Improving the nutritional status of hospitalized patients has been shown to reduce length of stay (LOS), hospital costs, readmission rates, complication rates, and mortality. Provision of nutrient-rich, liquid, oral nutrition supplements (ONS) is one approach to improving nutritional status. ONS use has been associated with improved outcomes among patients with diagnoses of orthopedic injuries and pressure ulcers, mainly using prospective designs among elderly and/or malnourished patients. Less information is available for other diagnoses, and no analysis of the effects of ONS could be found that considered the epidemiological triad of person, place, and time. This study used a quantitative, retrospective design to examine whether routine ONS use was associated with hospital length of stay (LOS) among 570 adult inpatients at a regional medical center diagnosed with heart failure, adjusting for significant personal, locational, and time variables. It was unique in the inclusion of epidemiological triad variables. Using multiple logistic regression to control for covariates, ONS use was associated with higher LOS in this sample (odds ratio=2.43). High LOS was also associated with higher Charlson Comorbidity Index (CCI) values, discharge destination, White ethnicity, female gender, and hospital room location. This study is expected to contribute to positive social change by helping inform hospital staff on factors affecting patient outcomes and LOS, and highlighting the need for continued research on interventions to improve care in hospitals.

There has been an increase in the number of individuals with mental illness being housed in correctional facilities over the last 50 years. In this study, the length of pretrial detention was compared for inmates who have a mental illness and are compliant with psychiatric medications, inmates who have a mental illness and are noncompliant or not prescribed psychiatric medication, and inmates with no mental illness. I also examined if inmates who have a mental illness have less severe charges and if there was a difference in the classification of mental health diagnoses for inmates who are and are not compliant with psychiatric medications. The study used the closed charts of 427 male inmates from 1 county jail in New Jersey from the year 2016. The theoretical foundation of this study is Abraham Maslow's hierarchy of needs, as it is believed that the basic physiological and safety needs should be met in order to provide mental health treatment. A combination 1-way analyses of variance (ANOVA) and chi-squared analysis was used to examine the data. It was concluded that inmates with mental illness who are medication compliant are incarcerated significantly longer pretrial than inmates with no mental illness. It was also found that there was a difference in the types of charges received between those with and without a mental illness. Lastly, the study found that there was no significant difference between each of the classifications of mental illness when comparing inmates with mental illness who are and are not compliant with psychiatric medications. The implication for positive social change is the benefits to the inmates with mental illness and the correctional facilities, as it confirms that inmates with a mental illness require more tailored and treatment specific services for a longer period of time.

In Oregon, "Incompetent to Stand Trial (1ST) Patients" were observed to be increasing in number, remaining in the hospital longer, and costing more to treat. A study was designed to investigate variables that could be used to predict their length of stay at Oregon State Hospital. Data for thirteen independent variables (gender, age, having an Axis I psychosis level diagnosis, having an Axis I substance-related diagnosis, having an Axis II personality disorder diagnosis, evidence of involuntary medications, being on atypical medications at discharge, number of seclusion and restraint events, number of felony charges, number of misdemeanor charges, and number of inter-ward transfers) and one dependent variable (length of stay) were analyzed for 198 1ST patients discharged from Oregon State Hospital between January, 1999 and December, 2001. Bivariate correlations for all variables, and length of stay (LOS) means for all levels of each variable were examined and discussed. A standard multiple regression analysis was performed. The regression model accounted for 36.5% (32.7% adjusted) of the variability in (log) LOS. R for regression was found to be significantly different from zero. Five variables were found to be significant contributors to explaining the variability in (log) LOS: (square root) number of inter-ward transfers (16%), gender (5.8%), evidence of involuntary medications (5.2%), (square root) number of felony charges (2.8%), and (square root) number of seclusion and restraint events (1.6%). Despite accounting for more variability in LOS than several previous studies with psychiatric patients, 67.3% of the variability was unaccounted for by the regression model. Unstandardized regression coefficients for untransformed variables were interpreted, revealing that gender, number of inter-ward transfers, and evidence of involuntary medications significantly predicted the largest increases in LOS. Recommendations were made for further research related to LOS of 1ST patients. / Graduation date: 2003

The Ottawa Hospital cancels hundreds of elective surgeries every year due to a lack of beds, and has an average weekday occupancy rate above 100%. Our approach to addressing these issues, by way of informing administrators of resource needs, was to model the flow of patients coming and going from the hospital. We used administrative data from the Ottawa Hospital to build a time-series model of emergency department admissions, and studied models that would predict next-day discharge of patients currently taking up hospital beds. In the latter, we considered population-averaged models for groups of patients based on their primary medical condition, as well as subject-specific models. We included the random effects from subject-specific variation to improve on predictive accuracy over the population- averaged approach. The result was a model that provided more realistic probabilities of discharge, and stable predictive accuracy over patient length of stay.

The Ottawa Hospital cancels hundreds of elective surgeries every year due to a lack of beds, and has an average weekday occupancy rate above 100%. Our approach to addressing these issues, by way of informing administrators of resource needs, was to model the flow of patients coming and going from the hospital. We used administrative data from the Ottawa Hospital to build a time-series model of emergency department admissions, and studied models that would predict next-day discharge of patients currently taking up hospital beds. In the latter, we considered population-averaged models for groups of patients based on their primary medical condition, as well as subject-specific models. We included the random effects from subject-specific variation to improve on predictive accuracy over the population- averaged approach. The result was a model that provided more realistic probabilities of discharge, and stable predictive accuracy over patient length of stay.

The Ottawa Hospital cancels hundreds of elective surgeries every year due to a lack of beds, and has an average weekday occupancy rate above 100%. Our approach to addressing these issues, by way of informing administrators of resource needs, was to model the flow of patients coming and going from the hospital. We used administrative data from the Ottawa Hospital to build a time-series model of emergency department admissions, and studied models that would predict next-day discharge of patients currently taking up hospital beds. In the latter, we considered population-averaged models for groups of patients based on their primary medical condition, as well as subject-specific models. We included the random effects from subject-specific variation to improve on predictive accuracy over the population- averaged approach. The result was a model that provided more realistic probabilities of discharge, and stable predictive accuracy over patient length of stay.

Thesis (M.Sc.)--Memorial University of Newfoundland, 2004. / Bibliography: leaves 98-100.

Made available in DSpace on 2015-07-22T20:50:19Z (GMT). No. of bitstreams: 0 Previous issue date: 2010-01-27 / Fundação de Amparo à Pesquisa do Estado do Amazonas (FAPEAM) / Introdução: Centros de Informações Toxicológicas (CIT) prestam papel essencial na assistência de pacientes intoxicados, sem contar com financiamento seguro de suas atividades. Objetivo: verificar a diferença no tempo de internação dos pacientes intoxicados que receberam atenção remota de um CIT em comparação aos que não receberam. Métodos: foi organizada uma coorte retrospectiva incluindo todos pacientes intoxicados hospitalizados em um pronto-socorro de Manaus de 2005 a 2007, dos quais os pacientes selecionados (com agente tóxico conhecido, tempo de exposição inferior a 12 horas e sem comorbidades graves) tiveram a gravidade avaliada por dois revisores independentes e divergências resolvidas por outro revisor. A concordância foi calculada através do índice Kappa. Resultados: Foram incluídos 198 pacientes; aqueles com auxílio remoto do CIT ficaram em média 3,43 dias (- 6,10 a -0,77 IC 95%) a menos internados quando comparados a nenhum auxílio do CIT. Noventa pacientes tiveram gravidade avaliada; não houve diferença estatística na gravidade entre os pacientes com ou sem assistência do CIT (p > 0,5). A concordância entre os revisores foi significativa. Conclusão: Pacientes com assistência remota do CIT tiveram tempo de internação inferior a pacientes sem este auxílio. A análise de gravidade mostrou-se factível de ser incorporada à prática dos CIT brasileiros. / Introduction: Poison Control Centers (PCC) play an essential role in caring for poisoned patients, albeit without secure funding for their activities. Objective: to investigate differences in length of hospital stay among poisoned patients, between those who received remote assistance from a PCC and those who did not. Methods: a retrospective cohort including all poisoned patients hospitalized at an emergency service in Manaus between 2005 and 2007 was set up. Patients presenting a known toxic agent, with less than 12 hours elapsed since exposure and without severe comorbidities, were selected. Their severity of poisoning was evaluated by two independent reviewers and divergence was solved by another reviewer. Agreement was obtained by Kappa index. Results: 198 patients were included. Those who received remote assistance from a PCC stayed in hospital on average for 3.43 days less than those without PCC assistance (95% CI: -6.10 to -0.77). Severity was assessed in the cases of 90 patients: there was no statistical difference in severity between the patient groups (p > 0.5). Agreement between reviewers was substantial. Conclusion: Patients with PCC aid had a lower length of stay then patients without this aid. Severity assessment is likely to be incorporated into Brazilian PCC routine. / TEDE / BV UNIFESP: Teses e dissertações

Diversos serviços de saúde no Brasil vem apresentado episódios de superlotação, em um contexto onde os recursos são limitados. A redução do tempo de permanência em internações hospitalares tem como consequência direta a disponibilização de mais leitos-dia. O gerenciamento e melhoria do fluxo de pacientes ao longo das internações hospitalares é importante, sendo que o uso eficiente dos leitos pode acontecer devido a uma série de fatores. Estudos demonstram que equipes multidisciplinares podem realizar uma assistência de qualidade, reduzindo custos e o tempo em que os pacientes permanecem internados, sem impacto na reinternação ou mortalidade. Também há trabalhos que apontam a eficácia de unidades dedicadas ao atendimento de doenças específicas. A admissão de pacientes dentro de critérios bem definidos aumenta o giro de leitos. Com o objetivo de analisar se a equipe multidisciplinar Medicina Interna – Emergência (MIE) poderia contribuir para a redução do tempo de permanência hospitalar dos pacientes portadores de doenças prevalentes, sem alterar os indicadores de reinternação e mortalidade, o presente estudo experimental, controlado, não-randomizado, comparou o período pré e pós-intervenção, ou seja, a criação de uma Unidade de Curta Permanência no Serviço de Medicina Interna, do Hospital de Clínicas de Porto Alegre (HCPA). Foram analisadas internações ocorridas através da Emergência do HCPA, de pacientes com 14 anos ou mais, com as doenças prevalentes classificadas conforme grupos do CID-10 (J09-J018; J40-J47; N30-N39; I30-I52; I60-I69; B20-B24; C15-C26; A30-A49; e E10-E14), no período compreendido entre 01 de dezembro de 2008 a 30 de novembro de 2010 (n = 11040). Os resultados do estudo demonstram que após a criação da equipe E-MEI e a sua unidade de curta permanência, houve uma redução do tempo de permanência dos pacientes internados pelas causas selecionadas (antes: 10,89 ± 13,17 dias, após: 9,47 ± 11,24 dias, p = 0,006), e uma diminuição mais acentuada nas internações do Serviço de Medicina Interna [antes (n = 680): 14,33 ± 14,57 dias, após (n = 1243): 9,77 ± 10,62 dias, p = 0,000]. Não ocorreu alteração na taxa de mortalidade de todos os pacientes admitidos para as causas selecionadas [antes (n = 3800): 11,3%, após (n = 3958): 11,8% p = 0,123]. Também não houve alteração na taxa de reinternação de 7 dias na amostra estudada [antes (n = 3369): 7,2%, depois de (n = 3491): 6,7%, p = 0,407]. / Several health services in Brazil has shown episodes of overcrowding, in a context where resources are limited. Reducing the length of stay in hospital has as a direct consequence the provision of more beds-day. Managing and improving the flow of patients throughout the hospital is important, and the efficient use of beds can happen due to a number of factors. Studies have shown that multidisciplinary teams can perform quality care, reducing costs and the time patients remain hospitalized, with no impact on mortality or rehospitalization. There are also studies that show the effectiveness of units dedicated to the treatment of specific diseases. The admission of patients into well-defined criteria increases the turnover of beds. With the objective of analyzing the multidisciplinary team Internal Medicine – Emergency, could help to reduce the length of hospital stay of patients with diseases prevalent, without changing the indicators of rehospitalization and mortality, the present study experimental, controlled, not -randomized study compared the pre-and post-intervention, ie the creation of a Short Stay Unit in the Department of Internal Medicine, Hospital de Clinicas de Porto Alegre (HCPA). We analyzed hospital admissions through the Emergency HCPA, for patients aged 14 years or older with prevalent disease groups classified according to the ICD-10 (J09-J018, J40-J47, N30-N39, I30-I52, I60-I69; B20-B24, C15-C26, A30-A49, and E10-E14), during the period from December 1, 2008 to November 30, 2010 (n = 11,040). The study results show that after the creation of the multidisciplinary team, and its Short Stay Unit, there was a reduction in the length of stay of inpatients by selected causes (before: 10.89 ± 13.17 days after: 9 47 ± 11.24 days, p = 0.006) and a greater reduction in hospitalizations Service of Internal Medicine [before (n = 680): 14.33 ± 14.57 days after (n = 1243): 9, 77 ± 10.62 days, p = 0.000]. No change in the mortality rate of all patients admitted to selected causes [before (n = 3800): 11.3% after (n = 3958): 11.8% p = 0.123]. There was also no change in the rate of readmission than 7 days in our sample [before (n = 3369): 7.2% after (n = 3491): 6.7%, p = 0.407].

Base teórica: Existem controvérsias quanto à quantidade ideal de calorias que pacientes críticos com insuficiência respiratória aguda devem receber, bem como aos efeitos das estratégias de terapia nutricional hipocalórica versus normocalórica nos desfechos clínicos e de tolerância gastrointestinal. Objetivo: Comparar o efeito de duas estratégias de terapia nutricional enteral (nutrição hipocalórica versus normocalórica) nos desfechos clínicos e na tolerância gastrointestinal de pacientes criticamente doentes em insuficiência respiratória aguda. Bases de dados pesquisadas: MEDLINE, EMBASE, SCOPUS e Cochrane Central Register of Controlled Trials até o período de agosto de 2014. Seleção dos estudos: Ensaios clínicos randomizados que compararam o efeito das estratégias de nutrição hipocalórica versus normocalórica nos desfechos clínicos principais [mortalidade na unidade de terapia intesiva (UTI), tempo de internação na UTI e tempo de ventilação mecânica] e nos sinais e sintomas gastrointestinais (regurgitação, aspiração, vômito, diarreia, constipação, distensão abdominal, elevado volume de resíduo gástrico e uso de agentes prócinéticos). Extração dos dados: Informações sobre a execução e qualidade dos estudos e características dos pacientes e dos desfechos de interesse foram extraídas. As estimativas de risco relativo (RR) e média da diferença (MD) foram sintetizadas sob o modelo de efeitos aleatórios. A heterogeneidade foi avaliada com Teste Q e I2. A análise de sensibilidade foi conduzida através de análise de subgrupos os quais foram classificados conforme a estratégia de terapia nutricional enteral utilizada (nutrição trófica versus nutrição hipocalórica moderada). A metanálise foi realizada com apoio do software RevMan v5.3. Resultados: Dentre os 798 estudos encontrados, quatro ensaios clínicos randomizados que avaliaram 1540 pacientes foram incluídos na avaliação qualitativa e quantitativa. Não houve diferença na mortalidade geral (RR, 0.92; 95% CI, 0.73 – 1,19; I2 31% p=0.23 para heterogeneidade). A análise de subgrupos verificou mortalidade geral significativamente menor no subgrupo que recebeu 59-72% das necessidades nutricionais (RR, 0.72; 95% CI, 0.53 – 0.98; I2 0% p=0.78 para heterogeneidade). Não foram encontradas diferenças entre os grupos quanto à mortalidade na UTI, tempo de permanência na UTI ou hospitalar e tempo de ventilação mecânica. Quanto à avaliação da tolerância gastrointestinal, o grupo que recebeu nutrição hipocalórica foi associado a uma menor ocorrência de vômitos, diarreia e constipação quando comparado ao grupo nutrição normocalórica. Não foram verificadas diferenças entre os grupos quanto aos sintomas de aspiração e distensão abdominal. Conclusão: A estratégia de terapia nutricional enteral hipocalórica em aporte moderado (59- 72%) foi associada à menor mortalidade geral. A tolerância gastrointestinal foi superior no grupo que recebeu nutrição hipocalórica. A oferta de terapia nutricional enteral hipocalórica em aporte moderado deve ser preferida em pacientes criticamente doentes. / Context: Controversy exists regarding the optimal amount of calories that critically ill patients with acute respiratory failure should consume as far as clinical outcomes and gastrointestinal tolerability are concerned. Objective: To compare the effect of two enteral nutrition strategies (underfeeding versus fullfeeding) on clinical outcomes and gastrointestinal tolerability in critically ill patients with acute respiratory failure. Data Sources: MEDLINE, EMBASE, SCOPUS and the Cochrane Central Register of Controlled Trials up to August 2014. Study Selection: Randomized Controlled Trials that compared the effects of underfeeding with full-feeding strategies on major clinical outcomes (ICU and overall mortality, ICU and hospital length of stay and mechanical ventilation) and gastrointestinal signs and symptoms (regurgitation, aspiration, vomiting, diarrhea, constipation, abdominal distention, elevated gastric residual volume and use of prokinetic agents). Data extraction: Studies’ information, patient’s characteristics and outcomes were extracted. Risk ratio (RR) and Mean Difference (MD) estimates were synthesized under a randomeffects model. Heterogeneity was evaluated using the Q test and I2. A sensitivity analysis on overall mortality was conducted, wherein the groups were classified according to the feeding strategy used (trophic versus hypocaloric nutrition). Meta-analyses were performed using RevMan v5.3 analysis software. Data synthesis: Among the 798 studies retrieved, four studies of 1540 patients were included. Interventional studies comparing underfeeding with full-feeding were not associated with significant difference in overall mortality (RR, 0.92; 95% CI, 0.73 – 1,19; I2 31% p=0.23 for heterogeneity). Subgroup analysis of the groups according to the amount of delivered calories showed that the overall mortality was significantly lower in the subgroup that achieved 59-72% of energy intake than in the full-feeding group (RR, 0.72; 95% CI, 0.53 – 0.98; I2 0% p=0.78 for heterogeneity). No differences were found between the underfeeding versus full-feeding groups regarding in the ICU mortality, ICU and hospital length of stay and duration of mechanical ventilation. As far as gastrointestinal tolerability is concerned, the underfeeding group showed lower occurrence of vomiting, regurgitation, use of prokinetic agents, elevated gastric residual volume occurrence, diarrhea and constipation when compared with the full-feeding strategy. No differences between the two groups were found for aspiration and abdominal distention. Conclusion: The underfeeding strategy was associated with lower overall mortality in the subgroup that achieved initial moderate intake. Gastrointestinal tolerability was improved by the underfeeding strategy. Initial moderate intake should be preferred rather than trophic or full-feeding in critically ill patients.