Abstract Trends of Hospital Utilization among High-Utilizers of Inpatient Services in an Urban, Safety-Net Hospital Introduction: Although high-utilizers of healthcare services represent only a small portion of hospital population they account for huge healthcare cost in the United States. Hence, there is a need to understand the patterns of hospital utilization among high-utilizers in order to develop intervention to reduce overall hospital cost. Aim: To determine inpatient hospital utilization pattern among high-utilizers in Grady Hospital, Atlanta. Methods: Trend analysis was done to understand the pattern of health care utilization among high-utilizer (n=510) patients (HUPs) from 2011 to 2014. Multivariate logistic regression analysis was performed to determine the association between selected socio-demographic characteristics and HUPs. Results: Almost all HUPs were non-Hispanic Blacks (82.6%) with average mean age of 58. Significant proportion were employed with no health coverage. Approximately 27% of the 510 participants were HUPs at the end of 2012. At the end of 2013, the proportion of patients who became HUPs and NHUPs were 37% and 39% respectively. By 2014, 37% of patients who were HUP in 2013 remained HUP in 2014. Conclusion: The pattern of hospital utilization among high utilizers is unstable and unpredictable, and may be driven by race. Our study shows that reducing heath care cost may require developing predictive models to reduce hospital over-utilization usage among at risk group.

Background: Pain management is a major issue in post-operative care. Little is known about the pain management experiences of parents and adolescents following discharge from inpatient surgery. Studies examining pain outcomes following day surgery suggest that children often experience severe pain and parents are challenged in providing pain care. Objective: To explore the pain management experiences of parents and adolescents following discharge from hospital after inpatient surgery. Results: Thematic analysis found that parents and adolescents were challenged in providing pain care. School return was more difficult than anticipated yet parents and adolescents were unsure how to navigate pain at school. Discharge education focused on analgesic management, leaving participants to discover non-pharmacological strategies on their own. Conclusions: Recovery from post-operative pain following inpatient surgery is challenging; nurses and healthcare professionals need to better prepare parents and adolescents to meet pain care needs following discharge.

Atualmente os psicofármacos têm apresentado altas prevalências de consumo pela população. Visando fornecer subsídios para formulação de estratégias de gerenciamento de segurança no uso destes fármacos, o presente estudo teve como objetivos: identificar, entre pacientes internados em clínicas médica e cirúrgica de um hospital geral, a prevalência do uso de psicofármacos e, analisar a relação do uso destes fármacos com as variáveis demográficas, socioeconômicas e farmacoterapêuticas, com o histórico de saúde e com o resultado da aplicação do instrumento SRQ-20. Foi realizado estudo de corte transversal, com desenho correlacional descritivo e abordagem quantitativa, com 93 pacientes das clínicas em estudo. Para coleta dos dados utilizou-se a entrevista norteada por um questionário envolvendo as variáveis em estudo e pelo instrumento SRQ-20 (Self-Reporting Questionnaire), para a detecção de transtornos mentais comuns. Em seguida, foi verificado o prontuário destes pacientes, buscando a presença de prescrição de psicofármacos. Para avaliar a influência das variáveis independentes sobre o consumo de psicofármacos, foram investigadas associações estatísticas usando o teste Qui-quadrado. Para estimar a Razão de prevalência foi utilizado o modelo de regressão log-binomial simples e múltiplo. O ajuste do modelo foi feito através do procedimento PROC GENMOD do software SAS versão 9.0. Observou-se a prevalência de 38,71% de usuários de psicofármacos, evidenciando a associação do uso de psicofármacos com as variáveis sexo, custeio da internação, religião e resultado positivo no SRQ-20. Os benzodiazepínicos foram os psicofármacos mais consumidos pela amostra (64%), seguidos pelos antidepressivos (32%). As indicações dos benzodiazepínicos relatadas pelos pacientes foram: \"para dormir\" (54%), para \"depressão\" (14%), e para \"ansiedade\" (7%). A principal indicação dos antidepressivos foi a \"depressão\" (50%). Identificou-se que 25% e 22% dos pacientes estavam consumindo, respectivamente, benzodiazepínicos e antidepressivos, sem ter o conhecimento deste fato. Verificou-se que 70% das prescrições de psicofármacos foram realizadas por médicos não-psiquiatras, sendo os benzodiazepínicos a classe mais prescrita pelos não-psiquiatras e os antidepressivos os mais prescritos pelos psiquiatras. Dentre os pacientes em uso de psicofármacos, 59% realizavam apenas tratamento farmacológico, 27,8% possuíam diagnóstico de transtorno mental, 36,1% obtiveram resultado positivo e 36,1% obtiveram resultado negativo no SRQ-20. Foi identificada a automedicação em 5% dos pacientes. Espera-se que a presente pesquisa contribua para despertar a preocupação necessária relacionada ao tema, para a melhoria das informações que devem ser consideradas pelos profissionais de saúde quanto ao tratamento com psicofármacos bem como para implementação de estratégias direcionadas ao uso racional destes medicamentos. / Currently, psychotropic drugs have shown high prevalence rates of consumption by the population. Aiming to provide subsidies for formulation of strategies of security management in the use of these drugs, this study aimed to identify, among patients hospitalized in medical and surgical clinics of a general hospital, the prevalence of psychotropic use and analyze the relationship between the use of these drugs and the demographic, socioeconomic and pharmacotherapeutics variables, with the health history and the result of applying the SRQ-20. A cross sectional study with descriptive correlational design and quantitative approach was performed with 93 patients in the clinics. For data collection, an interview guided by a questionnaire involving the study variables and by the SRQ-20 (Self-Reporting Questionnaire) was used for the detection of common mental disorders. Then, the records of these patients were checked, looking for the presence of psychotropic prescription. To evaluate the influence of independent variables on the consumption of psychotropic drugs, statistical associations were investigated using Chi-square test. To estimate the prevalence ratio was used the simple and multiple log-binomial regression models. The model fit was achieved using the PROC GENMOD procedure of SAS software version 9.0. It was observed the prevalence of 38.71% of psychotropic drug users, showing the association between the use of psychiatric drugs and sex, cost of hospitalization, religion and positive result on the SRQ-20. Benzodiazepines were the most consumed psychotropic drugs by the individuals of the sample (64%), followed by antidepressants (32%). The indications of benzodiazepines reported by patients were: \"to sleep\" (54%), for \"depression\" (14%), and \"anxiety\" (7%). The main indication of antidepressants was \"depression\" (50%). It was found that 25% and 22% of the patients were taking, respectively, benzodiazepines and antidepressants, without having knowledge of this fact. It was found that 70% of prescriptions of psychotropic drugs were performed by physicians non-psychiatrists, and the most prescribed by non-psychiatrists were benzodiazepines and the most prescribed by psychiatrists were antidepressants. Among the patients using psychotropic drugs, 59% performed only pharmacological treatment, 27.8% had a diagnosis of mental disorder, 36.1% had positive outcome, and 36.1% had negative outcome in the SRQ- 20. Self-medication was identified in 5% of patients. It is expected that this research contributes to arouse the concern related to this theme required for the improvement of information that should be considered by health professionals regarding treatment with psychotropic drugs and to implement strategies aimed at the rational use of medicines.

Given the heterogeneity of symptoms allowed in the diagnosis of psychotic disorders, as well as other challenges of categorical diagnosis (e.g., First et al., 2002; Krueger, 1999), the increased specificity brought by dimensional ratings of underlying features is often important. Models using the factorial structure of psychotic symptoms perform as good as or better than traditional categorical models (Allardyce, Suppes, & Van Os, 2007). DSM-5 has provided such a system of ratings to aid clinicians, the Clinician Rated Dimensions of Psychosis Symptom Severity Scale (PSS; APA, 2013). In this approach, the clinician rates symptom severity in eight domains which emphasize traditional psychotic symptomatology, cognition, and mood. Given its accessibility and the support of the DSM-5, it is possible that the measure could achieve wide use. However, little is known about the measure and the challenges of applying it in clinical settings. This study is a conceptual analysis of the conceptual foundation of the PSS, including its psychometric properties, applications, and demonstrated validity. It is also compared to the widely used Brief Psychiatric Rating Scale – Revised (BPRS-R). The PSS is more concise that other measures, and five of the PSS domains parallel the DSM-5's "Key Features That Define the Psychotic Disorders" (p. 87-88) (although the brief instructions of the PSS differ at times from DSM-5 definitions, and little in the way of definition is offered in the PSS itself). In contrast, no rationale is given for adding the remaining three domains. The dimensional model of the PSS has similarities to the factor structure typically found for symptomatology in psychotic disorder, but a number of important differences are noted. The data required for making ratings is never defined, although the only mention of data that might be helpful for rating one of the domains depends upon extensive testing. Although anchors for the ratings might, at first glance, appear to be given in the PSS, in fact, they offer almost nothing beyond the adjectives of "equivocal," "mild," "moderate," and "severe." Finally, we found that very little research exists on the PSS, no field trial was done, psychometric properties are largely unknown, and normative data is unavailable. The PSS is brief and provides a quick way to rate the severity of the five key features of psychosis required by DSM-5 diagnoses. Thus, it can work as a quick quantification of these features. Beyond this its utility is unknown, and it appears to lack the specificity of other rating scales, such as the BPRS-R.

Background: Care transitions are a common and frequently adverse aspect of health care, resulting in a high-risk period for both care quality and patient safety (Coleman, 2003; Forster et al., 2003; Picker Institute 1999; van Walraven et al., 2004; Cook et al., 2000). Patients who have complex care needs and undergo treatment from multiple care settings may be at a greater risk for poor care transitions (Coleman et al., 2004). Using quantitative performance measurement scales is one method that can assess the quality of care transitions, and identify areas for improvement. The psychometric properties of the primary performance measurement scale, the Care Transitions Measure (CTM), have not been rigorously assessed, particularly within a higher risk, medically complex population such as older adults with musculoskeletal (MSK) disorders. Furthermore, despite the negative health implications that can result from poor transitions and the commonality of care transitions among persons with complex care needs, there is a significant dearth of research on this crucial aspect of health care. Methods: This research examines the ability of the CTM to adequately assess the quality of care transitions among a complex population of older MSK rehabilitation patients and explores care transitions from the perspective of the patient and the health care provider. Information was gathered through telephone administration of the CTM to MSK patients after they transitioned from inpatient rehabilitation units to home, and through a series of qualitative key informant interviews with a range of health care professionals in care settings relevant to the care continuum of older MSK patients. Inter-rater reliability, a type of reliability that has never been tested with the CTM, and construct validity were assessed and qualitative analyses were used to examine qualitative information obtained through the CTM administration to patients and through the interviews with health care providers. Results: The CTM demonstrated excellent inter-rater reliability for the overall score (intraclass correlation coefficient = 0.77; p=0.03) despite only fair agreement between each item. Internal consistency of the CTM was high (Cronbach’s alpha = 0.94). The construct validity of the CTM was supported; however qualitative data from the patient and health care provider perspectives suggest additional items should be considered for inclusion. Qualitative information from patients also suggests the need for revisions to the wording of some items and the response options. Health care provider interviews suggest that issues surrounding transitional care are similar regardless of the care setting involved. Conclusions: Although the CTM proved to be reliable, qualitative data suggests that the addition of items should be considered to improve the content validity of the CTM, which would in turn improve its construct validity as well. Recommendations for scale improvement are made, as are recommendations for an alternative scale to assess care transition quality from a health care provider perspective. The results of this study support efforts to improve the outcomes of care transitions, care planning, and the overall quality of life for older rehabilitation patients.

Problemformulering: Sjuksköterskan behöver ge patienten förutsättning till delaktighet i vårdandet. En patient som är delaktig i sin vård upplever minde obehag över situationer och mindre stress. Syftet med denna litteraturstudie var att belysa vilka faktorer som påverkar patientdelaktighet vid sjukhusvistelse och vad sjuksköterskan kunde göra för att underlätta detta. Metod: Studien genomfördes som en litteraturstudie och grundar sig på 13 kvalitativa artiklar. Resultat: I resultatet framkom att sjuksköterskan behövde bygga upp en relation till patienten och ge patienten tid och kunskap för att öka delaktigheten i vårdandet. Uppföljning av kunskapsnivån var av vikt för att observera hur mycket kunskap patienten hade. Konklusion: Patientens delaktighet kunde förbättras om sjuksköterskan gav information om situationen och kommunicerade med patienten. För att kunna öka patientens delaktighet var det väsentligt att en positiv relationen mellan patient och sjuksköterska fanns där båda vågade vara sig själva. När sjuksköterskan hade tid att vara med patienten kunde kunskap och en relation bildas. Implikation: Fördjupad undervisning i kommunikation och relation mellan sjuksköterska och patient föreslås. Det behöver uppmärksammas mer om delaktighet på vårdavdelningarna. Vidare forskning om hur sjuksköterskan kan göra män mer delaktiga i vårdandet och delaktighetens betydelse, inte enbart för patienten utan också för att ta reda på vilka fördelar samhället får av en delaktig patient, rekommenderas.

SAMMANFATTNING Bakgrund Malnutrition är ett globalt problem i både industri- och utvecklingsländer. Svenska studier genomförda under 2000-talet har påvisat att drygt var fjärde patient i slutenvården är malnutrierad. Vårdgivare är ansvariga att identifiera malnutrierade patienter och de som löper risk för malnutrition. Punktprevalensmätningen Dagen nutrition utförs årligen på Akademiska sjukhuset. Under ett dygn registreras inneliggande patienters nutritionsstatus för att utvärdera uppsatta nutritionsmål. År 2013 samt 2014 registrerades data på ca 60 % av patienterna. Orsaken till att registreringar inte genomfördes på alla aktuella patienter är inte kartlagt.   Syfte Att få fördjupad kunskap om involverad personals syn på varför alla aktuella patienter inte deltog i punktprevalensmätningen Dagen nutrition åren 2013 och 2014. Syftet var även att belysa förutsättningar som kan bidra till att öka patientdeltagandet i framtiden.   Design Kvalitativ metod. En deskriptiv studie med induktiv ansats. Datainsamlingen skedde genom semistrukturerade intervjuer.   Resultat Orsaker till att patienter inte deltog eller att resultatet från Dagen nutrition uteslöts var bristfälligt ifyllda registreringslistor, samt bristande kunskap och engagemang hos personalen. Respondenterna ansåg att delat ansvar, väl genomfört förarbete, personalengagemang samt avsatt tid skulle kunna öka patientdeltagandet. De belyste även vikten av utbildning och information. Det skriftliga informationsmaterialet ansågs vara svårtillgängligt. Respondenterna föredrog muntlig information framför webbaserad utbildning. De efterfrågade även återkoppling av resultatet från Dagen nutrition samt förbättringsförslag till avdelningarna.   Slutsats Ofullständiga registreringslistor samt bristande kunskap och engagemang hos personalen orsakade att alla aktuella patienter inte deltog eller uteslöts från Dagen nutrition. Respondenterna ansåg att det kan vara möjligt att öka patientdeltagandet om föreslagna åtgärder vidtas. / ABSTRACT   Background Malnutrition is a global health problem occurring in both industrialized and developing countries. Swedish studies conducted in the 21st century show that more than one in four inpatients are malnourished. Caregivers are responsible to identify the malnourished patients, and those at risk of malnutrition. The point prevalence survey Dagen nutrition, is performed annually at Uppsala university hospital. During one day inpatients' nutritional status is recorded in order to evaluate the set goals regarding nutrition. In 2013 and 2014 data was recorded on approximately 60 % of the patients. The reason why data wasn’t registered among all viable patients was not investigated.   Aim To gain in-depth knowledge in involved personnel´s views on why all viable patients did not participate in the point prevalence survey Dagen nutrition in the years 2013 and 2014. An additional aim was to highlight conditions which may contribute to increase patient participation in the future.   Design A qualitative design. A descriptive study with an inductive approach. Data was collected through semi-structured interviews.   Findings The reasons why patients did not participate or that the results from Dagen nutrition were excluded was inadequately completed forms and that the personnel lacked knowledge and engagement. According to the respondents a shared responsibility, well performed prepar-atory work, personnel engagement and dedicated time could improve the potential to increase patient participation. Moreover the respondents emphasised the importance of education and information. The written information was experienced as hard to understand. The respondents preferred oral information rather than web-based training. They also requested feedback on the results from Dagen nutrition along with suggestions for improvement to pass on to the wards.   Conclusions Inadequate filled out register forms and lack of knowledge and engagement among the personnel caused lack of participation and exclusion in Dagen nutrition among the viable patients. The respondents thought that it is possible to increase patient participation through suggested active measures.

The Indigent Care Collaboration (ICC), a partnership of Austin, Texas, safety net providers, gathers encounter data and manages initiatives for the community's medically indigent patients. One such initiative is the establishment of a care management program designed to reduce avoidable hospitalizations. This study developed predictive models designed to take year-one encounter data and predict inpatient utilization in the following two years. The models were calibrated using 2003 through 2005 data for the 41,260 patients with encounters with ICC partner providers in all three years. Predictor variables included prior inpatient admissions, age, sex, and a summary measure of overall health status: the relative risk score produced by the Diagnostic Cost Groups prospective Medicaid risk-adjustment model. Using the 44,738 patients with encounter data in each of years 2004 through 2006 data, the performance of the predictive models was cross-validated and compared against the performance of the "common sense" method of choosing candidate patients based on prior year chronic disease diagnoses and high utilization, referred to herein as the Utilization Method (UM). The 620 patients with three or more 2005 through 2006 inpatient admissions were considered the actual high use patient subset. Each model's highest-risk 620 patients comprised its high-risk subset. Only 344 high-risk patients met the UM’s criteria. Prediction accuracy was described in terms of positive predictive value (PPV), i.e., the proportion of identified high-risk patients who were high-use patients. Three of the predictive models had a PPV of near 25% or greater, with the highest, the linear model using the DCG relative risk score, at 26.8%. The PPV of the UM was 17.1%, lower than that of all predictive models. When all high-risk subsets were limited to 344 patients (the number identified by the UM), the performance of the UM and the predictive models was similar. This study demonstrated that “common sense” targets for case management can be identified via simple filter as effectively as through empirically-based predictive models. However, once the supply of easily identifiable targets is exhausted, predictive models using a measure of health status identify high-risk patients who could not be easily identified by other means. / text

Inpatient aggression has been increasingly problematic in psychiatric facilities across the United States and around the world. Psychological assessment measures, such as the Rorschach Inkblot Method, are often used in psychiatric facilities to clarify a patient's diagnostic issues and assist in treatment planning. An assessment measure that could provide information about the type, intensity, and direction of a patient's aggressive impulses would therefore be clinically useful. The current method for scoring aggression on the Rorschach provides limited information about a patient's aggressive drives; Gacono & Meloy have proposed a broader system for scoring Rorschach aggressive content. Thus far, research on this new aggression scoring system has neglected to examine patients with Axis I disorders. The purpose of this dissertation was to explore the differences between the types and frequencies of these newer aggression variables, as well as the utility of these scores in predicting aggression in an inpatient sample of depressed and paranoid patients. This sample was chosen based on psychoanalytic conceptualization of aggressive dynamics in these patients. Results of Poisson and negative binomial regressions indicated that there were no differences between the depressed and paranoid groups in terms of the types or frequencies of Rorschach aggressive content. Kruskal-Wallis tests indicated that there were some differences between the groups in terms of the type and severity of behavioral manifestations of aggression. Finally, a logistic binomial regression showed that Rorschach variables did not add significantly to the prediction of the presence of aggressive behavior in this population. Clinical implications, limitations of the study, and directions for future research are examined. / text

De senaste tio åren har det i Sverige visat en ökande trend med psykiatriska sjukdomar. I Sverige insjuknar cirka 15 personer av 100,000 i psykos årligen. Tiden från första symptomdebut till insjuknande kan vara mellan några dagar till flera år och symptomen för psykos kan variera och misstas för depression och ångest. Syftet med studien var att belysa synen på vad omvårdnad är vid psykos och genomfördes som en systematisk litteraturstudie där tio artiklar användes i resultatet. Insjuknande i psykos beskrivs som en oförmåga att kontrollera sig själv och leder ofta till stor rädsla hos patienterna. Teman som framkom var den vårdande psykiatriska miljön, engagemang och delaktighet från personal samt autonomi, stigmatisering och rädsla. Omvårdnad av en patient med psykossjukdom bör karaktäriseras av trygghet, empati, stöd och med utrymme för samtal och reflektioner. Emotionell delaktighet från sjuksköterskan under omvårdnaden är av stor vikt för skapande av en förtrolig relation. Genom att behandla och bemöta patienten som en frisk självständig individ bevaras patientens autonomi och självkänsla i större utsträckning. Vid yrkesverksamhet, vårdutbildningar på olika nivåer och forskning finns en stor okunskap och osäkerhet representerad av psykiatrisk omvårdnad och det är därför stor betydelse av att att utöka och utveckla kunskaperna inom sjukdomarna vid psykos och psykiatrisk omvårdnad. / The last 10 years in Sweden there has been a rising trend of psychiatric diseases. In Sweden approximately 15 people per 100.000 get diagnosed with acute psychosis. The time from the first symptoms to acute psychosis state varies between a few days to multiple years. The psychosis symptoms can also differ and be mistaken for depression and anxiety. The purpose of this study was to enlighten what nursing is with psychosis, and was executed as a systematic literature study, where ten articles was used. Psychosis is described as a disability to control one self and often leads to great fear for the patients. Nursing of a patient with psychosis should be characterized by security, support and empathy with room for talks and reflection. Emotional participation from nurses during the care is of great importance for the creation of steady relationship with the patient. By treating and meeting the patient as a healthy and self-serving individual, the patient maintains autonomous on a bigger scale.  Empirical studies, research and nurse education on different levels today hold a lack of knowledge regarding psychiatric nursing and there is therefore important to develop and increase knowledge of psychosis and psychiatric care.