A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / In the United States, bronchiolitis has consistently been the most common diagnosis leading to hospitalization in infants under one year of age, representing over 90,000 cases a year and a significant financial burden on the healthcare system. A condition with such widespread incidence should have an established algorithm for treatment of respiratory symptoms, but studies on the efficacy of certain therapies have been inconclusive. Some reports suggest that the use of positive pressure nebulization may be of benefit in treating bronchiolitis, but it has not yet been studied systematically. 1) To determine whether positive pressure nebulization (PPN) is more effective than standard nebulization (SN) in reducing admission rate in infants with bronchiolitis 2) To determine whether the use of positive pressure nebulization causes a change in Bronchiolitis Score, Pediatric Intensive Care Unit (PICU) admission rate, length of stay (LOS), and unscheduled returns to the pediatric emergency department (PED). The project is a retrospective study conducted at a single‐center tertiary care children's hospital. Participants included in the study were infants 2‐24 months of age with moderate to severe bronchiolitis, who were evaluated by trained respiratory therapists using an objective scoring tool and treatment algorithm that included suctioning, albuterol, and racemic epinephrine. Infants received the above nebulization therapies by either a standard or a positive pressure nebulization delivery device. The two treatment groups were compared to see if one approach was superior as measured by outcomes such as hospital and PICU admission rate, length of stay, and returns to the emergency department. Initial survey of the 2012‐2013 winter season at Phoenix Children's Hospital yielded 2,095 patients who were diagnosed with bronchiolitis. As the majority of patients were excluded due to age, comorbidities, or poor documentation of treatment, our study examined 19 patients who received positive pressure nebulization, which were matched in a 1:3 ratio (PPN:SN), for a total of 57 patients who received standard nebulization. In measuring the primary markers of outcome, we found that 12 of the 19 PPN patients (63%) were admitted to the regular pediatric ward, and 4 of the 19 (21%) were admitted to the PICU. 35 of the 57 SN patients (63%) were admitted to the regular pediatric ward, and 5 of the 57 (8%) were admitted to the PICU. Statistical analysis showed that the estimated minimum 'n' required in each treatment group was 252 patients, but our study was only able to obtain a sample size of 19 patients in the PPN group, which was not enough for statistical significance. An association between hospital admission rate with positive pressure nebulization or standard nebulization was not able to be determined.

Thesis (M.S.)--Boston University

Forty-six million individuals in the United States used tobacco products. People who use tobacco products attempt numerous strategies before giving up smoking habit altogether. The goal of this project was to evaluate the impact of a tobacco cessation program by evaluating pre-and post-cessation program data, and hospital records of participants attending the hospital smoking cessation program over a 6-month period to ascertain the degree of reduction in tobacco use and hospitalization from smoking-related diseases. The population sample comprised of both men and women between the ages of 18 years and above. The project question addressed whether the smoking cessation program had an impact on reducing the rate of tobacco use and hospital readmissions after attending a cessation program at a medical center. A paired samples t-test was conducted to analyze the pretest and posttest results. There was a statistically significant decrease (p <.001) in the participants' (N=49) rate of smoking after completing the smoking cessation program that lasted 6 months. The mean on smoking cessation pre-participation was 13.7 (SD = 1.56). The mean on smoking cessation post-six months participation was 6.67 (SD = 1.81). There was a statistically significant decrease in the rate of hospital admissions among participants. The mean on pre-participation hospital admissions was 4.18 (SD = .727). The mean on post-participation hospital admissions was 1.41 (SD = .643). Smoking cessation programs impact social change by improving the quality of life of participants and their families and decreasing the financial impact of hospital readmission cost

Class of 2007 Abstract / Objectives: Medication reconciliation is a formal process of obtaining a complete and accurate list of each patient’s current home medications. This process is done to prevent errors of omission, therapeutic duplication, dosing/frequency errors, or drug-drug/drug-disease interactions. As of January 1, 2006, University Medical Center (UMC) implemented a new, comprehensive medication reconciliation form which was intended to prevent medication-related discrepancies upon admission. The purpose of this study was to compare the percent of missing required prescription information upon hospital admission before and after the implementation of the medication reconciliation form. Methods: This study was an inferential retrospective chart review of patients admitted to UMC in Tucson, Arizona, between January 1, 2005 and August 1, 2006. While the overall goal was to measure the impact of a new medication reconciliation form on the completeness of a patient's medication history, the specific study objectives were to: (1) evaluate medication reconciliation form utilization and compliance and (2) compare the completeness of medication information upon hospital admission before and after the implementation of the comprehensive medication reconciliation form. Patients were included in the study if they were over 18 years of age and admitted to UMC at least once in 2005, and at least once between January 1, 2006 and August 1, 2006. The following patients were excluded: patients that were institutionalized in an assisted living facility or nursing home, admitted to the emergency room, intubated, transferred to the hospital from a nursing home or a long term care facility, and discharged from the hospital within 24 hours of admit. Two hundred and thirty-four patients, who met the inclusion criteria, were randomly selected from a UMC hospital census. The researchers reviewed each medical chart and recorded the physician-reported medication history, reason for admit, length of stay, and demographic information. Descriptive and inferential statistical analysis was completed using SPSS Version 11.0 (SPSS Inc., Chicago, IL). After collecting the data, counts were taken on missing prescription information, such as missing medication names, dose, route, and frequencies. If the collected data were normally distributed and were interval/ratio level data, a paired t- test was used for analysis. If the data were not normally distributed or were of nominal/ordinal level, a McNemar test was used. An a priori alpha level of 0.05 was used for all statistical tests. Results: A total of 234 patients were included in both the pre and post analysis. Approximately 53.8% of the sample was male. Fifty-one percent of the population was categorized as white in the patient’s chart. The average age at time of first admit was 50.3 years. Fifty-three percent of the population had a past medical history that included cardiovascular disease. Over 28% of the patients in the sample had diabetes and over 18% had pulmonary disease. The most common admit diagnoses for the population included shortness of breath, chest pain, and abdominal pain. Medication reconciliation forms were found in the chart 71.4% of the time. Of the 71.4% of the forms present in the patient’s medical chart, the form was utilized 66.6% of the time. The percentage of allergies recorded in the patient’s chart decreased from 89.3% before implementation of the form to 65.9% after implementation. This movement repeated itself with the recording of social history, which fell from 92.3% recorded before the form to 52.6% after implementation. Introduction of the new medication reconciliation form at UMC resulted in significantly fewer drug names missing, incorrect, or illegible from the patient’s medication history between pre and post (p=0.034), as well as a greater amount of medications recorded in the patient’s medication history (p=0.006). However, the use of the form did not result in significant differences between pre and post in the route, frequency, and dosing information being recorded. It also did not result in a significantly greater amount of non- prescription drugs recorded. Conclusions: The results of this study indicate the need for a systematic approach to ensure the process of obtaining accurate medication histories at the time of hospital admission. Utilization of a new comprehensive medication reconciliation form in this academic institution is far from optimal, and could have significant healthcare implications. Better methods of ensuring medication reconciliation at the time of hospital admission are needed.

MPH, Faculty of Health Sciences, University of the Witwatersrand / Introduction: The study analysed the admission trends at six adult medical wards in a regional hospital in Gauteng over 2005 and 2007. Methods: This was a retrospective analysis of data from admission ward registers and patient case notes. Information obtained included age, gender, duration of stay, clinical outcomes and disease profile. The study population comprised of all patients admitted to the adult medical wards at Tambo Memorial Hospital for the period 1 January 2005 to 31 December 2005 and 1 January 2007 to 31 December 2007. Results: The number of medical admissions increased by 2.07% during the years of study. The male admissions were slightly higher than the female admissions. The mean age of male patients decreased from 42.30 years to 40.41 years. In contrast the mean age for female patients increased from 38.00 years to 40.50 years. The average length of stay decreased from 6.16 days to 5.33 days. The younger age groups (15-34 years of age) accounted for the majority of admissions. Based on the ICD 10 coding, infectious and parasitic diseases accounted for the majority of the admissions followed by respiratory disorders. Tuberculosis became the most frequent diagnosis and was prevalent in the younger age groups followed by pneumonia. Hypertension was a common diagnosis in the older age groups (55 years and older). As was expected the majority of patients (86-95% in 2005 and 80.24% in 2007) were discharged home but a considerable number of patients were transferred to other institutions. Importantly, a decrease in the mortality rate from 4.02% to 0.03% was also demonstrated. Conclusions: An increase in the number of patient’s admissions, a decrease in the average length of stay and a decrease in mortality rate were noted during the study period. Changing trends with regards to gender, age and disease profile were also observed. The challenges and recommendations identified by the study will provide valid information that would be meaningful to hospital management as well as potential users such as budget planners, resource allocators and efficient referral pathways designers.

Class of 2006 Abstract / Objectives: To assess the accuracy of medication histories taken upon hospital admission. Methods: This study was a prospective chart review comparing the accuracy of hospital admission medication histories with outpatient pharmacy and physician records. Eleven hundred patients admitted to El Dorado Hospital were eligible for participation. Patients were excluded if they were: under 18 years old, non-English speaking, in a room with precautions, transferred from a hospital or skilled nursing facility, unable to give oral consent, or admitted to a geri-psychiatric unit. After verification of medication, dose, and schedule with outpatient pharmacy and physician records, the findings were documented as perfect agreement, error of omission, or error of commission. Results: One hundred and nineteen patient histories were analyzed. Forty three patients (36%) had at least one error in their medication history. Of the 582 medications verified for accuracy, 491 medications were accurate and 91 errors were identified. Of the errors identified, 64 were errors of commission and 27 were errors of omission. The average age of patients who had at least one error type was 74.9 years, and the average age of patients who did not have any errors was 68.3 years (p = 0.004). Medication histories with six or more medications were more commonly associated with errors (p = 0.001). There was no relationship between medication history errors and specific classes of medications such as cardiovascular, lipid-lowering, and antidiabetic agents. Conclusions: Medication histories for patients older than 75 years or those that contain six or more medications are more likely to contain an error. There appears to be no link between medication class and occurrence of error. While this study does not address methods to reduce error rates, verification of medication histories with outpatient pharmacies and physicians may help reduce hospital medication errors and promote positive health outcomes.

Heart failure (HF) is a clinical syndrome associated with high morbidity and mortality with a large economic burden, and is the leading cause of hospitalizations among Medicare beneficiaries in the United States. Healthcare reform has focused on strategies to reduce HF readmissions, including outpatient HF clinics. Purpose: The purpose of this DNP Project was to answer the following question: In adult patients diagnosed with HF, how does enrollment in the HF clinic, compared to non-enrollment affect hospital admission and readmission rates? Methods: A retrospective analysis of 767 unique patients and their 1,014 respective admissions and readmissions was conducted. Continuous and categorical data was analyzed and presented as a mean (M), standard deviation (SD), absolute number (N) and percentage (%). A Pearson Chi Square test was used for categorical variables and Analysis of Variance was used for age and ejection fraction (EF). Results: Study sample demographics (N=767); age (M=79.72, SD=7.48); gender (57.6 % male) and EF (M=0.43, SD=0.16) were evaluated. The No HF clinic (No HFC) and HF clinic (HFC) enrollment groups (N=573) were compared for age (M=79.49, SD=7.65) (M=80.39, SD=6.94), male gender (54.6%, 66.5%) and EF (M= 0.44, SD=0.17) (M=0.42, SD=0.15), respectively. Each sample patient had at least one admission for HF during 2015; of which 573 (46.2%) were in the No HFC group and 194 (8.4%) were in the HFC group (p<0.001). There was no difference in all-cause readmissions between the No HFC group [n=95(14.5%)] and the HFC group [n=37(16.2%)] (p=0.534) and no difference in HF-related readmissions between the No HFC group [n=72(11.0%)] and the HFC group [n=23(10.0%)] (p=0.700). Conclusions: This DNP project demonstrated a significant difference in HF admission rates in favor of the HFC group. While no differences were found in all-cause or HF-related readmission rates in No HFC and HFC groups, the rates are less than the national average. Unintended findings were that datasets can be very poorly constructed and populated, resulting in large amounts of unusable data. Recommendations are for more rigor in the organization of datasets to assure accurate comparisons between admission and readmission rates based on enrollment in HF clinics.

Abstract Objective: In Christchurch there is concern that winter air pollution, dominated by particulate matter (PM₁₀) from domestic heating, causes a local increase in cases of cardiorespiratory disease. Our aim was to investigate whether the particulate levels did influence emergency hospital admissions, and if so to what extent. Method: Air pollution and meteorological data was obtained from a Canterbury Regional Council monitoring station. Two local hospitals provided data on emergency admissions for both adults and children with cardiac and respiratory disorders. All data was obtained for the period from June 1988 to December 1998. Missing PM₁₀ data was interpolated from other known pollution values when necessary. The PM₁₀ data was compared to the admissions data using a time series analysis approach, with weather variables controlled for using a generalised additive model. Results: There was a significant association between PM₁₀ levels and cardiorespiratory admissions. For children and adults combined there was a 3.4% increase in respiratory admissions for every interquartile (14.8 µg/m³) increase in PM₁₀. In adults there was a 1.3 % increase in cardiac admissions for each interquartile increase in PM₁₀. There was no relationship between PM₁₀ levels and appendicitis, the condition that we selected to be our control. Conclusion: In Christchurch there is a significant relationship between particulate levels and the admissions for cardiac and respiratory illnesses. The size of the effect is comparable to other international studies, and the greatest impact is seen on the respiratory system.

Candidate: Kateřina Kukrálová1 Supervisor: prof. RNDr. Jiří Vlček, CSc.1 Consultant: PharmDr. Zuzana Očovská1 1 Department Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University Title of the master thesis: The analysis of drug-drug interactions in patients admitted to hospital (I.) The presence of potential drug-drug interactions (DDIs) is common in daily practice and only a small proportion of potential DDIs results in hospitalization of the patients. Nevertheless, DDIs represent a significant cause of hospital admissions. This study aims to identify DDIs in the medication history of the patients admitted to University Hospital Hradec Králové via the emergency department in August-November 2018. The objectives of this study are a) to determine the prevalence of potential DDIs; b) to categorize identified potential DDIs with respect to their mechanism, severity, risk rating, level of documentation and potential outcomes and c) to determine the prevalence of manifest DDIs. This study has a cross-sectional design. The following data were obtained retrospectively from electronic medical records: demographic data, medication history, past medical history, laboratory and clinical findings, and information about hospital admission. The identification of potential DDI was...

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