Israel Medical Association Journal

Background: Frequent readmissions significantly contribute to health care costs as well as work load in internal medicine wards.

Objective: To develop a simple scoring method that includes basic demographic and medical characteristics of  elderly patients in internal medicine wards, which would allow prediction of readmission within 3 months of discharge.

Methods: We conducted a retrospective observational study of 496 hospitalized patients using data collected from discharge letters in the computerized archives. Univariate and multivariate logistic regression analyses were performed and factors that were significantly associated with readmission were selected to construct a scoring tool. Validity was assessed in a cohort of 200 patients.

Results: During a 2 year follow-up 292 patients were readmitted at least once within 3 months of discharge. Age 80 or older, any degree of impaired cognition, nursing home residence, congestive heart failure, and creatinine level > 1.5 mg/dl were found to be strong predictors of readmission. The presence of each variable was scored as 1. A score of 3 or higher in the derivation and validation cohorts corresponded with a positive predictive value of 80% and 67%, respectively, when evaluating the risk of rehospitalization.

Conclusions: We propose a practical, readily available five-item scoring tool that allows prediction of most unplanned readmissions within 3 months. The strength of this scoring tool, as compared with previously published scores, is its simplicity and straightforwardness.
 

Background: Patients with heart failure (HF) have a poor prognosis. Heart failure centers with specialized nurse-supervised management programs have been proposed to improve prognosis.

Objectives: To evaluate the clinical outcome of patients with HF treated at a multidisciplinary HF center of Clalit Health Services in Jerusalem in collaboration with Hadassah University Hospital.

Methods: We evaluated clinical outcome including hospitalizations and death in all HF patients followed at the HF center for 1 year.

Results: Altogether, 324 patients were included and followed at the HF center; 58% were males with a mean age of 76 ± 11 years, and 58% were in New York Heart Association (NYHA) functional class 3-4. The overall 1 year survival rate was 91% and the 1 year hospitalization rate 29%. Comparing patients in the HF center to the whole cohort of patients with a diagnosis of HF (N=6618) in Clalit Health Services in Jerusalem demonstrated a similar 1 year survival rate: 91% vs. 89% respectively but with a significantly reduced hospitalization rate: 29% vs. 42% respectively (P < 0.01). Cox regression analysis demonstrated that treatment in the HF center was a significant predictor of reduced hospitalization after adjustment for other predictors (hazard ratio 0.65, 95% confidence interval 0.53–0.80, P < 0.0001). A subset of patients that was evaluated (N=78) showed significantly increased compliance. NYHA class improved in these patients from a mean of 3.1 ± 0.1 to 2.6 ± 0.1 after treatment (P < 0.0001).

Conclusions: Supervision by dedicated specialized nurses in a HF center increased compliance, improved functional capacity in HF patients, and reduced hospitalization rate. HF centers should be considered part of the standard treatment of patients with symptomatic HF.
 

Background: Parallel to increased life expectancy, the number of very elderly patients hospitalized in internal medicine departments is growing rapidly, although clinical data on hospital care are lacking.

Objectives: To investigate the sociodemographic data, hospitalization characteristics and outcomes of nonagenarian patients, as these measures are necessary for evaluating prognostic information and predictors of mortality.

Methods: We reviewed the medical records of all patients aged ≥ 90 hospitalized in our institute's Department of Internal Medicine. The data comprised 482 admissions of 333 patients hospitalized over a one year period.

Results: Half of the study patients were residents of nursing institutions. A high rate of atrial fibrillation was documented (106 patients, 32%). Acute infectious diseases constituted the leading diagnosis (276/482 admissions, 57%), followed by acute coronary syndrome (17% of admissions). In-hospital mortality occurred in 74 patients (22%). Chronic therapy with statins or acetylsalicylic acid was inversely related to mortality (P < 0.05). The main predictors for in-hospital death of nonagenarians were pressure sores, older age, atrial fibrillation, malignant disease, and admission due to an acute infection, especially Clostridium difficile-associated diseases. In addition, mental decline, permanent urinary catheter, leukocytosis, renal failure and hypoalbuminemia predicted post-discharge mortality. Admission due to an infectious disease but not acute coronary syndrome was significantly correlated to in-hospital and post-discharge mortality (P < 0.001).

Conclusions: Hospitalized nonagenarians comprise a growing group with distinct characteristics and increasing significance in the daily practice of internal medicine departments. Comprehensive assessment of the elderly at admission together with identification of the above clinical and laboratory risk factors for mortality will help determine in-hospital management, discharge planning and rehabilitation programs.

Background: Tight glucose control has been shown to improve the outcome of patients with severe acute illnesses who are hospitalized in intensive care units and on intravenous insulin-based regimens.

Objectives: To clarify the attitudes of internists towards tight control of glucose levels in acutely ill patients hospitalized in general medical wards.

Methods: A questionnaire on intensive glucose control in acutely ill patients hospitalized in medical wards was mailed to each of the 100 heads of internal medicine departments in Israel.

Results: Fifty physicians responded. Of these, 80% considered tight glucose control to be a major treatment target, but only two-thirds had defined it as a goal in their ward. Furthermore, only about half had a defined protocol for such an intervention. Most physicians considered patients with acute coronary syndrome, stroke and infectious diseases as candidates for a tight glucose control protocol. The most frequently used modalities were multiple blood glucose measurements and repeated injections of short-acting subcutaneous insulin. The main reasons given for not having a defined protocol were lack of guidelines, no evidence of a clear benefit during hospitalization on a medical ward, and a shortage of adequately trained staff.

Conclusions: Inconsistencies in physicians’ attitudes and in treatment protocols regarding tight control of glucose levels in acutely ill patients hospitalized on a medical ward need to be addressed. Evaluation of the feasibility, effectiveness and side effects of a defined protocol is needed before any regimen can be approved by the heads of the internal medicine departments.
 

Background: Children report various types of fear in the context of hospitalization, such as fear of separation from the family, having injections and blood tests, having to stay in the hospital for a long time, and being told “bad news” about their health.

Objectives: To examine the effects of the “Teddy Bear Hospital” method on preschool children’s fear of future hospitalization.

Methods: The study group comprised 41 preschool children aged 3–6.5 years (mean 5.1 ± 0.7 years), and 50 preschool children, age matched and from a similar residential area, served as the control group. Assessment included a simple one-item visual analog scale of anxiety about hospitalization. This was assessed individually one day prior to the intervention and again a week after the intervention in both groups

Results: While baseline levels of anxiety were not different between groups [t(89) = .4, NS], children in the “Teddy Bear Hospital” group reported significantly lower levels of anxiety than the control group at follow-up

Conclusions: Our results indicate that by initiating a controlled pain-free encounter with the medical environment in the form of a “Teddy Bear Hospital,” we can reduce children’s anxiety about hospitalization.

Background: Reports of burn injuries in children are usually made by highly specialized burn units. Our facility admits children with burns < 20% total body surface area, while those with major burns are transferred to burn units at tertiary care facilities.

Objectives: To review our experience with thermal burns.

Methods: We conducted a retrospective review of all thermal burns admitted to our hospital during a 5 year period.

Results: Among 266 patients (69.2% boys) aged 3.5 ± 3.6 years, children < 3 years old were the most frequently injured (64.7%). Scalds (71.4%) were the most common type of burn. Partial thickness burns were sustained by 96.6% of children and TBSA[1] burned was 4.2 ± 3.6%. The mean hospital stay was 3.8 ± 4.5 days, and was significantly prolonged in girls (4.6 ± 4.8 vs. 3.5 ± 4.3 days, P = 0.01). Percent TBSA burned was correlated with patient age (r = 0.12, P = 0.04) and length of hospital stay (r = 0.6, P < 0.0001). Six patients (2.3%) (mean age 3.4 ± 2.3 years) were hospitalized in the Pediatric Intensive Care Unit due to toxin-mediated illness.

Conclusions: Children under the age of 3 years are at increased risk for burn injury, but older children sustain more extensive injuries. Prevention and awareness are needed for child safety.

Background: Trauma management includes the care provided both in hospital and by emergency medical systems in the community. In many cases it is the parents who decide where to take an injured child for care, depending on the circumstances and severity of the injury, the personal characteristics of the injured or the carer and the availability and accessibility of services.

Objectives: To examine the use of pre-hospitalization services and reasons for their use by children and adolescents according to the injury and personal characteristics.

Methods: The study group comprised 924 Israeli citizens aged 0–17 years hospitalized for injuries in six hospitals across Israel. Carers were interviewed in the hospital regarding the circumstances of the injury event, the use of pre-hospitalization services, and sociodemographic characteristics. Data on the cause and nature of the injury were obtained from the hospital records.

Results: The proportion of severe injuries (Injury Severity Score 16+) was higher in Arab children than Jewish children (15% and 9% respectively). Sixty-three percent of the Arab children and 39% of the Jewish children used community services prior to hospitalization. The odds ratio of proceeding directly to the hospital was 0.44, 95% confidence interval 0.29–0.69, for the Arab compared to the Jewish children, controlling for severity, cause and nature of the injury, sociodemographic characteristics, and the reported availability of ambulance services.

Conclusions: More Arab than Jewish carers tended to seek care in the community for an injured child, but the effect of personal characteristics on seeking care was similar in both population groups. Issues of availability and accessibility of services may explain the differences.

Background: We recently published preliminary evidence on the effectiveness of hypertonic saline in infants with viral bronchiolitis.

Objective: To further establish the efficacy of nebulized hypertonic saline in these infants

Methods: In a continuing, second-year randomized, double-blind controlled trial, an additional 41 infants (age 2.6 ± 1 months) hospitalized with viral bronchiolitis were recruited during the winter of 2001–2002. The infants received inhalation of 1.5 mg epinephrine dissolved either in 4 ml normal (0.9%) saline (Group I, n=20) or 4 ml hypertonic (3%) saline (Group II, n=22). The therapy was repeated three times daily until discharge. Pooling our 2 years of experience (2000–2002), a total of 93 hospitalized infants with viral bronchiolitis were recruited; 45 were assigned to Group I and 48 to Group II.

Results: The clinical scores at baseline were 7.6 ± 0.7 for Group I vs. 7.4 ± 1.3 for Group II (P = NS). However, the clinical scores at days 1 and 2 after inhalation differed significantly between the two groups, invariably favoring Group II: 7 ± 1 vs. 6.25 ± 1.1 (P < 0.05), 6.45 ± 1 vs. 5.35 ± 1.35 (P < 0.05), respectively. Adding aerosolized 3% saline to 1.5 mg epinephrine reduced the hospitalization stay from 3.5 ± 1.7 days in Group I to 2.6 ± 1.4 in Group II (P < 0.05). The pooled data of both years revealed that adding 3% saline to the inhalation mixture decreased hospitalization stay from 3.6 ± 1.6 to 2.8 ± 1.3 days (P < 0.05).
Conclusions: This second-year experience and our 2 year pooled data analysis strengthen the evidence that the combination of 3% saline/1.5 mg epinephrine benefits hospitalized infants with viral bronchiolitis

Background: Analysis of the trends in psychiatric admissions and discharges is necessary to correctly plan and distribute resources, especially given the current international climate of “deinstitutionalization." Israel, too, is implementing “reform” in the national psychiatric system – to transfer psychiatric treatment from a hospital to a community setting

Objectives: To analyze admission and discharge patterns, explore trends in psychiatric hospital length of stay, and compare these characteristics between first-episode and chronic patients, between children, youth and adults, and between hospitals.

Methods: All admissions and discharges from inpatient psychiatric wards between the years 2000 and 2004 were analyzed and characterized according to age, length of hospitalization, legal status, and nature of admitting institution (state hospital, health fund, general hospital).

Results: Mean length of stay in adults decreased during the 5 year study period, from 37.6 days in 2000 to 36.4 days in 2004. In years with higher admissions, hospital stay was shorter (P < 0.05). Length of stay in psychiatric wards in general hospitals was shorter than in state hospitals (P < 0.001). In contrast to adults and children, length of stay among adolescents showed a gradual increase (P < 0.05). Involuntary hospitalization comprised 25.3% of all admissions, and 16.8% of discharged patients were readmitted within 30 days. A dramatic decrease (24.3%) in the number of chronic hospitalizations was noted.

Conclusions: Various factors may account for these developments. Protracted hospitalizations may be reduced through changes in various aspects of treatment planning and psychiatric care continuum. The decrease in number of admissions, length of stay and number of chronically admitted patients remains in line with international practices. Particular attention needs to be devoted to planning and funding so that availability of community services matches reduction in psychiatric hospitalization.
 

In the last few decades there has been a tendency towards reinstitutionalization.

Objectives: To describe the sociodemographic, medical and functional characteristics of people aged 80–90 and 90+ who were admitted to a sub-acute geriatric hospital and to compare the hospitalization outcomes between these subgroups.

Methods: We compared the demographic and clinical data (extracted by means of chart review) of two groups of elderly who were admitted to the Reuth Medical Center during 2001–2002: those aged 90+ and those 80–89. Among survivors, the main outcome measures at discharge were mortality rate, functional ability, and place of residence.

Results: The study included 108 patients who were admitted to different divisions of Reuth: 55 patients aged 90+ and 53 aged 80–90. The mortality rate was significantly elevated in the older age group (49.1% vs. 28.1% in the younger age group) on multivariate analysis. The most important prognostic factors for mortality were incontinence (odds ratio 3.45) and being dependent before admission (OR[1] 4.76). Among survivors an association was found between being incontinent and dependent before hospitalization, and being dependent on discharge.

Conclusions: The main prognostic factors for mortality and functional outcome in patients admitted to a non-acute geriatric hospital are incontinence and functional state prior to admission, and not age per se.

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[1] OR = odds ratio