 (28 hours) for accelerometry. No further costs were involved in behavioural mapping, but clinical backfill was required. Accelerometry involved a financial investment for accelerometers (A$11,100/€6,894 for 22 ActivPAL devices). CONCLUSION: Agreement between behavioural mapping and accelerometry was good for measuring 'lying', 'sitting' and 'upright', but poor for 'standing' and 'walking' in an acute inpatient setting. Both behavioural mapping and accelerometry were labour-intensive, with high costs for the accelerometry equipment.

Is Promotion of Mobility in Older Patients Hospitalized for Medical Illness a Physician's Job?-An Interview Study with Physicians in Denmark.

: The aim of this study was to identify the most common barriers and facilitators physicians perceive regarding their role in the promotion of mobility in older adults hospitalized for medical illness as part of on an intervention to promote mobility. Twelve physicians at two medical departments were interviewed face-to-face using semi-structed interviews based on the Theoretical Domains Framework. The physicians' perceived barriers to promoting mobility were: the patients being too ill, the department's interior does not fit with mobility, a culture of bedrest, mobility not being part their job, lack of time and resources and unwillingness to accept an extra workload. The facilitators for encouraging mobility were enhanced cross-professional cooperation focusing on mobility, physician encouragement of mobility and patient independence in e.g., picking up beverages and clothes. The identified barriers and facilitators reflected both individual and social influences on physicians' behaviors to achieve increased mobility in hospitalized older medical patients and suggest that targeting multiple levels is necessary to influence physicians' propensity to promote mobility.

Prophylaxis of venous thromboembolism in medical patients. / La profilaxis de la enfermedad tromboembólica venosa en los pacientes con enfermedad médica.

Venous thromboembolism (VTE) is a prevalent and serious complication in hospitalized medical patients. Pulmonary embolism is the most common preventable cause of hospital death. VTE extends hospitalization, with a higher resource consumption and an increase in healthcare costs. Risk factors for VTE include intrinsic factors and those related to hospitalization. It is important to know and to identify these factors at the moment of hospital admission and during the course of disease. VTE prophylaxis has demonstrated to be an efficient and effective action. Its implementation reduces life-threatening pulmonary embolism, symptomatic deep vein thrombosis and death rate three months after discharge. An individual and detailed assessment of prophylaxis risk-benefit is a priority. In our country, low molecular weight heparins are still the first option for VTE pharmacological prophylaxis. In those patients at high risk of bleeding or in whom anticoagulation is contraindicated mechanical methods could be used.

Predicting postdischarge hospital-associated venous thromboembolism among medical patients using a validated mortality risk score derived from common biomarkers.

BACKGROUND: Discharged medical patients are at risk for venous thromboembolism (VTE). It is difficult to identify which discharged patients would benefit from extended duration thromboprophylaxis. The Intermountain Risk Score is a prediction score derived from discrete components of the complete blood cell count and basic metabolic panel and is highly predictive of 1-year mortality. We sought to ascertain if the Intermountain Risk Score might also be predictive of 90-day postdischarge hospital-associated VTE (HA-VTE). METHODS: We applied the Intermountain Risk Score to 60 064 medical patients who survived 90 days after discharge and report predictiveness for HA-VTE. Area under the receiver operating curve analyses were performed. We then assessed whether the Intermountain Risk Score improved prediction of 2 existing VTE risk assessment models. RESULTS: The Intermountain Risk Score poorly predicted HA-VTE (area under the curve = 0.58; 95% confidence interval [CI], 0.56-0.60). Each clinical risk assessment model was superior to the Intermountain Risk Score (UTAH area under the curve, 0.63; Kucher area under the curve, 0.62; Intermountain Risk Score area under the curve, 0.58; P < .001 for each comparison). Adding the Intermountain Risk Score to these scores did not substantially improve the performance of either risk assessment model (UTAH + Intermountain Risk Score, 0.65; Kucher + Intermountain Risk Score, 0.64). CONCLUSION: The Intermountain Risk Score demonstrated poor predictiveness for HA-VTE when compared to existing risk assessment models. Adding the Intermountain Risk Score to existing risk assessment models did not improve upon either risk assessment model alone to justify the added complexity.