Emergency department (ED) overcrowding has been a common complaint in Emergency Medicine in Canada for many years. Its adverse effects of prolonged waiting times cause patient dissatisfaction and unsafety. Previous studies indicate that adding a physician in triage (PIT) can increase accuracy and efficiency in the initial process of patient evaluation. However, the scientific evidence of the PIT impact on ED is far away from sufficient before its widespread implementation. This research is to search solutions using PIT to identify areas of improvement for the ED patient flow, based upon a validated discrete-event simulation (DES) model. As an efficient decision-making tool, the DES model also helps to develop an understanding of the current ED performance and quantitatively test various design alternatives for ED operations. / February 2017

Introduction: Opioid poisoning has been rapidly increasing in the past decade, and has been driven in large part due to increases in opioid prescribing. This has been accompanied by intervention efforts aimed at preventing and reversing opioid poisoning through naloxone prescription programs. Current literature have not quantified the economic burden of opioid poisoning. Understanding this information can help inform these efforts and bring light to this growing problem. In addition understanding various determinants of increased costs can help to identify the types of populations more likely to have greater costs. Main Objectives: The objectives are 1) to quantify the economic burden of opioid poisoning, 2) to evaluate differences in costs, LOS, and in-hospital mortality depending on opioid type, 3) to identify opioids most likely to result in hospitalization for opioid-related ED visits and 4) to determine differences in the odds of admission to various hospital admission categories with respect to opioid type. Methods: A cost-of-illness approach was used to estimate the economic burden of opioid poisoning. Direct costs and prevalence estimates were obtained from nationally representative databases. Other sources of direct costs were obtained from the literature. Indirect costs were measured using the human capital method. Differences in costs, LOS, and in-hospital mortality were measured through generalized linear models using the National Inpatient Sample in 2009 from the Healthcare Cost and Utilization Project. The Drug Abuse Warning Network database was used to evaluate opioids most likely to result in hospitalization and to evaluate the likelihood of different opioids to cause admission into different types of hospital settings. Results: Opioid poisoning resulted in an economic burden approximately $20.4 billion dollars in 2009. Productivity losses were associated with 89% of this total. Direct medical costs were associated with $2.2 billion. Methadone was associated with the greatest inpatient costs and LOS, while heroin was associated with a greater likelihood of in-patient mortality compared to prescription opioids. Heroin, methadone, and morphine were associated with the greatest odds of hospitalization. Among admitted patients, methadone, morphine, and fentanyl were each associated with the greatest odds of ICU admission compared with other opioids. Conclusions: Opioid poisoning results in a significant economic burden to society. Costs, length of stay, in-patient mortality and the odds of hospitalization and admission type depend on the type of opioid involved. The results from this study can be used to inform policy efforts in providing interventions to reduce opioid poisoning and help focus efforts on populations at highest risk for increased costs.

Bakgrund: Hälso- och sjukvården är skyldiga att främja patienters delaktighet i vården. För att patienter ska känna sig delaktiga behöver deras enskilda behov tillgodoses, för att uppnå detta behöver vårdpersonalen lyssna till patienten, ge adekvat information och tillsammans med patienten planera för dennes vård på ett respektfullt sätt. Bröstcancer är den vanligaste cancerformen för kvinnor, vårdtiden efter ett kirurgiskt ingrepp är kort. Kvinnor som drabbats av bröstcancer uttrycker ett stort behov av känslomässigt stöd och att känna sig delaktiga i vården. Syfte: Att beskriva kvinnors upplevelser av delaktighet vid kort vårdtid i samband med bröstcancerkirurgi. Metod: En kvalitativ induktiv metod har använts där semistrukturerade intervjuer genomfördes, dessa analyserades med Elo och Kyngäs innehållsanalys Resultat: Deltagarna ansåg att ett bra bemötande och närvarande vårdpersonal var viktigt för att de skulle känna sig delaktiga i vården särskilt med tanke på den korta tiden de befann sig på avdelningen. Dock uttryckte deltagarna att det hade varit svårt att få ett förtroende för vårdpersonalen då de vårdades under så pass kort tid. De upplevde att personalen utförde arbetet på rutin, vilket resulterade i att personliga samtal uteblev. Deltagarna hade önskat mer information och känslomässigt stöd under vårdtiden. Det framkom även upplevelser av att inte bli involverade i planeringen kring vården. Slutsats: För att göra kvinnor med bröstcancer delaktiga i den korta postoperativa vården behöver vårdpersonalen bemöta patienterna på ett respektfullt och individanpassat sätt, tillsammans med patienten planera vården, tänka på patientens integritet, vara närvarande och ge patienterna känslomässigt stöd. / Background: Healthcare is obliged to promote patients' participation in healthcare. In order for patients to feel involved, their individual needs need to be met, in order to achieve this, the healthcare staff need to listen to the patient, provide adequate information and, together with the patient, plan for their care in a respectful manner. Breast cancer is the most common form of cancer for women, the length of stay after surgery is short. Women who suffer from breast cancer express a great need for emotional support and to feel participation in the care. Aim: To describe women's experiences of participation in short-term care in connection with breast cancer surgery. Method: A qualitative inductive method has been used in which semi-structured interviews were conducted, these were analyzed with Elo and Kyngäs content analysis. Results: The participants felt that the interaction and a caring relationship, including a present healthcare staff, were important to feel involved in the care, especially in view of the short time they were in hospital care. However, the participants stated that it has been difficult to gain confidence in the healthcare staff when they were cared for in such a short time. They felt that the staff performed the work on routine, which resulted in personal conversations not being fulfilled. The participants wanted more information and emotional support during the care period. Experiences of not being involved in the planning of the care were also reported. Conclusion: To involve women with breast cancer in their postoperative care, healthcare professionals need to respond to the patients in a respectful and individualized manner, plan the care together with the patient, think about the patient's integrity, being present and give the patients emotional support.

Thesis (M.S.)--Massachusetts Institute of Technology, Dept. of Mathematics, 1982. / MICROFICHE COPY AVAILABLE IN ARCHIVES AND SCIENCE / Bibliography: leaf 67. / by Edward Harris Kaplan. / M.S.

Os serviços de emergências hospitalares (EH) desempenham um papel fundamental no sistema de saúde, servindo de porta de entrada para hospitais e fornecendo cuidados para pacientes com lesões e doenças graves. No entanto, as EH em todo o mundo sofrem com o aumento da demanda e superlotação. Múltiplos fatores convergem simultaneamente para resultar nessa superlotação, porém a otimização do gerenciamento do fluxo dos pacientes pode auxiliar na redução do problema. Nesse contexto, o tempo de permanência dos pacientes na EH (TPEH) é consolidado na literatura como indicador de qualidade do fluxo de pacientes. O tema desta dissertação é a previsão e gestão da demanda em EH com alto grau de congestionamento, que é abordado através de três artigos científicos. O objeto de estudo é o Hospital de Clínicas de Porto Alegre (HCPA). No primeiro artigo, são aplicados quatro modelos de previsão da procura por atendimento na EH, avaliando-se a influência de fatores climáticos e de calendário. O segundo artigo utiliza a técnica de regressão por mínimos quadrados parciais (PLS – partial least squares) para previsão de quatro indicadores relacionados ao TPEH para hospitais com alto grau de congestionamento. O tempo médio de permanência (TM) na EH resultou em um modelo preditivo com melhor ajuste, com erro médio absoluto percentual (MAPE - mean absolute percent error) de 5,68%. O terceiro artigo apresenta um estudo de simulação para identificação dos fatores internos do hospital que influenciam o TPEH. O número de exames de tomografias e a taxa de ocupação nas enfermarias clínicas e cirúrgicas (ECC) foram as que mais influenciaram. / Emergency departments (ED) play a key role in the health system, serving as gateway to hospitals and providing care for patients with injuries and serious illnesses. However, EDs worldwide suffer from increased demand and overcrowding. Multiple factors simultaneously converge to result in such overcrowding, and the optimization of patient flow management can help reduce the problem. In this context, the length of stay of patients in ED (LSED) is consolidated in the literature as a patient flow quality indicator. This thesis deals with forecast and demand management in EDs with a high degree of congestion. The subject is covered in three scientific papers, all analyzing data from the Hospital de Clínicas de Porto Alegre’s ED. In the first paper we apply four demand forecasting models to predict demand for service in the ED, evaluating the influence of climatic and calendar factors. The second article uses partial least squares (PLS) regression to predict four indicators related to LSED. The mean length of stay in the ED resulted in a model with the best fit, with mean percent absolute error (MAPE) of 5.68%. The third article presents a simulation study to identify the internal hospital factors influencing LSED. The number of CT exams and the occupancy rate in the clinical and surgical wards were the most influential factors.

Introdução: Nas últimas décadas, vários fatores determinaram importantes modificações no modo de prover assistência psiquiátrica. Entre estes, destacam-se as mudanças no modo como entendemos os transtornos mentais, os avanços e melhora na disponibilidade de tratamentos psiquiátricos, o aumento do interesse político em saúde mental, além da ênfase nos custos da assistência médica. Com isto, a internação psiquiátrica passou a representar uma parcela menor entre os recursos utilizados na assistência em saúde mental. A Psiquiatria hospitalar atual cumpre a função de realizar diagnóstico e tratar sintomas agudos com a finalidade de esbater riscos, focada em estabilização, segurança do paciente e curta permanência. Neste contexto, o estudo de desfechos negativos entre pacientes que internam em leito psiquiátrico de hospital geral torna-se cada vez mais necessário. Objetivos: Identificar determinantes de desfechos negativos entre pacientes que internaram em leito psiquiátrico de hospital geral, definidos a priori como tempo de internação prolongado, reinternação e morte por qualquer causa em um ano a partir do momento da alta hospitalar. Métodos: Estudo naturalístico, longitudinal e prospectivo, realizado em unidade psiquiátrica de um hospital geral universitário de nível terciário. Pacientes admitidos entre junho de 2011 e dezembro de 2013 com 18 anos ou mais foram considerados elegíveis, exceto os que tivessem transtorno por uso de substâncias como diagnóstico principal, agitação psicomotora grave nas primeiras 72 horas da admissão, comprometimento cognitivo suficiente para comprometer a avaliação ou recusa em participar da pesquisa. Dados sociodemográficos e clínicos foram coletados na admissão, alta e um ano após a alta. Resultados: No artigo 1, seis variáveis explicaram 14,6% da variabilidade no tempo de internação: ausência de renda própria, história de internações psiquiátricas nos últimos dois anos, escore total na Brief Psychiatric Rating Scale e na Clinical Global Impression, diagnóstico de Esquizofrenia e história de tentativas de suicídio. O artigo 2 reafirmou o papel das internações anteriores em predizer internações futuras (RC1.38; IC 1.16-1.60) e demonstrou que para pacientes que internaram em episódio depressivo, não estar em remissão no momento da alta aumenta o risco de reinternação (RC 2.40; IC 1.14-5.07), assim como maiores escores na Brief Psychiatric Rating Scale no momento da alta para aqueles admitidos por Esquizofrenia. O artigo 3 reportou a mortalidade entre os pacientes acompanhados um ano 9 após a alta, mais de três vezes maior que a mortalidade da população geral para o mesmo período e área geográfica. Discussão: Os três estudos produzidos por esta tese colaboram para o corpo de evidências sobre desfechos adversos entre pacientes que internaram em leito psiquiátrico de hospital geral. O modelo de internação psiquiátrica em hospital geral é amplamente defendido pela Psiquiatria contemporânea como o melhor para tratamento de agudizações de transtornos mentais graves. Entretanto, não é o modelo majoritário tanto no Brasil como no mundo. Portanto, os resultados desta tese refletem os desfechos de um modelo assistencial preconizado, porém não predominante. Considerações finais: Ainda carecemos de pesquisas que se dediquem a avaliar desfechos negativos em internação psiquiátrica de hospital geral. / Introduction: In the last decades, several factors have determined significant changes in the way to provide psychiatric care. These include changes in the way we understand mental disorders, advances and improvements in the availability of psychiatric treatments, increased political interest in mental health, and emphasis on health care costs. With this, psychiatric hospitalization started to represent a smaller portion of the resources used in mental health care. It fulfills the function of diagnosing and treating acute symptoms with the purpose of avoiding risks, being focused on stabilization, patient safety and short stay. In this context, the study of negative outcomes among patients hospitalized in the psychiatric beds of general hospital becomes more and more necessary. Objectives: To identify determinants of adverse outcomes in patients admitted in psychiatric beds of a general hospital, defined a priori as longer hospital stay, rehospitalization and death from any cause one year after discharge. Methods: This is a naturalistic, longitudinal and prospective study carried out in a psychiatric unit of a general university-level tertiary care hospital. Patients admitted between June 2011 and December 2013 aged 18 years and over were considered eligible, except those who had substance use disorders as the main diagnosis, severe psychomotor agitation in the first 72 hours of admission, cognitive impairment sufficient to compromise the evaluation or refusal to participate in the research. Sociodemographic and clinical data were collected on admission, discharge and one year after discharge. Results: In article 1, six variables explained 14,6% of the variability of length-of-stay: absence of own income, history of psychiatric hospitalizations in the last two years, the total score of Brief Psychiatric Rating Scale and Clinical Global Impression, Schizophrenia diagnosis and history of suicide attempts. Article 2 reaffirmed the role of previous admissions in predicting future hospitalizations. Also, for patients admitted in a depressive episode, not being in remission at discharge increases the chance to be readmitted (OR 2.40; CI 1.14-5.07), as well as higher scores in the Brief Psychiatric Rating Scale at discharge for patients with Schizophrenia (OR 1.28, CI 1.11-1.48). Article 3 reported the mortality among patients followed up, more than three times greater than the mortality of the general population for the same period and geographical area. Discussion: The three studies produced by this thesis collaborate to the body of evidence about adverse outcomes among patients admitted in psychiatric beds of a general hospital. Contemporary psychiatry widely advocates the model of psychiatric hospitalization in general hospital as the best for treatment of acute mental disorder exacerbations. However, it is not the majority model in Brazil as in the world. Therefore, the results of this thesis reflect the outcomes of a recommended, but not predominant, care model. Final considerations: We still lack researches that focus on evaluating negative outcomes in general hospital psychiatric hospitalization.

Bariatric surgery is an effective procedure type for morbidly obese patients when all else fails. Because obesity is a chronic disease, prolonged assessment and understanding of the credibility of procedure types and their effects on bariatric surgery outcomes are essential, yet current evidence shows decreasing utilization of one of the dominant procedure types. To better compare outcomes of procedure type, this research was designed to control for volume, hospital size, age, gender, season, month, year, and ethnicity. The goal of the study was to compare the outcomes of laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) bariatric surgery using the epidemiologic triad model. This study was a retrospective cross-sectional review of Nationwide Inpatient Sample (NIS) from 2009 to 2014. Univariate and multivariate logistic regression were conducted to analyze the data. This study was based on a secondary analysis previously collected from NIS data. A convenience sample of 73,086 patients who underwent bariatric surgery using ICD-9 diagnosis and procedure codes was used. Multiple logistic regression analysis indicated that LAGB (odds ratio [OR] =.043) and LSG (OR =.030) were positively associated with in-hospital mortality. Similarly, LAGB (OR =.041) and LSG (OR =.425) were positively correlated to length of stay (LOS). Finally, LAGB (OR = .461) and LSG (OR = .480) was positively related to reoperation. LAGB, when compared to LSG for LOS, had a substantial advantage over biliopancreatic diversion. The LOS findings may contribute to patients' value proposition, including cost reduction for third party insurance payers and for the community.

Extended hospital length of stay (LOS) causes increased health care costs and incidence of never events, such as hospital-acquired infections, pressure ulcers, and falls, which are not reimbursed by Medicare. This study examined if there would be a statistically significant decrease in the LOS of patients after the implementation of a discharge process improvement initiative (DPII), The model for improvement and small tests of change concept were used to guide the DPII at a hospital in northern California. Sources of data included archival data obtained from the hospital's quality improvement department that showed LOS prior to and after the implementation of the DPII. The LOS for 2015 and 2017 were compared using the t test for independent samples. The LOS in 2015 was longer (M = 4.59, SD = 3.66) than in 2017 (M = 4.09, SD = 3.81), a statistically significant difference, M = 0.50, 95% CI [0.32, 0.67], t (77) = 5.574, p = .005, d = 1.3, showing that the implementation of the DPII led to a reduction in the LOS. This reduction cannot be attributed solely to the DPII because other projects were implemented at the same time, such as the Clinical Decisions Unit and multidisciplinary rounds. Future research could focus on the relationship between reduced LOS and readmission and the degree of collaboration among health care team members. The implications of this study for social change include the potential to lower health care costs and increase patients' awareness of their responsibility for their own health.

Excess inpatient length of stay (LOS) varies between hospitals and is burdensome to patients and the overall healthcare system. Variation in LOS has often been associated with hospital-level factors, such as hospital efficiency and quality. Clostridium difficile infection (CDI) is an increasingly common hospital-acquired (HA) infection. This thesis explores the connection between hospital incidence of CDI and excess LOS in patients without a CDI. It is hypothesized that HA-CDI incidence may act as a "proxy variable" to capture unobserved hospital characteristics, such as hospital quality or efficiency, associated with prolonged LOS. In addition, hospitals with longer LOS may tend to observe more HA-CDI cases prior to discharge. This thesis analyzes the ability of CDI incidence to capture excess LOS variation across hospitals, while controlling for CDI cases that occur after discharge. We use data on hospital inpatient visits, spanning the years 2005-2011, from three data sources distributed by the Healthcare Cost and Utilization Project: the Nationwide Inpatient Sample (NIS), and the State Inpatient Databases (SID) for California and New York. The NIS provides discharge records from a nationwide sampling of hospitals in a given year. The SIDs are longitudinal populations of inpatient records in each state, and patient records can be linked across stays. We compute a variety of different measures of hospital CDI incidence and identify HA-CDI cases that occur after a patient is discharged. Various multivariable regression models are analyzed to predict LOS at an individual patient level. A generalized linear modeling approach is used, and different distributions and link functions are compared using the Akaike information criterion. A multilevel modeling approach is also used to estimate the amount of between-hospital variation in LOS that can be explained by HA-CDI incidence. We find CDI incidence to be a strong predictive factor for explaining a patient's LOS and is one of the strongest predictive variables we identified. Moreover, CDI incidence appears to primarily capture between-hospital variation in excess LOS. Although we find evidence that present-on-admission indicators may underreport cases of HA CDI, our findings suggest the connection between CDI incidence and excess LOS is driven primarily by CDI cases that are HA. In addition, when we account for HA-CDI cases that occur post-discharge, the relationship between CDI incidence and LOS appears even stronger. Our results suggest that CDI incidence may be a powerful tool for making comparisons of excess LOS across hospitals.

<p>Spinal cord injury is a devastating condition, and its consequences impact on many facets of an individual&rsquo / s life. Activities of daily living such as personal care and housework might be difficult to perform post injury. The majority of spinal cord injury patients receive hospital-based rehabilitation to address these consequences. The normal length of hospital stay among spinal cord injury patients ranges from three to twelve months, and an increased length of stay are caused by development of secondary complications such as pressure sores, urinary tract infection and respiratory infection. The purpose of this study was to determine factors affecting length of hospital stay for individuals with spinal cord injuries at Kanombe Military Hospital in Rwanda. To achieve this, a retrospective study, utilising a quantitative approach was used. The records of individuals with spinal cord injuries discharged from the hospital between 1st January1996 and 31st December 2007 were reviewed to collect data. A data gathering instrument was developed by the researcher and there after used to capture the relevant information from the patients&rsquo / folders. Information collected included demographic data, information relating to the injury, occurrence of medical complications and length of hospital stay. One hundred and twenty four medical folders of patients discharged from 1st January 1996 to 31st December 2007 at Kanombe Military Hospital were reviewed for data extraction. The Statistical Package for Social Sciences (SPSS) version 16.0 for windows was used to analyse the data. Both descriptive and inferential statistics were determined in SPSS. Associations were made between demographic factors and occurrence of secondary medical complications with length of hospital stay. These were computed by means of chi-square tests. One level of significance, alpha set at 5% was used throughout. The linear regression analysis was used to determine factors affecting the length of stay.</p>